CARE HOMES FOR OLDER PEOPLE
Balmoral Nursing Home 6 Beighton Road Woodhouse Sheffield South Yorkshire S13 7PR Lead Inspector
Shirley Samuels Key Unannounced Inspection 17th April 2007 09:00 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 DS0000021767.V334858.R01.S.doc Version 5.2 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. DS0000021767.V334858.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Balmoral Nursing Home Address 6 Beighton Road Woodhouse Sheffield South Yorkshire S13 7PR 0114 254 0635 0114 254 8159 balmoral@fshc.co.uk None Four Seasons Healthcare (England) Limited (Wholly owned subsidiary of Four Seasons Health Care Ltd) Mrs Catherine Matthews Care Home 85 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) Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (60) of places DS0000021767.V334858.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Old Age not falling within any other category - 5 places to be for people over 60 years old within the total of 60 places. Dementia, over the age of 60 years - 5 places within the total of 25 places. 18th August 2006 Date of last inspection Brief Description of the Service: Balmoral is a purpose built home, which provides nursing and personal care to older people. It is situated in the village of Woodhouse, within easy reach of shops, churches, public transport and small parks. Balmoral is a large home and accommodation is provided over three floors. There are stairs and lifts to each floor. There are TV lounges, sitting rooms and separate dining rooms were service users are able to have meals with other service users or their relatives. Chiropodist, hairdressers and various complementary therapists attend the home. Whist the majority of the service users are permanent, the home also provides short term and respite care. A copy of the previous inspection report was on display and available for anyone visiting or using the home. Information about how to raise any issues of concern or make a complaint was on display in the entrance hall. The manager confirmed that the range of monthly fees from 1st April 2007 were £318.00 - £550.00 per week. Additional charges included newspapers, hairdressing and private chiropody. DS0000021767.V334858.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced visit carried out by two inspectors, Shirley Samuels and Sue Turner, over eight hours from 9.00 am - 5.00 pm. Fifteen service users, four relatives, twelve staff, the registered manager and operations manager were spoken to. Observations were made of the care provided to service users, the interaction between staff and service users, and the communication between the staff. Opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home and check the homes policies and procedures. Pre inspection information was returned to CSCI and surveys from three service users, one member of staff and two professionals that visit the home were also returned. What the service does well:
Service users were assessed prior to moving into the home, care plans were in place these however needed further development. Records were kept of service users health care needs and service users said there were no delays in calling a GP if they were ill. The medication system was well managed and monitoring systems were in place. Service users who were able managed their own medication. Staff were able to verbalise how they maintained the dignity and respect of service users on a daily basis and service users spoke positively about the staffs attitude. There was however some observation and practices in place that did not promote service users dignity. Service users were able to maintain contact with family and friends. Some relatives visited the home daily and in the main were positive about their observations of the care provided. Service users were provided with wholesome balanced meals, which the service users said were in the main “enjoyable”. Appropriate records were kept of complaints; relatives and service users said action was taken when they raised issues. There have been no complaints made directly to the commission for social care inspection since the last inspection.
DS0000021767.V334858.R01.S.doc Version 5.2 Page 6 Staffing levels agreed at the time of the inspection were being maintained, these were sufficient to meet the needs of the service users. What has improved since the last inspection? What they could do better:
Since the last key inspection one allegation of abuse had been reported to social services adult protection team, resulting in the suspension of a member of the staff team. There was also one ongoing investigation which had been delayed due to the legal process associated with a police investigation again this had resulted in a staff member being suspended from duty. A third suspension took place the day after the inspection following the inspectors bringing a potential allegation to the attention of both the regional and homes manager during the inspection of 17th April 2007. This again resulted in the suspension of a staff member. Care plans did not detail; all the information needed to inform staff of service users emotional, personal and social care needs and the action staff needed to take to fully meet service users needs. The service users family or representatives should be invited to be involved in the care planning and reviewing process.
DS0000021767.V334858.R01.S.doc Version 5.2 Page 7 It was the view of the service users and the staff that there was not enough social contact and opportunity to take part in activities. Records of the activities that did take place were not always appropriately recorded. There should be more variety of options available for service users on a diabetic diet. Staff spoken to described banter with service users, some of which was inappropriate and did not promote service users dignity. Staff should have training in appropriate communication. There was an incident observed involving service users being verbally aggressive and abusive to each other. Staff had not received training in how to deal with this and did not manage this appropriately. There was an example of a serious issue which affected the wellbeing of a service user not been followed though when reported to management. All staff, including the manager requires training in adult protection procedures. Some bathing facilities were not in working order and service users were having to move to other floors to be bathed. Central heating levels need to be monitored to ensure there is an appropriate temperature throughout the home. Thorough checks were not always undertaken during the recruitment process. Training is ongoing for staff; some staff had not yet received essential adult protection training, moving and handling training, NVQ training, care planning and reviewing training. The manager said that training has been booked for all staff. The staff spoken to identified some gaps in their knowledge. Where necessary fire doors must be kept locked/shut and service users assessed, as needing footplates on their wheelchairs, must have them in situ at all times. 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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000021767.V334858.R01.S.doc Version 5.2 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 DS0000021767.V334858.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2 and 3. Standard 6 is not applicable to this home. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each service user had a written contract/statement of terms and conditions with the home. This provided service users with important information that helped them understand what they could expect from the service. Service users did not move into the home without having their needs assessed and been assured that these will be met. This ensured that staff had the information they needed to make a judgement about whether are not they could meet individuals needs. The home did not provide intermediate care. DS0000021767.V334858.R01.S.doc Version 5.2 Page 10 EVIDENCE: Relatives spoken to said they had recently been provided with a contract to sign. Three service users flies were checked all contained a contract detailing their individual terms and conditions. Service users files contained an assessment carried out by a social worker prior to admission to the home. Representatives from the home also carried out an assessment. These assessments were used to inform staff and set in motion the service users care plan. DS0000021767.V334858.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users care plans did not fully detail their emotional, personal and social care needs. This resulted in service users assessed need (in some areas) not being met. In the main service users health care needs were met. This ensured that service users received the support they needed to stay healthy and receive treatment from health care professionals were necessary. Staff training in care planning, reviewing and managing aggression is necessary to ensure that service users needs are recorded, monitored and acted upon effectively. Service users or/and their family and friends were not invited to be involved in the care planning and evaluation process, which would have contributed to ensuring that service users specific needs were met.
DS0000021767.V334858.R01.S.doc Version 5.2 Page 12 Where appropriate service users were able to manage their own medication. There were policies and procedures in place for the management of medication, which protected service users. Service users spoken to said they were treated with respect and their right to privacy upheld. Some of the practices observed did not promote service users dignity. EVIDENCE: Three service user care plans were checked. The standard of the care plans had improved since the last inspection and the staff had clearly made an effort to meet the requirements made at the last inspection. Care plans seen contained a lot of clinical information and lacked sufficient detail of service users emotional and social care needs. The majority of information recorded was given by the nursing staff, which had contributed to them being in a clinical style. Some examples in care plans showed a lack of understanding of the information needed and where it fitted into the care plan format. Reviews were recorded but did not identify where information was lacking, inadequate or inappropriate. One relative said that although they visited the home every day they had not been asked to contribute to the care plan or reviewing process. Staff spoken to gave examples of service users who displayed aggressive behaviour, however care plans didn’t include information on how to manage aggression or the likelihood of this, neither had staff received any training about this. Care plans contained detail of all health care contacts, appointments and treatments, and the home supported access to these to ensure health was maintained. Access to dentists, chiropodists and opticians was available. Two relatives said that they were not always notified of hospital appointments in time to allow them to escort there loved ones. A visiting chiropodist and specialist nurse completed a professional comment card and said that individual’s health care needs were ‘usually and sometimes’ met by the care service and that the care service ‘usually and sometimes’ sought advice to improve individuals health care needs. The inspectors observed that service users were well dressed in clean clothes and had received a good standard of personal care.
DS0000021767.V334858.R01.S.doc Version 5.2 Page 13 Relatives said that the staff were “helpful”, “friendly”, “nice” and “provided a good of standard of care”. Trained staff administered medications in the home. Medicines were securely stored around the home in locked cupboards within treatment rooms. Medicine Administration Records (MAR) checked were completed with staffs’ signatures. Service users said that staff at the home respected their privacy and dignity by knocking on their doors and waiting for a response before entering. During lunch two service users were observed sitting at the same table and being verbally abusive to each other. Staff made no attempt to discourage this, even though it was very apparent that other service users were unhappy and upset by this behaviour. When spoken to about this staff said it was “an every day occurrence”. The manager and staff were unable to verify that any action had been taken or considered to resolve this. Whilst speaking to staff they said that they participated in sexually orientated banter with one service user. The service user did not have full cognitive ability, making this type of discussion even more unacceptable. DS0000021767.V334858.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Social activities both inside and outside of the home were very limited. Service users would benefit from a programme of activities, which suited the capabilities and preferences of the service users. Service users had a choice of lifestyle within the home and were able to maintain contact with family and friends. The home had an open visiting policy, which assisted in maintaining good relationships with service users representatives. Meals served at the home were, in the main, of a good quality and offered choice to ensure service users received a healthy balanced diet. However, the desserts served to diabetics did not offer sufficient variety. DS0000021767.V334858.R01.S.doc Version 5.2 Page 15 EVIDENCE: Service users said that there weren’t enough activities at the home to “pass their time”. One service user said there used to be “knitting and dominoes” but recently there had been “very little to do”. Two service users who spend their time sat in the lounge said they got bored and “the television wasn’t big enough to see properly”. Staff said that they also believed there weren’t enough activities or trips out of the home. There had been no activities worker for a number of months and although staff were trying to “do some activities” they were finding this a struggle, fitting this in alongside their own jobs. Service users social interests and preferences were not recorded in the care plans seen. Relatives were seen freely visiting the home on the day of the inspection. Relatives spoken to said they were able to visit at any time and could see their loved ones in private if they wished. Service users said that they were able to get up and go to bed when they chose to. Staff said they offered service users choices about many things in their daily life, for example, what clothes to wear and when they wanted a bath. The inspectors observed breakfast and lunch being served in three dining rooms. In two of the dining rooms, meals were served in a pleasant relaxed manner and service users were sat at tables, which had been nicely set. Staff asked service users their preferences and some service users were assisted to eat in a supportive way. The ambience in the third dining room was unpleasant for all, due to the way two service users were reacting to each other. Menus seen offered a good variety of choice; kitchen staff interviewed said they were catering for a number of special diets. Diabetic service users were offered mostly yogurt or ice cream for their dessert, which did not provide them with the variety of options available to others. When asked about meals, service users made such comments as “there’s plenty of it”, “the majority of time I’m happy with the food”, “sometimes the meat is tough and the vegetables are hard” and “we always know what’s on the menu but we sometimes forget what we’ve ordered”. DS0000021767.V334858.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures were in place to enable service users and relatives to feel confident that any concerns they voiced would be listened to. Some staff had not been provided with essential training in adult protection, others that had undertaken training still had a limited understanding of abuse and of the procedures to follow if an allegation was made. Adult protection incidents at the home raise concerns about the health, safety and well being of the service users. EVIDENCE: The homes complaints policy was on display in the entrance area of the home. It contained relevant information and informed the reader who to contact external to the home, should the complainant wish to do so. Since the last inspection the home had received one complaint, which had been investigated and found to be partially substantiated and the manager confirmed that action had been taken to resolve the issues identified. DS0000021767.V334858.R01.S.doc Version 5.2 Page 17 This inspection was brought forward following allegations of an adult protection concern at the home. An investigation was underway in relation to this. On the day of the inspection a number of incidents were observed or brought to the attention of the inspectors, which raised concerns of an adult protection nature. Feedback regarding these concerns were given to the homes Registered Manager and the company’s Regional Manager and action was taken to ensure that service users were kept safe. One adult protection concern was reported to the Sheffield Adult Protection Team and an investigation was initiated. An action plan was requested to be forwarded to CSCI detailing the actions the company were taking to address these issues. The action plan was received on 18th April 2007. Since the last inspection a number of the staff had undertaken training in adult abuse. Staff said those who had not completed this training had been given dates to attend in the near future. Some staff that had attended the training were asked about their understanding of adult abuse and were unable to give examples of what might constitute abuse. DS0000021767.V334858.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 20 21 25 and 26. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was clean and generally well maintained providing a pleasant environment for service users. Bathing facilities were insufficient and did not fully meet the individual needs of the service users. The air temperature was not at a level that promoted the service users health and well-being. Controls of infection procedures were in place, however staff had not undertaken training in infection control in order to promote service users health and welfare. DS0000021767.V334858.R01.S.doc Version 5.2 Page 19 EVIDENCE: The home was clean and tidy. Lounge and dining areas were domestically furnished to a good standard. Since the last inspection refurbishment of the home had continued. Carpets and furniture has been replaced and areas of the home had been redecorated. This refurbishment had markedly improved the aesthetics of Balmoral and provided a more “homely” feel to the building. A tour of the building identified that some areas of the home were still in need of decoration. Bedrooms checked were comfortable and homely. Service users said their beds were comfortable and bed linen checked was clean and in a good condition. Service users said they “liked their bedrooms” and some said they “had lots of space”. One relative said that there was “dust and litter under some of the beds” and another relative said, “the mirrors in the bedrooms were to high for some service users”. Some of the specialist bathing facilities had started to undergo refurbishment, however staff were transporting people to other parts of the home for them to bathe. This was not upholding people’s dignity. The air temperature in the home was uncomfortably warm. A relative said at times the heat was “unbearable” and service users said they were “very uncomfortable” in the heat. The company therefore must look into why the heat is so high and take action to rectify the problem. Controls of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. Some domestic staff and those working in the kitchen had not received training in infection control. DS0000021767.V334858.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff were employed in sufficient numbers to meet the service users needs. Recommended levels of NVQ trained staff had not been achieved and staff had not received all mandatory training and refreshers, which did not ensure staff had the competencies to meet the service users needs. There remained a number of shortfalls in the details held and recorded in staff recruitment files, therefore not ensuring the protection of service users. EVIDENCE: The homes rota indicated that agreed levels of staff were being maintained to meet the needs of service users. In the main service users and relatives spoken with felt that enough staff were provided. One service user said that staff were “worked off their feet”’ another service user said “help is always there if we need it” and another said” when staff have time they listen to us”. One relative said that staff “needed reorganising as some were always busy and others were hanging around”. Staff said they worked well as a team helping each other out when necessary.
DS0000021767.V334858.R01.S.doc Version 5.2 Page 21 Of the 32 care staff, 8 staff had achieved NVQ level 2 in care. This falls well below the recommended 50 of the care staff trained to NVQ level 2 in care by 2005 to ensure the staff team were qualified and competent to carry out their duties. Three staff records were checked. The files contained enhanced Criminal Record Bureau (CRB) checks, evidence that ID had been checked, personal details and two written references. However in two files, gaps in employment records had not been explored or explained and employment histories were very brief. There was no photograph in any of the three files seen and in one file a reference had not been sought from the previous employer. The manager said that there was a training and development plan for the staff. Staff said they were encouraged to attend training on various core topics but this training was on an adhoc basis. Staff said that they had undertaken training in topics such as Moving and Handling, COSHH, Fire and Health and Safety, staff also said they were due refreshers in various subjects. Some care, kitchen and domestic staff spoken to said they would welcome further training, including NVQ. DS0000021767.V334858.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users were not overall, benefiting from the leadership and management approach of the home at this point, even though it is acknowledged that the manager was very experienced. The service users health and safety had not been promoted and protected in several areas. DS0000021767.V334858.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager is a registered nurse with previous management experience in residential care settings. The manager was co-operative with the inspectors and responded to all requests for information. Staff spoken to said they were able to speak to the manager about any issues of concern and she would assist them, however she was referred to as “office based” and “isn’t hands on”. There was an example of a serious issue which affected the wellbeing of a service user not been followed though when reported to management. The number of and the severity of the issues raised in this report demonstrate that current management arrangements were not organised and there was little evidence of direction. The care given to the service users did not meet the full range of health care needs. At present the home is not meeting the service users needs in an acceptable manner. Some policies and procedures were not being followed which was not consistent and put service users at risk from harm. The manager stated that quality assurance visits by the registered provider had been carried out each month, as required by the regulations. Reports were seen in the home for visits that were undertaken. Since the inspection CSCI have clarified with the provider that these reports must be forwarded to the CSCI Sheffield office. Informal supervision took place on a daily basis. However, formal staff supervision, to support and enhance staff skills did not take place. Whilst walking around the home the inspectors noted that doors marked “Fire door must be kept locked shut” had been left unlocked and with the key in the door. The cupboard containing the central heating boiler had also been left unlocked. The equipment at the home was serviced and maintained. Fire records evidenced that weekly fire alarm checks took place. Staff said fire drill training took place on a regular basis. The majority of service users had footplates fitted to their wheelchairs. One service user did not have footplates fitted, in her/his care plan it was clearly recorded that she/he must use footplates at all times. Some staff said that they had not received updated training in moving and handling and non care staff said they had never received training in moving and handling. DS0000021767.V334858.R01.S.doc Version 5.2 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 3 2 X X X 2 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 DS0000021767.V334858.R01.S.doc Version 5.2 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. Standard OP7 Regulation 15 Requirement Care plans must contain sufficient detail to ensure that service users receive a consistent high standard of care. Including emotional, personal and social care needs. Service users and/or their representative must be involved in the care planning and reviewing process. Staff must receive training, which is appropriate to their work role. This must include training in care planning, reviewing, appropriate communication, managing aggressive behaviour, infection control and moving and handling. Where necessary, service users behaviour must be monitored and reviewed to ensure their behaviour does not have a negative impact on other service users. Timescale for action 01/07/07 2. OP7 15 01/07/07 3. OP7 OP10 OP18 OP38 OP30 OP26 18 01/10/07 4. OP10 13 01/07/07 DS0000021767.V334858.R01.S.doc Version 5.2 Page 26 5. OP12 16 Service users must be consulted regarding the variety of activities offered. Further activities and trips out of the home must be provided, to ensure that service users social and recreational needs are met. 01/07/07 6. OP14 16 Service users requiring a diabetic 01/07/07 diet must be offered a wider variety of options. All staff, including the Registered 01/07/07 Manager must be trained in adult protection procedures. There must be a system in place to ensure that staff have a clear understanding of adult abuse and their own roles and responsibilities in ensuring that service users are kept safe. Bathing facilities, that are upholding with peoples privacy and dignity must be provided. Central heating levels must be maintained at an appropriate temperature, throughout the home at all times. 50 of care staff must be trained to NVQ level 2 in care. Previous timescale 18/10/06 and 01/01/07 not met. A thorough recruitment procedure must be in operation, therefore: All gaps in employment history must be explored. Photographs must be placed in each file. A reference must be sought from the previous employer. Improvements must be made in
DS0000021767.V334858.R01.S.doc 7. OP18 18 8. OP18 18 01/07/07 9. OP21 23 01/07/07 10. OP25 23 17/04/07 11. OP28 18 01/07/07 12. OP29 19 17/04/07 13. OP31 9 17/04/07
Page 27 Version 5.2 OP33 17 26 how the home is run, therefore the manager/provider must: Ensure that a thorough check is made of all aspects of the service provision following his monthly monitoring visits to the home. Action all the requirements issued within the timescales identified. Staff must receive formal supervision at the required frequency of 6 times a year. Previous timescale 18/10/06 and 01/12/06 not met. 01/07/07 14. OP36 18 15. OP38 13 The health, safety and welfare of 17/04/07 all service users must be promoted and protected at all times, therefore: Where instructed, fire doors must be kept locked/shut. Service users risk assessed as requiring footplates on their wheelchairs must have footplates in situ at all times. 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 OP29 Good Practice Recommendations Records should be organised in a way, which allows information to be easily retrieved. DS0000021767.V334858.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000021767.V334858.R01.S.doc Version 5.2 Page 29 - 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!
