Inspection on 24/05/07 for Beechy Knoll

This inspection was carried out on 24th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Beechy Knoll 19/05/08

Beechy Knoll 05/06/06

Beechy Knoll 10/11/05

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Beechy Knoll 378 Richmond Road Sheffield South Yorkshire S13 8LZ Lead Inspector Diane Wilkinson Key Unannounced Inspection 09:30 24th May 2007 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 DS0000065505.V331721.R02.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. DS0000065505.V331721.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechy Knoll Address 378 Richmond Road Sheffield South Yorkshire S13 8LZ 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) 0114 239 5776 0114 264 6063 beechyknoll378@yahoo.co.uk Pearlcare (Richmond) Ltd Mrs Wendy Barnes Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places DS0000065505.V331721.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The minimum numbers of care staff on duty must comply with that required by the `Residential Forum - Care Staffing in Care Homes for Older People`. 5th June 2006 Date of last inspection Brief Description of the Service: Beechy Knoll is a privately owned care home that provides care and accommodation for forty older people of both sexes. It is situated in a residential area of Sheffield, close to local amenities and bus routes. The home is built over two floors and all areas of the home are accessible to service users via the use of ramps and a passenger lift. Private accommodation is provided in thirty-three single and three shared rooms; twenty-two bedrooms have ensuite toilet facilities. Communal accommodation is provided in a variety of lounges, dining areas and a conservatory. Seating is provided in the home’s gardens and there is a small car park available for staff and visitors to the home. A copy of the previous inspection report was 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 accommodation fees from April 2007 ranged from £308 - £340 per week and there is an additional charge for hairdressing, diala-ride and private chiropody. DS0000065505.V331721.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last inspection of the home, from the pre-inspection questionnaire provided by the registered manager and from the site visit on the 24th May 2007. This unannounced site visit is part of a key inspection and was undertaken by one inspector over one day; the site visit commenced at 9.30 am and finished at 4.15 pm. The site visit consisted of a tour of the premises and examination of documentation, including four care plans. On the day of the site visit the inspector spoke on a one to one basis with several residents, as well as two members of staff and the registered manager. Prior to the day of the site visit surveys were sent out to five health care professionals, five service users and five members of staff. Five were returned by service users and two were returned by health care professionals. On the day of the site visit, the inspector asked the registered manager to remind the staff to return their surveys to the CSCI. Comments from surveys and from discussions with service users and staff were positive, such as these comments from health care professionals, ‘Residents always appear clean and tidy and usually contented with Beechy Knoll’ and ‘The staff in Beechy Knoll always ask for advice and support’. Such comments will be included throughout the report (anonymously). The inspector would like to thank service users, staff and the registered manager for their assistance on the day of the site visit, and to everyone who responded in a survey. What the service does well: Service users are assessed prior to their admission to the home and only offered accommodation if their assessed needs can be met. Service users and health care professionals express satisfaction with the care provided by staff at the home and speak highly of the staff group. One health care professional said, ‘I regularly visit Beechy Knoll to attend to residents health care needs. The staff always seek advice from me if they have any concerns about residents’. Service users express satisfaction about the meals provided by the home. Beechy Knoll provides a pleasant homely environment for the people who live there, with good standards of cleanliness and decor throughout the home. DS0000065505.V331721.R02.S.doc Version 5.2 Page 6 The home is well organised and managed, and staff state that they are well supported. The inspector observed that there was a good rapport between service users, staff and managers. The registered manager informed the inspector that staff are paid at ‘time and a half’ if they work additional shifts and that they receive a bonus at the end of the month if they achieve full attendance. The recording of accidents is monitored via the use of a separate monitoring form to enable the registered manager to identify any specific areas of concern. What has improved since the last inspection? What they could do better: Recruitment practices are not robust and this could result in staff that are not suitable to be working with vulnerable adults being employed at the home. The laundry room was not tidy on the day of the site visit and was being used as a storage area. This must be kept clear of clutter so that it is easy to be kept clean and hygienic. DS0000065505.V331721.R02.S.doc Version 5.2 Page 7 The written statement of the policy, organisation and arrangements for maintaining safe working practices, including risk assessments, needs to be reviewed and updated. This would evidence that the health, safety and welfare of service users and staff is being protected. 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. DS0000065505.V331721.R02.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 DS0000065505.V331721.R02.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): 3 and 5. Standard 6 was not assessed as there is no intermediate care provision at the home. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are only admitted to the home following a full assessment that evidences that their current care needs can be met. EVIDENCE: The inspector examined the records for two newly admitted service users. These included a full needs assessment that had been completed by the home, as well as various risk assessments that included general mobility, the risk of falls and ‘the risk of walking around without a frame’. In addition to the assessment undertaken by the home, community care assessments completed by Care Management had been received for those service users funded by the local authority. DS0000065505.V331721.R02.S.doc Version 5.2 Page 10 The inspector observed in these records and in the records of other service users that a pre-admission assessment is completed by the home prior to the initial assessment. The initial assessment undertaken by the home, and information gathered from other sources, is used to form the basis of an individual care plan. On the day of the site visit, the inspector saw a prospective service user and their relatives having a look around the home and meeting staff. DS0000065505.V331721.R02.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): 7, 8, 9, 10 and 11. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of service users are met in a way that respects their privacy and dignity. The arrangements for the administration of medication are not robust and could pose a risk to service users. EVIDENCE: The inspector examined the records for four service users. These evidenced that an individual care plan has been developed for each service user apart from the service user admitted during the last few days. Each care plan now includes a thorough explanation of a service user’s daily routine and the assistance required by staff. Entries in daily information forms are made each day; the inspector recommends that staff make an entry for each shift rather than once a day, so that diary notes are a true reflection of how service users spend their day, including meals taken, visitors seen, personal care tasks undertaken and any activities undertaken. Monthly reviews of the care plan DS0000065505.V331721.R02.S.doc Version 5.2 Page 12 take place and dependency profiles are updated on a monthly basis. Records in some service user files evidence that care plans have been reviewed by the placing local authority. Some records, but not all, include a photograph; a photograph is needed in care plans to assist new staff with identifying individual service users and in the event of a service user going missing. The inspector observed a medical emergency on the day of the site visit and noted that this was dealt with quickly, professionally and sensitively by staff. The inspector spoke to several service users at the time of the site visit. All spoke highly of the care provided by staff and said that medical help is sought as needed. All accidents are recorded on accident record forms - the inspector recommends that details of any accidents should be recorded in a service user’s care plan as well as on accident forms. All contact with GP’s and other health professionals is recorded in a separate book; this information should be cross referenced to care plans so that a full picture of a person’s health and social care is available in one place. Pressure care is managed appropriately and service users have been provided with pressure care equipment; they also receive satisfactory assistance with any continence needs. One health care professional said, ‘I regularly visit Beechy Knoll to attend to residents’ health care needs. The staff always seek advice from me if they have any concerns about residents’. On the day of this site visit to the home, the inspector observed the administration of medication; this was done in a safe and hygienic manner. Medication was stored safely and there are appropriate facilities in place for the storage and administration of controlled drugs. Each member of staff that administers medication has undertaken medications training; two staff have undertaken accredited training and the remaining staff have undertaken training with the Pharmacist used by the home. In addition to this, staff undertake an in-house training programme and are not allowed to administer medication until they are considered to be competent by the person assessing them. All staff that administer medication should attend accredited medications training. Sample signatures are recorded to enable medication administration records to be checked. The inspector reminded the registered manager that staff should sign medication administration records after service users have taken medication, not when it is taken from the medication trolley. Service users may refuse medication when it is offered to them and medication administration records would need to be altered. Unused or discontinued medication is returned to the Pharmacist; the inspector saw documentation confirming this. The inspector identified one concern regarding the incorrect recording of controlled drugs (delivery and returns); this was an issue regarding a lapse in recording rather than administration of medication and was rectified on the day of the site visit. Some medication is DS0000065505.V331721.R02.S.doc Version 5.2 Page 13 stored in a fridge in the medications room – fridge temperatures are recorded, although this recording has not been consistent in recent months. The inspector observed that service users were treated with respect and that their right to privacy was upheld. A health care professional stated in the survey, ‘Staff always close the toilet door when taking residents to the toilet’. Staff were seen to knock on doors before entering and were observed to speak to service users with patience and understanding. Most service users have a single room and are able to see health and social care professionals and their visitors in private. There are also private areas of the home where meetings can take place. The inspector saw written evidence in all records examined that service users and/or their families have been consulted about their wishes in the event of their death. The registered manager has made particular efforts to obtain this information when it has not been given to the home by service users, including those service users who are from a different cultural background. DS0000065505.V331721.R02.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): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported to live their chosen lifestyle and to take part in activities both inside and outside of the home. Meal provision at the home is good. EVIDENCE: The inspector observed that care plans seen on the day of the site visit included details of a person’s previous lifestyle and interests. Service users confirm that they are able to exercise their choice in relation to routines of daily living including where to spend their day, where to take their meals and about taking part in social activities. Service users told the inspector that there is an activities coordinator employed on three days per week and that they take part in craft work sessions, bingo and quizzes, and that the activities coordinator also spends one to one time with some service users. Service users said that two different service users go out every week with the activities coordinator, usually to one of the local shopping centres. DS0000065505.V331721.R02.S.doc Version 5.2 Page 15 The activities coordinator records all activities undertaken and which service users have taken part in an activities record book. The inspector recommends that this information should be cross-referenced to care planning records to provide a full picture of how service users spend their day. The inspector observed that routines at the home were relaxed and that service users were supported and encouraged to maintain their level of independence. Most service users have their own TV in their bedroom so that they are able to watch programmes of their choice whenever they wish to do so. Service users told the inspector that they have regular visitors and that their visitors are made welcome. The inspector observed on the day of the site visit that staff had a good rapport with visitors and relatives. The registered manager informed the inspector that service users were assisted to undertake a postal vote in the recent elections, and that two service users were taken by staff to the polling station as they wished to vote in person. The inspector advised the registered manager to obtain information about local advocacy services to be displayed in the home should it be needed by service users or their relatives. The registered manager informed the inspector that she has downloaded the latest advice from the CSCI website about nutrition for older people, and that service users were consulted at a resident’s meeting about the choices they would like to see on the menu. The registered manager supplied a copy of the menu for two weeks along with the pre-inspection questionnaire, and the inspector observed that these offer a choice at each mealtime. On the day of the site visit, the inspector observed the serving of lunch and noted that service users had a choice of two main meals. Service users told the inspector that they are asked each morning what they would prefer for lunch, and that there is also a choice of meal at breakfast time and teatime. Service users told the inspector that they have ample amounts of food to eat, that they are offered fresh fruit on the tea trolley every day and that they are offered a snack with their supper. Some service users choose to take meals in their room but most service users have their meals in one of the dining areas. The inspector observed that service users were assisted appropriately to eat their meals and that staff provided service users with a relaxed and pleasant atmosphere so that they could enjoy their lunch at a leisurely pace. DS0000065505.V331721.R02.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): 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Most service users know who to speak to if they have any concerns, and complaints received by the home are dealt with in a satisfactory manner. Staff are aware of, and follow, safeguarding adults policies and procedures; this protects service users from the potential to be abused. EVIDENCE: The inspector observed on the day of the site visit that the complaints policy and procedure is displayed in the entrance hall, along with a form to be completed should people wish to make a complaint. The inspector examined the complaints log and noted that complaints are recorded appropriately. The CSCI have received one complaint since the last inspection of the home and full details of this were recorded in the complaints log; this records the date, details of the complaint and the outcome of the complaints investigation. Some service users told the inspector that they were not sure about how to make a complaint but others said that they knew how to do so; all said that they would speak to staff members if they had any concerns. There is also a suggestion box situated in the entrance hall. The inspector examined the staff training plan and noted that most staff have now completed training on safeguarding adults. In conversation with members of staff, the inspector noted that they had an understanding of safeguarding DS0000065505.V331721.R02.S.doc Version 5.2 Page 17 adults and whistle blowing policies, procedures and practices. The registered manager told the inspector that she has undertaken safeguarding adults training designed specifically for managers, and that the home’s policy has recently been reviewed. Evidence of this was seen on the day of the site visit. DS0000065505.V331721.R02.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): 19 and 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides service users with attractive, comfortable, clean and wellmaintained accommodation. EVIDENCE: The home is comfortably and attractively decorated and furnishings are of a high quality. The grounds are kept tidy, safe, attractive and accessible to service users and allow ample access to sunlight; all lounge areas look out over the garden area and there is a conservatory at the rear of the building. DS0000065505.V331721.R02.S.doc Version 5.2 Page 19 There is no maintenance programme in place but maintenance sheets are used to record all minor repairs that are identified by staff during their day-to-day work. The registered manager informed the inspector that she or a team leader checks that this work has been undertaken by the handyman used by the home. A service chart has been set up to record the dates when equipment needs to be serviced. However, information on the chart has not been kept up to date so this does not assist in evidencing that equipment is well maintained. The premises were clean and hygienic on the day of the site visit. The staff rota evidences that there are two or three domestic staff on duty each day, with an additional two hours domestic work being provided in the evenings. All five service users that completed a survey reported that the home is always fresh and clean. There had been some concerns about stained carpets at the last inspection of the home; the rooms concerned were shown to the inspector and it was noted that all carpets have been cleaned and have minimal staining. There was a slight odour in one bedroom but this situation was being managed appropriately; there were no odours in communal areas of the home. The inspector saw laundry facilities and these were found to meet required standards and service users told the inspector that they are satisfied with the laundry service provided by the home. There are no separate hand washing facilities provided for staff in the laundry room; this results in the risk of cross infection. Some staff have undertaken training on infection control and the registered manager showed the inspector a new training pack that has been purchased to enable the home to offer training or refresher training for staff. The inspector observed that staff used disposable gloves and aprons whenever assisting service users with personal care or handling laundry. The inspector noted that the laundry room is being used as a store room and that this makes the room difficult to keep clean and hygienic - the registered manager agreed to ask staff to tidy this room. DS0000065505.V331721.R02.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): 27, 28, 29 and 30 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Well-trained staff are employed in sufficient numbers to ensure that the needs of service users accommodated at the home can be met. Recruitment practices do not ensure that only people who are safe to work with vulnerable people are recruited. EVIDENCE: On the day of this site visit the inspector observed that there are three staff rotas in place, one for day care staff, one for night staff and another for ancillary staff. However, the role of each member of staff is not identified on the rota and this addition would make it easier to identify any shortfalls on the rota. The inspector observed that the staff recorded on the rota were actually on duty, and that the rota now evidences that sufficient domestic and catering staff are employed; this enables care staff to concentrate on care duties. In response to the question in the survey, ‘Are the staff available when you need them?’, three service users responded ‘always’ and two responded ‘usually’. The registered manager informed the inspector that staff are paid at ‘time and a half’ if they work additional shifts and that they receive a bonus at the end of the month if they achieve full attendance; this is good practice. DS0000065505.V331721.R02.S.doc Version 5.2 Page 21 Eighteen care staff have achieved NVQ Level 2 or 3 in Care. A further three care staff are currently enrolled on this training programme and this should ensure that the home is able to maintain the requirement for 50 of care staff to have achieved this award. Information sent to the inspector in the pre-inspection questionnaire records that there is a low turnover of staff. This was confirmed by staff spoken with on the day of the site visit. The inspector examined the recruitment records for recently employed staff. These evidence that an application form is used and that this records a person’s employment history, but does not record the dates of these periods of employment. This makes it difficult for the registered persons to explore any gaps in employment history and this could result in unsafe recruitment. A CRB check or POVA first check and two written references are obtained prior to staff commencing work at the home in most instances. There was one instance where a CRB check had been received a few days after the person had commenced work at the home. The registered manager said that she believed that the organisation had obtained a POVA first check for this person, but there was no evidence available to support this. On another occasion, the form used to record the second reference was blank; the registered manager informed the inspector that this was an oversight – the person giving the reference worked at the home and had given a good verbal reference but had forgotten to complete the details on the form, and it had been filed away in error. The registered manager is reminded that a satisfactory CRB check (or POVA first check in exceptional circumstances) and two written references must be in place prior to staff commencing work at the home. Some other references were not dated and this could lead to confusion – the letter sent by the home to request a reference should be dated and the response received by the home should also be dated. Photocopies of documentation confirming a person’s identity are retained and some of these include photographs. The inspector observed that information about induction training is retained in individual staff records. However, this is very brief and should be more detailed to evidence the areas covered by staff to prepare them for their role at the home. Individual records are held of the training achievements of staff, including copies of training certificates, and there is a training and development plan in place. This evidences that staff undertake health and safety training such as fire awareness, first aid, health and safety and moving and handling. Most staff have undertaken the ‘accountable person’ first aid training that is valid for three years; this is not yet due for renewal. Some other training may be out of date; it was difficult to determine if fire training had taken place and had not been recorded, or if this training was overdue. The training and development plan that is in place should be kept up to date otherwise it could result in staff not being trained in current practices and not having access to the most recent information. DS0000065505.V331721.R02.S.doc Version 5.2 Page 22 As previously stated, the registered manager has purchased a training pack on infection control and all staff are due to undertake this training, or have refresher training, shortly. DS0000065505.V331721.R02.S.doc Version 5.2 Page 23 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): 31, 33, 35 and 38 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well-managed and service users and others are able to affect the way that the home is operated. The health, welfare and safety of service users and staff are protected, with the exception of recruitment practices and the recording of safe working practice topics. EVIDENCE: The registered manager has completed both NVQ Level 4 in Care and the Registered Manager’s award. She informed the inspector that she keeps her practice up to date by using the CSCI website and by attending refresher training; she is due to attend first aid and fire safety training this year. DS0000065505.V331721.R02.S.doc Version 5.2 Page 24 The quality assurance systems at the home have been further developed. Staff meetings and residents meetings take place; the inspector saw minutes of both meetings. Staff told the inspector that they are able to make suggestions at these meetings and that any concerns or ideas are listened to. The registered manager informed the inspector that questionnaires have been given or sent out to service users and relatives. The outcome of these questionnaires has been collated and participants have been given feedback – some relatives were spoken with on a one-to-one basis, and a notice recording the outcome of the survey was placed on the home’s notice board. Verbal feedback was given to residents; the inspector recommends that this feedback could be given to residents at a residents meeting; this allows the feedback to be recorded and shared with all service users in the minutes of the meeting. The registered provider makes visits to the home under Regulation 26 of the Care Homes Regulations 2001 – records of these were seen by the inspector. In addition to this, the registered manager undertakes a monthly inspection of the home and completes a ‘manager’s monthly inspection’ form. This includes checks on cleanliness, maintenance and fire safety. The recording of accidents is monitored via the use of a separate monitoring form; this is good practice. The inspector saw evidence that some policies and procedures had been updated in line with good practice guidelines and following recommendations from an independent company used by the home. Some service users hold their own money and the registered manager informed the inspector that all service users have a locked drawer where they can hold this money safely. Family and friends hold monies on behalf of most service users, but personal allowances are held on behalf of some service users. The inspector checked the records held for four service users against balances of monies held and all were found to be correct. Receipts are given to friends and relatives when they hand over money to the home, and receipts are obtained for any monies spent on behalf of service users. All health and safety documentation was examined by the inspector on the day of the site visit, including service certificates and fire records; this information is now well organised and readily available. In-house fire tests take place on a regular basis and the fire alarm system had been tested by a contractor in November 2006. There is a current landlord’s gas safety certificate in place. No fire doors were held open using unauthorised means on the day of the site visit. Water temperatures at outlets accessible to service users have been tested each month – these records were seen by the inspector and they evidence that water temperatures are maintained at an acceptable level to protect service users from the risk of scalding. Records evidencing that the water tanks had DS0000065505.V331721.R02.S.doc Version 5.2 Page 25 been cleaned and chlorinated in March 2007 were seen on the day of the site visit. The registered manager has provided a written statement of the policy, organisation and arrangements for maintaining safe working practices, including risk assessments. However, this documentation is now out of date and needs to be reviewed and updated to be effective. As previously recorded, the recruitment and selection of staff employed at the home must be more robust to ensure that the health and welfare of service users is protected. There are risk assessments in place for the control of substances hazardous to health (COSHH) and the inspector observed that all substances are stored in the locked laundry room. The registered manager informed the inspector that all domestic staff have undertaken COSHH training. At the last inspection of the home, it was noted that staff did not move service users in a safe manner. On the day of this site visit, the inspector did not see any unsafe manual handling practices and noted that most staff have undertaken moving and handling training; some new staff have not yet done this training but it is in the process of being organised. DS0000065505.V331721.R02.S.doc Version 5.2 Page 26 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 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 DS0000065505.V331721.R02.S.doc Version 5.2 Page 27 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 OP29 Regulation 19 Requirement Staff files must contain all of the required information, including: Photographs; Dates of all previous employment; Evidence that gaps in employment history have been explored. (Previous timescales of 31/01/06 and 01/08/06 not met). Two written references and a CRB check or POVA first check must be in place prior to staff commencing work at the home. Full details of a person’s induction training should be held at the home. The written statement of the policy, organisation and arrangements for maintaining safe working practices, including risk assessments, needs to be reviewed and updated. Timescale for action 31/07/07 2. OP29 19 24/05/07 3. 4. OP29 OP38 18 13 24/05/07 31/07/07 DS0000065505.V331721.R02.S.doc Version 5.2 Page 28 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. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Refer to Standard OP7 OP7 OP7 OP9 OP9 OP9 OP12 OP14 OP19 OP26 OP27 OP29 OP30 Good Practice Recommendations A care plan should begin to be developed for service users at the time of their admission. Any accidents that have occurred and any visits from health care professionals should be cross referenced to care plan records. Diary notes should include an entry for each shift, rather than each day. Temperatures should be taken and recorded for the medication fridge consistently. All staff that administer medication should undertake accredited training. Staff should sign administration records when service users have taken their medication, not when it is taken from the medication trolley. Any activities undertaken by service users should be cross referenced to their care plan, in addition to being recorded in the activities record book. Information about advocacy services should be made available for service users and others. There should be a maintenance programme in place. The service chart used by the home should be used consistently to achieve its purpose. The laundry room should be tidied up to ensure that it can be kept clean and hygienic. Hand washing facilities should be available for staff in the laundry room. The role of each member of staff should be recorded on the rota. Reference requests and responses should be dated. The training and development plan should be kept up to date to avoid any confusion over the need for refresher training. DS0000065505.V331721.R02.S.doc Version 5.2 Page 29 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 DS0000065505.V331721.R02.S.doc Version 5.2 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. 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