Inspection on 28/11/07 for Birchdale

This inspection was carried out on 28th November 2007.

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

Birchdale 10/11/08

Birchdale 22/05/08

Birchdale 04/07/07

Birchdale 21/07/06

Birchdale 18/10/05

Birchdale 03/06/05

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 Birchdale 6 Tennyson Avenue Bridlington East Yorkshire YO15 2ES Lead Inspector Diane Wilkinson Unannounced Inspection 28th November 2007 10:00 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 DS0000062588.V355908.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. DS0000062588.V355908.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birchdale Address 6 Tennyson Avenue Bridlington East Yorkshire YO15 2ES 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) 01262 676275 01262 674908 birchdale@pcslimited.net Pennine Care Services Ltd. Ms Julie Dawn Pearson Care Home 25 Category(ies) of Dementia (25), Old age, not falling within any registration, with number other category (25) of places DS0000062588.V355908.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP and Dementia - Code DE The maximum number of service users who can be accommodated is: 25 4th July 2007 2. Date of last inspection Brief Description of the Service: Birchdale is a care home that is owned by a small private company. It is situated in a period property in the centre of Bridlington, in the East Riding of Yorkshire. The home is in close proximity to local amenities including transport, shops, health care and leisure facilities. It is registered to provide care for a maximum of 25 older people, including those with dementia. Private accommodation is provided over three floors in nineteen single rooms and three shared en-suite rooms, with access via a passenger lift to the upper floors. Communal accommodation is provided in two lounges and a dining room, and a conservatory is currently being built. There is a small courtyard style garden at the rear of the property, which has been made accessible to service users. Wheelchair access to the home is provided via a permanent ramp to the main entrance. Information about the home is provided in a statement of purpose, a service user’s guide and a brochure; these inform service users and others about the scope and nature of the care and facilities on offer. The registered manager told us that fees charged are between £286.00 and £390.00 per week, and that chiropody, hairdressing, transport and outings/holidays are not included in this fee. DS0000062588.V355908.R01.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 Key Inspection of the home on the 4th July 2007, including information gathered during a site visit to the home. The unannounced site visit was undertaken over one day; it began at 10.00 am and ended at 4.00 pm. On the day of the site visit we spoke with several residents and the manager on a one to one basis, and chatted to other residents and staff. Inspection of the premises and close examination of a range of documentation, including four care plans, were also undertaken. The manager submitted information about the service in advance of the site visit by completing and returning an Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service, as well as giving us some numerical information about the service. Survey forms were sent out as part of the inspection; one was returned by a resident, two were returned by relatives, four were returned by staff and two were returned by care managers. Comments from returned surveys and from discussions with service users, staff and others varied, such as, ‘If service users wish to go out, staff support is available to enable this to happen on a regular basis’ and ‘I have concerns about the training of both the manager and the staff’. Comments from surveys and from discussions on the day of the site visit will be included, anonymously, throughout the report. In order to improve the way the Commission for Social Care Inspection involves and engages with people who use services, someone with knowledge about residential care provision known as an ‘Expert by Experience’ assisted with this inspection visit. This person, Gill Perks, spoke to people living in the home and staff working in the home, and looked around the home with the inspector. In addition to this, she had lunch with the residents. Following her visit to the home, the ‘Expert by Experience’ prepared a report for the CSCI and information from the report was used in the preparation of this key inspection report. DS0000062588.V355908.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The fire door between the kitchen and the corridor has been made safe, protecting residents and staff. Medication is now stored safely, including controlled drugs. Some bedrooms have been refurbished and most include the furniture and fittings required by regulation. The new conservatory is almost ready to be used by residents. The manager is now registered with the Commission for Social Care Inspection. Monies held on behalf of residents are now recorded accurately. This protects residents from the potential to be financially abused. The home is now fully staffed, including catering and domestic staff. This enables care staff to concentrate on care duties and reduces the risk of cross infection. Staff recruitment policies and procedures have improved; only staff that are safe to work with vulnerable people are employed. Most equipment and appliances at the home are now maintained and serviced appropriately and in-house checks of the fire alarm system and of water temperatures are carried out on a regular basis. This has improved safety levels for residents. DS0000062588.V355908.R01.S.doc Version 5.2 Page 7 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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000062588.V355908.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 DS0000062588.V355908.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): 3. Standard 6 was not assessed, as there is no intermediate care provision at the home. 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. Residents are assessed prior to their admission to the home and only admitted if it is considered that their assessed needs can be met, but there is some delay in the development of an individual care plan. EVIDENCE: The inspector checked the care records for a newly admitted resident. The registered manager told the inspector that the deputy manager and herself had visited this person in hospital prior to them being transferred to the home for a period of respite care. A thorough needs assessment had been completed at this stage and this was seen by the inspector. The assessment includes risk assessments for pressure care, nutrition, safety and moving and handling. DS0000062588.V355908.R01.S.doc Version 5.2 Page 10 A meeting had recently taken place between the resident, their family, the care manager and staff from the home, when it had been agreed that the resident would remain at the home on a permanent basis. The examination of records and discussions with residents and staff evidenced that most residents have respite care at the home prior to considering permanent care. A Social Services care plan had been obtained from the resident’s care manager and this was being used, along with the homes own assessment, as the resident’s individual care plan. The registered manager told the inspector that they had not started to develop their own plan of care as yet. As the resident had been at the home for two weeks, the inspector advised the registered manager that they should have started to develop a care plan. DS0000062588.V355908.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): 7, 8, 9 and 10. 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 health and personal care needs of residents are met in a way that respects their privacy and dignity but people are not involved in the development of their care plan and care planning documentation is disorganised; this could lead to confusion for staff who are providing care for residents. The storage of medication has improved but recording systems and staff training are not robust enough to ensure the safety of residents. EVIDENCE: The inspector examined the care records for four residents; these records included a photograph apart from for the resident who had only lived at the home for two weeks. Care plans were based on the assessment undertaken by the home and, in some instances, community care assessments/care plans provided by care management. Care plans had been reviewed formally by care management, and records evidenced that residents attended their review if they wished to do DS0000062588.V355908.R01.S.doc Version 5.2 Page 12 so. A care manager recorded in a survey when asked about care assessments, ‘Not really completed at time of reviews’. This may have referred to the completion of information requested by care management in preparation for annual reviews. There is no evidence that residents have been involved in the care planning process. All of the care plans examined by the inspector included a manual handling assessment, but forms placed in care plans intended to record risk assessments about falls and fractures had not been completed in some instances. Risk assessments for nutrition and pressure care that were seen at the last key inspection of the home were not seen in the care plans examined on the day of this site visit. Some residents had been weighed as part of nutritional screening but others had not; this needs to be consistent to serve any purpose. Some more specific risk assessments had been completed for some residents but not for others. Examples of these are ‘dizziness’ and ‘use of the stairs’. In some care records there is a copy of an ‘old’ care plan and a ‘new’ care plan being used side by side. The registered manager told the inspector that a new care plan is being devised; the inspector advised that these should be implemented as soon as possible to ensure that a person’s current care needs are recorded and that staff are using the latest version of the care plan to ensure that a person’s current needs are being met. Staff record a daily account of the care provided to residents, including any concerns about pressure care and continence care. However, daily diary sheets in general were found to be disorganised. Some other documentation that was in place in care plans served little purpose, as it had only been used spasmodically. For example, a checklist recording ‘full bed change, part bed change, hair brushed and walking aid checked for faults’ had ten entries for walking aid checks but only one entry for ‘hair brushed’. The registered manager was advised that this documentation must be used consistently or not at all, as the information recorded is misleading and could lead to allegations of neglect. Reports completed by key workers were also found to be inconsistent; some had not been completed since December 2006. The registered manager told the inspector that she believed that all documentation in care plans was up to date; a monitoring system should be set up to ensure that care planning documentation is always up to date. Visits from health care professionals, including the reason for the visit and any outcome, are recorded in individual care plans. The inspector observed the administration of medication by the care supervisor on the day of the site visit. Residents were provided with a drink with which to take their medication and medication records were not signed until the staff member had observed that medication had been taken. This member of staff had not undertaken accredited medications training and the registered manager was informed that they should not administer medication at the home until this training had been completed. DS0000062588.V355908.R01.S.doc Version 5.2 Page 13 There was evidence that all other staff that administer medication had undertaken accredited training and the registered manager told the inspector that in-house refresher training has been arranged for these staff. Medication administration records included a list of the names of staff that had completed medications training, but a sample signature had not been included; a sample signature is needed to enable medication records to be checked and monitored. Medication administration records had been completed in a satisfactory manner apart from some omissions of recording when residents refuse medication or medication is not given. The storage of medication has improved. A cupboard has been built in the ‘quiet’ lounge and the medication trolley is stored within the cupboard; this is locked at all times. Separate storage facilities for controlled drugs are provided within the same cupboard. There is a separate record for recording the administration of controlled drugs and records included two staff signatures and a ‘running total’ of medication remaining. The registered manager told the inspector that, when medication details are added to medication administration records by staff, for example, when antibiotics have been prescribed, staff have been told that there must be two staff signatures to evidence that the details have been double checked. The inspector noted that some of these entries had been signed by only one member of staff. The registered manager must have monitoring systems in place to ensure that policies, procedures and practices are followed by staff. There is no separate fridge for the storage of medication that requires a cool temperature, such as antibiotics. Ideally, a separate fridge should be provided for the storage of such medication; temperatures would have to be taken and recorded on a daily basis. The inspector observed that staff respected the privacy and dignity of residents. They used the resident’s preferred name and knocked on doors before entering. The registered manager informed the inspector that staff are told about privacy and dignity as part of their induction training and when undertaking National Vocational Qualification (NVQ) training. Staff were seen to talk to residents sensitively regarding personal care needs. There are now two male care workers employed at the home and this enables male residents to be assisted with personal care tasks by someone of the same gender if they so wish. DS0000062588.V355908.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): 12, 13, 14 and 15 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. Residents are supported to make choices about their day-to-day lives and to live their chosen lifestyle; visitors to the home are made welcome. Meal provision at the home is satisfactory but would be improved by staff offering more assistance, a menu being displayed and food always being served hot. EVIDENCE: The care plans that we saw recorded details about a person’s previous lifestyle, including leisure and social interests and likes and dislikes; these were quite detailed. Daily diary sheets record activities undertaken by residents, such as listening to music, sitting in the garden, playing cards and going out with friends. Some residents told us that they like to go out independently and that staff support them to do so. The staff said that activities are mainly craftbased and usually take place on Wednesday and Friday afternoons. On the day of the site visit to the home, two people went out for a walk or to see friends. One person was sitting on a hard chair in the dining room listening to music; they told us that they would like to sit in a comfortable chair for a change and would welcome being assisted to the ‘quiet room’. People told us DS0000062588.V355908.R01.S.doc Version 5.2 Page 15 that they would enjoy a trip out, if one were offered. A care manager recorded in a survey, ‘If service users wish to go out, staff support is available to enable this to happen on a regular basis’. We observed on the day of the site visit that staff were able to spend some one to one time with residents, but the Expert by Experience said, ‘A little more time spent by staff in one to one conversations with individual residents could have resolved some of the issues I have raised’. We observed on the day of the site visit that people were supported to maintain their individual lifestyle and that the views of staff were not imposed on individuals. Residents said that they are supported to remain in contact with friends and relatives, and that their visitors are made welcome by staff at the home. Under the heading of ‘What we could do better’ in the AQAA, the registered manager recorded, ‘Look for activities in the community that may be of interest either collectively or individually’. The Expert by Experience suggested that there could be a local charity that hires out an adapted minibus with driver for a day’s activity; this should be investigated by staff at the home. It is the policy of the home that key workers complete monthly reports about their involvement with residents, and to record any changes that need to be made to individual care plans. These were mostly out of date. The registered manager should monitor the systems in place to ensure that they are being adhered to by staff. There are no details about advocacy services available for residents and others; the manager agreed to obtain information to display in the home. Residents are able to make some choices, for example, where to spend their day, how to spend their day and where to take their meals. Service users are encouraged to bring some of their personal items into the home. Most residents had their lunch in the dining room on the day of the site visit and they chatted to each other and to staff. The Expert by Experience had lunch with residents and the inspector observed the serving of lunch; the meal provided looked appetising and was well presented. There was no menu on display; a menu would encourage residents to become involved in meal provision at the home and may encourage conversation. There was some confusion over the choices offered to residents; the main course that was served was different to the choices offered verbally. Two meals were placed on the table before the residents arrived in the dining room, and one complained that their meal was cold. One resident asked for a cheese sandwich instead of the hot meals on offer, and this was provided for them. A resident recorded in a survey, ‘I love all meals at the home, especially fish – they are hot and tasty’. DS0000062588.V355908.R01.S.doc Version 5.2 Page 16 Water or blackcurrant squash was offered to residents at lunchtime but not ‘topped-up’ during the meal. The Expert by Experience was concerned that no record of the actual food eaten by residents was made, so there is no on-going record of the food and fluid intake for residents. She also said, ‘I felt two residents could have been encouraged to eat more if they had been assisted’. The cook had only just started to work at the home; despite this, they appeared to be ‘in control’ and told us that they planned to offer hot and cold alternatives at teatime. They also told us that there is a hot cabinet in the kitchen where food could be stored to keep plated food warm until residents actually sit down at the table. DS0000062588.V355908.R01.S.doc Version 5.2 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. 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. Information about how to make a complaint is provided to residents and others and a complaints log is used to record complaints received by the home. There are appropriate policies and procedures in place on safeguarding adults and some staff have undertaken appropriate training. EVIDENCE: There is a complaints policy and procedure in place at the home and the complaints procedure is displayed in the entrance hall. There is a complaints form available should anyone wish to make a complaint and there is now a complaints log in place. The manager informed the inspector that she intends to introduce a ‘grumbles’ book and there is already a comments book in place. One relative that returned a survey said that they did not know how to make a complaint but the other said that they did know how to do this; the two residents that returned a survey said that they knew how to make a complaint. One complaint has been received by the CSCI since the last inspection of the home. The complaint referred to poor staffing levels, poor standards of cleanliness, inappropriate food provision and poor personal care practices. The registered provider was asked to investigate the complaint and did so in a satisfactory manner; the outcome was that all regulations were met. We DS0000062588.V355908.R01.S.doc Version 5.2 Page 18 observed that details of this complaint were held within the complaints log ready for an entry to be made. The manager informed the inspector that three staff have now completed safeguarding adults training. The manager has not yet attended training specifically designed for managers; care staff and the manager should attend the training that is specifically designed for them to ensure that they are fully aware of the procedures that should be followed in the event of an allegation being made, and that they are able to identify unacceptable practice. There are appropriate safeguarding policies and procedures in place that have been produced by the home, and the Hull and East Riding local authority’s policy is also in use. The registered manager told the inspector that the staff handbook includes information on safeguarding adults – this was seen by the inspector - and that staff receive this at the time of their induction training. Staff sign a document to record that they have read the policies and procedures in place at the home, including safeguarding adults and whistle blowing. The registered manager told the inspector that she plans to recirculate these policies and procedures to staff and to discuss this topic in forthcoming staff meetings, to ensure that staff are up to date with the latest policies and procedures. Staff will also cover this topic when they commence NVQ training. DS0000062588.V355908.R01.S.doc Version 5.2 Page 19 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, 20, 22, 24 and 26 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 Maintenance at the home has improved and communal areas of the home now provide comfortable accommodation for residents. Domestic staff are now employed and this has improved hygiene standards at the home. EVIDENCE: On the day of the site visit we found the communal rooms to be clean and comfortable; the main lounge is light and airy and improvements have been made to the ‘quiet’ lounge. The ‘quiet’ lounge now includes comfortable seating, and shelves containing books and board games. This room is no longer used for storage, apart from a mobility scooter; the registered manager is in the process of arranging alternative storage for this. At the time of the last visit to the home, the medication trolley was stored in this room. A cupboard has now been built to enclose the medication trolley so that it no DS0000062588.V355908.R01.S.doc Version 5.2 Page 20 longer intrudes on the resident’s living space. Furnishings in communal rooms are domestic in character and of good quality. Some bedrooms have been refurbished and most now meet required standards. However, the Expert by Experience recorded, ‘One bedroom gave me cause for concern, being very small with curtains that were pulled only slightly apart, thus restricting the daylight and the view. I was unable to draw them back any further. The carpet in this room was very worn, the en-suite toilet had a permanent drip, a tap was loose on the washbasin and the strip light over the washbasin did not work. The bathroom light switch (within reach of the washbasin) was a standard box rather than a pull-cord switch’. We recommend that this bedroom be next to be refurbished, so that the standard is raised to that of other bedrooms in the home. In the meantime, it may be possible to offer this resident a move to an already refurbished bedroom. A conservatory is currently being built at the home; this had almost been completed on the day of the site visit. Residents told us that they were looking forward to it being finished, and would enjoy the small garden beyond. The garden needs to be made more attractive to encourage residents to sit outside in the warmer months; the Expert by Experience said that ‘a pleasant garden area would also provide a stimulus and a welcome change of scene’ and suggested that a local voluntary group looking for a project could be contacted to ‘transform the garden area’. There is still no maintenance programme in place for the home. However, the home now employs a handyman, and various areas of the home have been redecorated; maintenance in general has improved. The door between the kitchen and the corridor has been made safe; this has been checked by the Fire Officer, who considers the current arrangements to be satisfactory. The home provides specialist equipment to maximise residents’ independence, but the inspector remains concerned about the ramp that is in place at the entrance to one bedroom. The ramp has a steep gradient and the registered person should arrange for this to be checked by an appropriate person, such as an occupational therapist, to evidence that it is safe for use. Most bedrooms now include all of the furniture that is required, although the registered manager should check that all bedrooms to be occupied include drawers, hanging space, overhead/bedside lighting and comfortable seating for two people. The equipment provided in the laundry room is satisfactory but facilities need to be provided so that staff can either wash or disinfect their hands. There is now a domestic assistant in post who works for five days per week. The home was clean and hygienic on the day of the site visit, with the exception of two bedrooms where there were unpleasant odours. Staff told us about the action being taken to deal with this problem. A cook has very recently started to DS0000062588.V355908.R01.S.doc Version 5.2 Page 21 work at the home so care staff no longer have to carry out caring duties and catering duties; this reduces the risk of cross infection. The registered manager has recorded in the AQAA form that two staff have now completed training on infection control; all staff should complete this training in due course. DS0000062588.V355908.R01.S.doc Version 5.2 Page 22 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 good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home now employs enough staff to fulfil the care needs of service users. The recruitment and selection of staff is more robust and no longer leaves service users in a vulnerable position. The training and development plan is out of date so there is insufficient evidence that staff have attained the necessary training and qualifications to carry out their role effectively. EVIDENCE: There is a staff rota in place at the home and this evidenced that there are now sufficient staff employed to meet the needs of the current number of residents. A cook and a domestic assistant are now employed and this allows care staff to concentrate on care duties, as well as reducing the risk of cross infection. The staff rota should record the role of each member of staff so that it is clear who is on duty at any one time. Because some staff have left the home and new staff have been recruited, the home no longer meets the requirement for 50 of care staff to have achieved NVQ Level 2 in Care. Four of the eleven care staff have achieved this award. One member of staff recorded in a survey, ‘I have been working here quite a while and still haven’t begun an NVQ’. The registered manager told the inspector that there are plans in place for other staff to achieve this award; six DS0000062588.V355908.R01.S.doc Version 5.2 Page 23 staff are due to commence this training and it is planned that they will achieve their awards within six months. Improvements have been made to recruitment practices at the home. The records for two newly recruited staff were examined by the inspector. In one instance a Protection of Vulnerable Adults (POVA) first check had arrived two days after the member of staff had started work at the home, but the registered manager assured the inspector that the member of staff had only undertaken induction training in the interim period. A POVA first check for the other new recruit plus two written references addressed to the manager for both recruits were in place prior to them commencing work at the home. Application forms seen by the inspector included information on the applicant’s employment history and details of any qualifications held or training undertaken. The Expert by Experience recorded, ‘I found very caring and capable staff who spoke in a friendly and encouraging manner to the residents’. A care manager recorded, ‘I have concerns about the training of both the manager and the staff’. Training records held at the home were not up to date so it was difficult to determine the training achievements and training needs of staff. Staff that have been employed at the home for a long time have undertaken training on fire safety, first aid, health and safety, moving and handling, safeguarding adults, food hygiene and risk assessment. Because the training and development plan is out of date, there is no record of the training undertaken by new staff. However, the registered manager told the inspector that two staff have recently undertaken training on infection control, that all new staff have undertaken Induction training and that all staff have had fire safety training; evidence of this was seen in fire records. The training matrix must be updated and a copy must be sent to the CSCI. DS0000062588.V355908.R01.S.doc Version 5.2 Page 24 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 outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is run by a manager who is registered with the CSCI. Money held on behalf of residents is managed safely and the health and safety of residents and staff are promoted. The quality assurance system does not currently enable residents and other to affect the way in which the home is operated. EVIDENCE: The manager is now registered with the CSCI. She has restarted the Registered Manager’s award, as her previous work towards this award has been lost. She expects to finish this award in September 2008 and will then continue with training to achieve NVQ Level 4 in Care. The registered manager told the inspector that she recently attended fire safety training with the rest of the staff group, and that she keeps her practice up to date by attending DS0000062588.V355908.R01.S.doc Version 5.2 Page 25 management meetings within the organisation, via contact with the head office and by meeting other managers during training sessions. On the day of the site visit a representative from the local authority visited the home to check on the home’s progress towards the Quality Development Scheme (QDS), the local authority’s quality award. This person has arranged to return to the home in December to undertake a mock inspection and to prepare an action plan with the home. Residents meetings and staff meetings are held at the home. Satisfaction surveys were sent to relatives in September 2007 but the response rate was low, so this information has not assisted the registered manager to make decisions about any improvements that need to be made. The quality assurance system at the home should be expanded to include the regular review of policies and procedures, the production of an annual development plan and to allow residents and others to affect the way in which the home is operated. The outcome of any quality surveys should be published. Monies held on behalf of residents and associated monies were checked by the inspector; these were found to be accurate. The records held include details of monies received, monies paid out and a running total, and receipts are obtained for any financial transactions carried out. Some residents are given money by relatives and they are then responsible for holding these monies. Residents are provided with a lockable storage facility in their bedrooms so that they can hold money safely. There is a fire risk assessment in place and records show that all staff undertook fire safety training on the 6th November 2007. There is a gas safety record dated June 2007 and the fire alarm system was checked by a qualified person in July 2007. In-house weekly fire tests are been done consistently; this offers some protection to residents and staff regarding the risk of fire. The handyman undertakes room temperature checks, checks on the call system and water temperature checks at all outlets accessible to residents; associated records evidence that water temperatures are controlled to reduce the risk of scalding. The handyman also undertakes a portable appliance test on electrical appliances within the home; this test is not due again until December 2007 and the handyman told the inspector that the equipment is currently being calibrated. No electrical wiring certificate has been forwarded to the CSCI as required at previous inspections. Evidence that electrical wiring within the home is safe must be forwarded to the CSCI within the required timescale; failure to do so will result in enforcement action. The inspector saw evidence that the passenger lift, bath hoists and the mobility hoist were serviced in September 2007. Cleaning materials are now stored safely to meet the requirements of the Control of Substances Hazardous DS0000062588.V355908.R01.S.doc Version 5.2 Page 26 to Health (COSHH) guidelines. Accidents that occur at the home are recorded appropriately. As previously recorded, there is little information available to evidence that staff have undertaken appropriate health and safety training, either at the time of induction training or on an on-going basis. DS0000062588.V355908.R01.S.doc Version 5.2 Page 27 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 X 1 X 2 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 2 DS0000062588.V355908.R01.S.doc Version 5.2 Page 28 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 OP9 Regulation 13(2) 18(1)(a) Requirement All staff that administer medication must have undertaken accredited training, and there must be a sample of their signature available to enable records to be checked. Previous timescale of 31/10/07 not met. The ramp within one bedroom must be checked to ensure that it is safe for use. Previous timescale of 30/09/07 not met. The training and development plan must be updated, and a copy must be forwarded to the CSCI. The quality assurance system must be developed to include feedback from all interested parties, the results of which must be published and used to produce an annual development plan. Previous timescales of 1/11/06 and 31/10/07 not met. An electrical wiring safety DS0000062588.V355908.R01.S.doc Timescale for action 31/01/08 2. OP22 23 31/01/08 3. OP30 18 08/02/08 4. OP33 16/24 29/02/08 5. OP38 12,13 29/02/08 Version 5.2 Page 29 certificate must be available for examination at the home. Previous timescale of 31/10/07 not met. 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 OP3 Good Practice Recommendations Each resident should have a plan of care for daily living and longer-term outcomes that has been developed by staff at the home. Residents should be involved in the care planning process. There should be one care plan in operation to ensure that a person’s current care needs are recorded and are being met by staff. Documentation included in care plans should be completed to ensure that there is a full record of each person’s individual needs. Nutritional screening should be consistent to be effective. The registered person should consider purchasing a separate fridge to store medication. Medication administration records should be checked periodically to ensure that recording is satisfactory; there should be no gaps in recording. Residents should be given opportunities for stimulation through leisure and recreational activities inside and outside of the home. Information about advocacy services should be made available for residents and others. A menu should be displayed to encourage independence and to promote conversation. 2. 3. OP7 OP7 4. 5. 6. OP8 OP9 OP9 7. OP12 8. 9. OP14 OP15 DS0000062588.V355908.R01.S.doc Version 5.2 Page 30 10. 11. OP15 OP18 Staff should offer appropriate assistance with eating and drinking. Meals should always be hot when served. Staff and the registered manager should attend training courses on safeguarding adults to ensure that they are fully aware of the procedures that should be followed in the event of an allegation being made, and that they are able to identify unacceptable practice. The garden should be made pleasant for service users to sit out. There should be a maintenance programme in place that records all plans for refurbishment, replacement of equipment etc. to evidence financial viability and financial planning. The carpet in one bedroom needs to be replaced. Mobility equipment should not be stored in communal areas of the home. The role of each member of staff should be recorded on the staff rota. 12. 13. OP19 OP19 14. 15. 16. OP19 OP20 OP27 DS0000062588.V355908.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000062588.V355908.R01.S.doc Version 5.2 Page 32 - 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. 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