Inspection on 15/12/05 for Adel Grange

This inspection was carried out on 15th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Adel Grange 05/11/07

Adel Grange 14/12/06

Adel Grange 23/05/06

Adel Grange 07/07/05

Adel Grange 27/01/05

Adel Grange 31/08/04

Adel Grange 20/04/04

Adel Grange 17/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Adel Grange Adel Grange Close Leeds LS16 8HX Lead Inspector Carol Haj-Najafi Announced Inspection 15th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Adel Grange Address Adel Grange Close Leeds LS16 8HX Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 261 1288 0113 2611288 Parkfield Healthcare Ltd Care Home 30 Category(ies) of Dementia - over 65 years of age (30) registration, with number of places Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th July 2005 Brief Description of the Service: Adel Grange is a converted, detached property situated in a residential area in Adel. There is a small area for car parking directly in front of the home. The home is located close to local bus routes. There are gardens to the rear and side of the property which can be accessed by ramps. The home is registered to provide personal care for thirty older people with dementia. Accommodation is provided on three floors with some service areas located in the basement. A passenger lift links both floors, although one bathroom and bedroom can only be accessed by stairs. The accommodation consists of twenty single bedrooms, eight of which have en suite facilities, and five double rooms, three with en suite facilities. There are six communal bathrooms and two communal toilets. There are two lounges and a separate dining room. The kitchen is adjacent to the dining room. Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out over two days by two inspectors. A total of fifteen hours was spent in the home by each inspector. The purpose of the visit was to assess where the home is meeting the national minimum standards and where the home is failing. During the visit, time was spent talking with residents, staff and management, observing practice and looking at records. Due to the home continuing to fail to meet a significant number of the minimum standards, twelve additional unannounced visits have been made, since April 2005, to make sure that improvements are being made to give better outcomes for the residents. Two enforcement notices have been served. The management arrangements have changed recently and the new manager and deputy were on duty during the inspection. A two-hour feedback was given to the registered provider, manager and deputy manager at the end of the inspection. Timescales for the requirements were agreed during the feedback session. What the service does well: What has improved since the last inspection? Staff have attended moving and handling training and have a good awareness of how residents should be transferred. The registered provider has completed several maintenance works that were identified at previous inspections. This includes some general maintenance Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 6 work and fixing broken locks and toilet roll holders and replacing torn curtains. All bedrooms have been fitted with hand washing facilities, this makes it easier for staff to maintain a good standard of hygiene. New medication facilities have been purchased, therefore medication is now stored securely. The registered provider has employed more domestic staff. The home was clean and tidy. Residents have been given their own personal toiletry bag to prevent the use of communal toiletries. There is still some work to do in this area to make sure toiletries are not shared but there has been a clear improvement. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 7 contacting your local CSCI office. Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 The home’s brochure does not give prospective residents accurate or fair information about the home. Contracts are given to residents when they move into the home but they need to include more information and must not be altered after they have been issued and/or signed. Residents and relatives are encouraged to look around the home before they make a decision about moving. However, resident’s needs are not properly assessed before they move into the home, therefore residents cannot be assured that their needs can be met. EVIDENCE: Residents have contracts about the terms and conditions of the home. The cost of the placement is included. One contract had been changed after it had been signed. This is unacceptable because a new contract should be issued if changes are made. The room number should also be included in the contract. The admission process for two residents that recently moved in to the home were looked at. The manager had visited one resident in hospital before they moved in, and the other resident had visited the home and spent several hours Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 10 there, during which time the manager said she carried out an assessment. Two relatives confirmed that they had looked around the home before making a decision. The only assessments that were available were those completed by the home. The manager had completed pre admission assessments but the information in the assessments was not detailed. Assessments stated ‘just a little confused, needs a lot of prompting with diet, wandersome, full assistance with personal care’. The needs of both residents should have been written with far more detail. A brochure for the home has recently been published. One relative said one reason they chose the home was because the brochure stated ‘frequently supervised trips in our minibus’. The registered provider said a minibus was shared with two other homes but acknowledged it had not been used to take residents out on supervised trips. Most staff were not aware the home had access to a minibus. The information in the brochure is therefore not accurate and is misleading. Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Care planning and risk assessments remain poor placing residents at risk as staff are not provided with the information they need to meet the residents’ needs. Care plans and assessments also contained contradictory information, therefore care instructions are confusing. These problems have been identified at previous inspections and progress is unsatisfactory. Staff consult health care professionals for advice and record this information well. Medication systems and practices are satisfactory. Staff help residents to feel and look comfortable but some practices show a lack of respect for the residents. Generally staff interact well with residents and during the inspection staff were seen to treat people with respect, although staff must be made aware of appropriate and inappropriate personal contact. EVIDENCE: Care records for five residents were looked at. Each resident had a care plan and risk assessments but these did not cover all their needs. Some elements of care plans gave good information about needs but others were general and applied to general care, for example ‘ensure zimmer is in good working order, ensure wearing correct footwear, ensure dressed according to style’. It is not Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 12 necessary to record this information in care plans and this practice should be automatically applied throughout the home. Daily records were generally good and contained information about residents’ health, diet and personal care. Records stated that regular consultation with GPs and other health care professionals take place. Evidence that staff follow up test results was also seen. Care needs and risks were seen in the daily notes and other records but were not recorded in the care plan or risk assessments. Some assessments had contradictory information compared to the resident’s care plan. For example one assessment showed that a resident needed two carers when mobilising. Further on in the file the manual handling assessment stated one carer was needed. This file had not been amended to reflect changes in the resident’s condition. A nutritional assessment had been completed and had highlighted a ‘cause for concern’ but no care plan was made. The home is registered to provide care to people with dementia but there was no information in care plans about how their needs should be met in relation to their dementia. One resident’s daily record identified a lot of unexplained injuries over a short period of time. On the 5/11 bruising was noticed to left leg at the side, 6/11 they had a sore eye, 7/11 they had a bruise on the left leg at the top, 27/11 a small scratch to forehead was noticed and on the 8/12 a small bruise and lump to the head, a swollen ankle and bruise to the left eye was noted. There was no evidence to show how these occurred or what action had been taken to investigate these matters. The same issue regarding unexplained injuries was raised at the last inspection. One resident was regularly removing their clothing, eating inedible objects and moving furniture. Their care plan did not contain clear guidance on how this should be managed. The last inspection identified that staff were struggling to manage a situation where a resident was becoming agitated. The manager said since the last inspection she had spoken to staff and given advice on how different residents should be managed if they become aggressive. This information had not been recorded in their care plan. Issues with recording, care plans and assessments that have been identified at this inspection have also been identified at previous inspections. Medication is stored appropriately in two trolleys. An inspector observed medication being administered to residents during breakfast on the second day Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 13 of the inspection. The member of staff carrying out this task was competent, methodical and thorough. She was seen to take time with residents; in one case ensuring the resident was sat in a suitable position to take a drink. She talked to residents and explained what her actions would be. She was patient and attentive. Residents’ personal appearance was generally good. Clothing was clean and people were dressed appropriately. Staff had to adjust one resident’s clothing to maintain her dignity, they soon realised that this would be a reoccurring problem, and supported the resident to change into more suitable clothes. The last inspection identified that there were a number of issues that demonstrated a lack of respect for the residents. In the home there were communal toiletries, hairbrushes, razors, tights, socks, and underwear. Since the inspection, all residents have been given individual toiletry bags with basic toiletries. However, there was still evidence that communal combs and tights were still in use. This is unacceptable. Staff also confirmed that toiletries sometimes go missing and replacements are not readily available in the home. The majority of wardrobes and furniture in bedrooms had sticky labels attached displaying the resident names. It is strongly recommended that an alternative method of recognition should be introduced which takes into account resident dignity and privacy. It is strongly recommended that the method used to label personal items of clothing be reviewed. Examples were seen where clothing had been written on using a large permanent marker pen and this could be seen through the material of the garment. Generally staff interacted with residents very well and it was evident that residents were comfortable with staff. However, one staff was observed to kiss a resident on the lips and said ‘I love you’. This can lead to confusion for some residents and is not an acceptable care practice. There was evidence in daily records that one resident was confused and there had been a problem of a sexual nature when the resident had wanted a ‘hug and a kiss’. Their care plan for expressing sexuality did not contain any relevant information. Each resident had a care plan for sexuality but most plans contained exactly the same information. If a care plan for sexuality is relevant it should reflect the needs of the individual. Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Relatives and healthcare professionals are satisfied with the service provided at Adel Grange. However, the routines of the home seem to revolve around the needs of the home rather than the needs of the individual residents, therefore choice is not promoted. Recreation must improve and be suitable for the people who live at Adel Grange. EVIDENCE: Comments made by relatives confirmed they were satisfied with the care provided in the home. One resident had only recently moved to Adel Grange, the other was a long standing resident. One relative confirmed they visit on a regular basis and are made to feel welcome whenever they visit. Ten comment cards were returned to the commission. Eight were from relatives and two from health care professionals. All of the comment cards stated they were satisfied with the overall care provided to service relatives within the home. Two of the cards stated there had been an improvement in the care provided. One resident, who was able to express her views, said she loved the food and when she returned to Adel Grange following a recent hospital stay she said Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 15 ‘Thank god I’m home’ as the ambulance turned into the street. She said she is treated very well and enjoys all aspects of the care provided. One resident had been moved from a single room to a double room, which resulted in the resident having to share a room. The staff were not able to give a valid reason why the move had taken place or say how the resident had benefited. The issue of moving residents for the benefit of the home has been raised at previous inspections. This is unacceptable practice. The hairdresser visits every two weeks and uses a resident’s bedroom. This particular resident likes to go to bed in the afternoon. On the days when the hairdresser visits the resident cannot use their room. The home must find an alternative room for the hairdresser to use. Staff talked about the general routines of the home. They said that residents that need the assistance of two staff go to bed between 7.00 and 7.30pm and the majority of residents are in bed before staff handover at 7.45pm. They also confirmed that night staff get the majority of residents up from 6.00am on a morning. One resident’s admission record stated she liked to ‘settle around 11.00pm’ but her care plan stated she wanted to go to bed at 8.00pm. There was clear evidence that her bedtime had gradually been getting earlier and daily records stated that recently she had been getting ‘distressed’ when going to bed. Another resident, who shares a room, had to go to bed before 7pm as staff said the resident she shares with ‘kicks off’ if she is not in bed by then. The same person said that they had to be dishonest to the resident already in the room to allow her stay up longer. This is against the choice of the resident involved and must be addressed. The last inspection highlighted similar issues and the report stated ‘one resident’s assessment showed that she liked to get up at 8.30am, yet her daily records showed staff were getting her up and dressed at 6am’. The home has several bathrooms, three baths are fitted with hoists. However, only one bathroom is used. Staff said this is because it is more efficient and easier to use. The manager should look at the use of bathrooms and introduce bathing routines which are carried out in the best interests of residents. Staff were unable to give examples of suitable recreation that is offered to people with dementia. They spoke about playing bingo and board games but said most residents were unable to engage in such activities. Staff said they thought residents should be taken out more and that this did not happen often. They gave an example of when a recent trip to the White Rose Centre shopping was cancelled. The person providing the transport had to use her car to take a resident to hospital following an accident. As noted in standard 1, the home does have access to a minibus, which is shared with two other homes. However it is clear that Adel Grange residents do not use the Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 16 minibus and most of the staff were unaware of it being available. It is also understood that only one member of staff can drive the minibus thus reducing availability. Lunchtime was pleasant, relaxed and well organised, and staff were seen to spend time with residents, asking what they would like to eat. Staff were patient, considerate and dealt with people individually. The main meal of the day is served at lunchtime. The inspector sampled this on the first day of the visit. The mashed potato was lumpy and the shepherd’s pie lacking in flavour, these two dishes were also tepid and not hot. The vegetables and cheese and onion pie were warm and had flavour. It is acknowledged that the sample dish may have been stood for a while, however at the time of sampling residents were still being served in the dining room and bedrooms. One breakfast meal was observed. Residents were offered a choice of cereal, hot and cold drinks, toast and preserves. A variety of containers were used for drinks to maximise resident’s independence. Staff sat alongside residents who needed assistance to eat. This ranged from prompting to full feeding. Prompting was done in a discrete and professional manner. Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 A complaints procedure is in place but there is no evidence to confirm that complaints are properly recorded. An adult protection procedure is available and the manager is familiar with how it should be implemented. EVIDENCE: The complaints procedure is displayed in the entrance of the home. Contact details, which include the Commission for Social Care Inspection are included. The manager has set up a complaints record book to record any complaints about the home. A previous inspection identified that a complaint had not been recorded and there was no evidence that demonstrated what action had been taken to deal with the complaint. The manager has still to complete this task. The manager and two staff have recently attended adult protection training with the local authority. The manager was familiar with the adult protection procedures and knew when to report any allegations of abuse to the relevant authority. Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 The environment is generally pleasant, the home has some very nice features. Some maintenance work is required. The home was clean, some odours were noted but action has been taken to try and eliminate them. EVIDENCE: The home was clean and tidy and generally well organised. The general decoration is satisfactory and residents are encouraged to personalise their rooms. Improvements have been made to the environment over the past few months. Some areas of maintenance have been identified at previous inspections. Most of the work has been completed but there were some areas still outstanding. These are as follows: Room 23 – Doors to the bedroom and en suite are sticking on the new carpet. Room 15 – No lock on en suite door (double room). Assisted bathroom (ground floor) – Floor needs attention where the bath hoist has been moved. Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 19 There are two toilet cubicles in one room near the main lounge, which are used constantly by both male and female residents. The layout of this room makes it difficult for the residents to maintain their privacy and dignity when using these facilities. This was brought to the attention of the registered provider at the last inspection. The registered provider said there are plans to address the privacy issue and this would be completed by the end of February 2006. Particular areas of the home felt cold. Temperature readings confirmed the home was below the required temperature on the fourth floor near the upstairs office; in the corridor outside bedroom number 19; bathroom on second floor (not used currently); bedroom number 8 and 25 (vacant). This issue has been discussed at a previous inspection. Elsewhere in the home felt warm. Further maintenance work was also identified at this inspection. These are as follows: The passenger lift door was not closing properly. The manager said the lift engineers had been out to look at it and were waiting for a part. The manager also said the lift was occasionally getting stuck. Rm 19 - Has a low window, which does not have toughened glass. The glass must be replaced with glass that meets the health and safety requirements to make sure it is safe. Some of the furniture in bedrooms was in need of repair or replacement. Drawer fronts were missing and handles were broken on wardrobes and chest of drawers. Whilst it is acknowledged that some items are the personal property of residents’ appropriate action needs to be taken to make sure furniture is not kept which is in a poor state of repair or could pose a safety risk to the resident. The water pressure on the second floor was very low and running a bath would take a long time. By the time the bath had sufficient water it would not be warm enough for a resident to bathe. The bathroom on the top floor had no curtaining at the window. Some zimmer frames and resident’s handbags were dirty. There was a strong malodour in three bedrooms. It was noted that an odour was present in two of the bedrooms at the last inspection. New flooring has been put down in two bedrooms but there was still an odour. The manager was advised to look at more frequent cleaning in these two rooms. The door to the now unused sluice was found to be open. The manager confirmed there is a bolt in place but this had been left open. This room and the equipment should not be available to residents or visitors. The type of locking devise must be risk assessed as a matter of course. Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 Staffing levels are appropriate for the current numbers of residents living at the home. The recruitment process is very poor which could result in inappropriate persons working at the home, therefore residents are at risk. The manager and staff do not have adequate knowledge of dementia to be able to satisfactorily meet the needs of people with dementia. Staff need to receive more training to equip them with the skills to look after people living at the home. EVIDENCE: There are 22 residents currently living at the home. Staff said the current staffing levels were appropriate for the current number of residents. Four care assistants and one senior work between 8.00am and 8.00pm, and 2 care assistants and one senior work between 8.00pm and 8.00am. The manager and assistant manager are additional to these staffing numbers. The home is registered to provide care to people with dementia. The inspectors asked staff and the manager about their knowledge and understanding of dementia. Staff and the manager had only very limited knowledge of dementia and said they needed to do training. As stated earlier in the report, care plans and activity provision are not geared towards meeting needs of people with dementia. Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 21 There is no specific training plan in place. Resident specific training is required in addition to mandatory topics. In particular training around the effects of dementia and managing challenging behaviour. The manager said she was planning to do a registered manager’s award, having completed NVQ level 3. Staff said they had completed an induction programme. The depth of knowledge and duration ranged from two days to two weeks. Training files showed course titles such as fire procedures, moving and handling, food hygiene and aggression management. The manager strongly agreed that a significant amount of training was still required. Records for two staff that recently started work in the home were looked at. Application forms had been completed by both applicants. Only one application form had a full employment history. One applicant had written they had left employment because allegations against them had been made. This had not been explored. One applicant had a work permit that enabled them to work in this country but the permit expired one day after they started work. The home should have received confirmation that the person was eligible to work before they employed them. The applicants had obtained their own references. They had been given blank references and then had brought them back in after referees had supposedly completed them. A reference request had not been obtained from the last employee of one applicant. The other applicant had one written reference and the assistant manager from Adel Grange had obtained two verbal references. Referee details were personal telephone and addresses. The inspector checked the validity of one referee who claimed to be a senior working at another care home. It was discovered that the referee was not authentic. The recruitment process for these two workers was completely unacceptable and very bad practice. Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 36, 37, 38 The quality of the service provided is not monitored properly. Staff are not receiving regular supervision. Residents’ daily records were generally good but there were some gaps in other recording systems. Staff were confident when transferring residents and their moving and handling techniques were good. EVIDENCE: There is no formal quality assurance system in place. This has been highlighted at previous inspections. Visits to make sure the home is running properly should be carried out once a month by the registered provider. These are called Regulation 26 visits. The registered provider would have identified many of the problems highlighted at this inspection and previous inspections if effective Regulation 26 visits had been carried out. Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 23 Staff do not receive formal supervision. The manager and deputy are planning to introduce supervision for all staff. This has been highlighted at previous inspections. As stated earlier in the report, daily records about residents contained good information, several entries are made each day. Accident records showed the number of incidents since June 2005. The manager said records prior to this date had gone missing. The accident book showed the date and time of the accident, the person affected and the injury sustained. However, once the record has been completed it is torn out of the book and filed in the residents’ personal file. The stub remaining in the accident book shows the date and the residents’ name only. There is no information of the accident. The torn off record is not filed in any particular order. These were found either loose in files or had been tucked in between other records, which are held in plastic sleeves. It was not possible to find records to match all the stubs in the book. Three stubs were not dated and three others had no date or name. Routine monitoring forms for weights and reviews should be dated according to the time the information was sought. In all cases the month and year were shown. Therefore the time lapse between the events could range from a minimum of one day to a maximum of thirty days depending on the time of the month. A number of care plans and assessments were not dated. Staff were observed several times supporting residents from a chair to a standing position. They used suitable equipment and supported the residents appropriately. All staff have recently completed moving and handling training. The gas safety certificate was dated 26th September 2005 and stated the heat safety shield had cracked and the insulation to the burner. The certificate also stated it was not a gas safety record. The registered provider must make sure the necessary checks have been completed to the gas supply and provide the necessary supporting documentation. The electrical hard wiring had been tested and a certificate was seen confirming a further inspection was due in 2008. A cleaning trolley containing hazardous substances was found in an unlocked area of the home, which is accessible to residents. Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 1 1 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 1 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 2 X X 2 2 2 STAFFING Standard No Score 27 3 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X X 1 2 2 Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP1 OP2 Regulation 5 5 Requirement The registered person must ensure information in the home’s brochure is accurate. The registered person must ensure contracts are not changed after they have been issued and signed. The registered person must ensure resident’s needs are assessed before they move into the home. The registered person must be able to demonstrate that the home can meet the needs of residents admitted. The registered person must ensure that the care plans encompass all the assessed needs of the resident and demonstrate how those needs are met, review resident plans monthly and involve the resident and or their relative/representative. (Timescale of 30/09/05 & 15/12/05 not met) Risk assessments must be fully completed and contain sufficient DS0000001405.V262526.R01.S.doc Timescale for action 31/01/06 31/01/06 3 OP3 14 31/01/06 4 OP4 12, 14 31/01/06 5. OP7 15 31/01/06 6. OP8 12 31/01/06 Adel Grange Version 5.0 Page 26 7. OP8 12 information so that staff know the action they need to take to safeguard the resident. (Timescale of 15/12/05 not met) The registered person must 31/01/06 ensure that the home is conducted so as to make proper provision for the health and welfare of residents- this relates specifically to investigating unexplained injuries and taking action to avoid reoccurrence, staff appropriately managing challenging or aggressive behaviour and ensuring residents are not moved to a different bedroom without good reason. (Timescale of 30/09/05 & 15/12/05 not met) Residents must have their own clothing and personal toiletries which are for their sole use. (Timescale of 15/12/05 not met) The registered provider must introduce a system for marking residents clothes and furniture, if required, that does not compromise their dignity. Staff must receive training that provides guidance on how to ensure residents are treated with dignity, this must include appropriate and inappropriate personal contact with residents. The registered person must ensure activity provision is appropriate for the residents living at the home. Consideration must be given to people with dementia The registered person must ensure residents are given choice and decisions are made in the best interests of residents and they must demonstrate how decisions have been made. This DS0000001405.V262526.R01.S.doc 8 OP10 13 31/01/06 9 OP10 12 31/01/06 10 OP10 18 28/02/06 11. OP12 16 28/02/06 12. OP14 12 31/01/06 Adel Grange Version 5.0 Page 27 12. OP16 22 13. OP24OP19 23 16 23 must include bedtime and bath time routines, changes in bedroom allocation and the use of bedrooms which are not for the benefit of the occupier. The registered person must ensure all complaints are recorded and records must clearly show the action that has been taken to deal with the complaint. The registered person must complete the maintenance works identified in the report. The registered person must provide toilets that allow residents to maintain their privacy and dignity- this relates specifically to the toilets on the ground floor. All areas must be maintained at an appropriate temperature. The malodour in three bedrooms must be eradicated. 06/01/06 31/01/06 14. OP21 28/02/06 15. 16. 17. OP25 OP26 OP29 23 23 19 31/01/06 31/01/06 The registered person must 31/12/06 provide and implement a robust recruitment procedure and must ensure that all information detailed in schedule 2 is obtained before new staff start work. The registered provider must ensure staff and the manager receive training that equips them with the skills and knowledge to look after people with dementia. The registered person must provide a foundation and ongoing training programme for staff that meets the NTO specifications. The registered person must develop and implement a quality assurance system and annual DS0000001405.V262526.R01.S.doc 18. OP30 18 31/03/06 19. OP30 18 28/02/06 20. OP33 24 28/02/06 Adel Grange Version 5.0 Page 28 development plan for the home. 21. OP36 19 The registered person must 28/02/06 develop and implement a programme of formal supervision for care staff at least six times a year. The registered person must 31/01/06 ensure accurate records are maintained. These should also be dated and signed. This relates specifically to accident records, weight charts, assessments and care plans. The registered provider must forward to the commission a copy of the home’s gas safety certificate. The registered provider must ensure residents do not have access to hazardous substances. The registered provider must carry out monthly regulation 26 visits. The visits must be carried out in sufficient detail to establish whether the conduct of the home is satisfactory. 30/06/06 22. OP37 17 23. OP38 23 24. 25 OP38 *RQN 13 26 31/01/06 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP2 Good Practice Recommendations The registered person should include bedrooms allocated to residents in the contract/statement of terms and conditions. Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Adel Grange DS0000001405.V262526.R01.S.doc Version 5.0 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!