Inspection on 23/05/07 for Blackthorns

This inspection was carried out on 23rd 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

Blackthorns 31/08/06

Blackthorns 18/01/06

Blackthorns 09/06/05

Blackthorns 14/03/05

Blackthorns 20/10/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Blackthorns 21-29 Dooley Road Halstead Essex CO9 1JW Lead Inspector Pauline Dean Key Unannounced Inspection 23rd May 2007 09:40 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 Blackthorns DS0000017771.V343764.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. Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Blackthorns Address 21-29 Dooley Road Halstead Essex CO9 1JW 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) 01787 472170 01787 476342 blackthorns@runwoodhomes.co.uk www.runwoodhomecare.com Runwood Homes Plc Manager post vacant Care Home 44 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (44) of places Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 44 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 23 persons) The total number of service users accommodated in the home must not exceed 44 persons Staffing levels will be monitored over the first six months and will be reviewed with the inspectors six months after the date of the registration The registered person must not admit persons subject to the Mental Health Act 1983 or the Patients in the Community (Amendment) Act 1995 31st August 2006 Date of last inspection Brief Description of the Service: Blackthorns is an established care home, which provides residential care for older people and older people with dementia. The home also provides accommodation for 5 people on a short-term respite basis. It is a large purpose-built property situated in a residential area of Halstead. There is registered accommodation for forty-four people within four units. The home has a large lounge for all of the people living at the home and each of the four units has its own communal area. All accommodation is on ground floor and there are thirty-four single bedrooms and five double rooms. Three of these bedrooms have en-suite facilities. Bathrooms and toilets are found on each unit. Blackthorn’s has a central courtyard garden with seating and a patio area and around the home there are gardens with flowerbeds and borders with further seating areas. Car parking is available at the side of the property. The current range of fees, as at the site visit were said to be £407.58 per week to £429.03 per week. Toiletries, newspapers, hairdressing and chiropody are an extra cost. Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was undertaken on one day and took into consideration information from the visit, people who live at the home, relatives and healthcare professionals. The inspection involved checking information received by Commission for Social Care Inspection (CSCI) since the last inspection in August 2006, looking at records and documents at Blackthorns Care Home talking to Mrs Suzanne Smith, the Acting Home Manager, Acting Deputy Manager, Care Team Managers, care staff, catering staff and visitors. Questionnaires were left with the manager for distribution to all of the people living at the home and twelve completed surveys were returned to the Commission. In addition questionnaires were left for distribution to family and friends and six completed survey was returned to the Commission. This enabled them to give theirs views about the service directly to CSCI. Mrs Suzanne Smith, the Acting Home Manager came into the home for the site visit. The Acting Deputy Manager was also present. They and care staff and catering staff were spoken with and all were able to provide detailed information about the services provided, procedures, policies and working arrangements. Both management and staff were positive about the care service they offered, showing enthusiasm and dedication in the work they do and choose to do through fundraising events. During the site visit four people who live at Blackthorns were spoken with. All were pleased with the service and happy about way they are supported and assisted by the staff. They considered staff to be kind and courteous. One visitor to the home was also spoken with and they were positive with regard to the care of their relative. Twenty-four National Minimum Standards were inspected. This included all key standards. Six requirements were made as a result of this inspection. An improvement from the last inspection when there were fifteen requirements. What the service does well: The admission processes and information provided were found to be consistent and following good practices. People who live at the home and relatives said that they felt they had received sufficient information to make an informed choice about moving into Blackthorns. There was evidence of good health care practices and record keeping. Action is taken to access healthcare professionals and facilities as needed. Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 6 As at the last inspection the home continues to positively promote links with family and friends. Fundraising events continue with participation from the people who live at the home, their relatives and friends and staff members. What has improved since the last inspection? 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. Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 7 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 Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 8 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): 1, 3 and 6. 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. Clear detailed information, by the way of the Statement of Purpose and the Service Users’ Guide, is available. A comprehensive admissions process ensures that people who come to live at Blackthorns are assured that their needs are met. Intermediate care is not offered at Blackthorns. EVIDENCE: The Statement of Purpose as devised by Runwood Homes plc has been revised and reviewed in April 2007, as has the Service Users’ Guide. This now reflects the changes in the management of the home – Acting Home Manager – Mrs Suzanne Smith and the staffing structure of the home. Within this document there are details of fees charged and what they cover, with items, which are Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 9 not covered by the fees listed. This includes some activities arranged by the home, which are not funded by staff fundraising events. The files of three people living at Blackthorns were sampled and inspected. The pre-admission process and admissions of these individuals was considered. All three of these documents had good assessments of needs, including social, psychological, health and spiritual needs. The Acting Home Manager spoke of prospective residents visiting the home if possible and involving families and friends in this process. Survey work completed by the Commission resulted in completion and returns from twelve people who use this service. Ten of these said that they had received enough information about the home before they had moved in so that they were able to decide if Blackthorns was the right place for them. Two felt that they had not received enough information to make an informed choice. A visitor spoken to at the site visit said that they had been able to visit the home before their relative moved in for respite care. They had been able to meet the staff and see the proposed bedroom for their relative. They said that there were pleased to be involved in this process. No intermediate care is offered at Blackthorns Care Home. Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 10 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 good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care planning documents detailed health, personal and social care needs. They did not however, detail what actions were required to meet the individual’s needs, who was to take this action and how this was to be done. Management of medication was well managed ensuring that the people living at Blackthorns are safeguarded and protected. People who live at the home were treated with sensitivity and respect. EVIDENCE: The admission procedures in the home provided sufficient introductory information. From this information the home could determine whether they could meet the identified needs and commence an individualised plan of care. Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 11 The care plans of three people living at the home were sampled and inspected and they were used to case track care in the home. An assessment of needs identified health, personal and social cares needs. However, as found at the last inspection the care plans lacked detail about what actions were required to meet the individual’s needs, who was to take this action and how this was to be done. Within the sampled care plans, there was evidence of monthly reviews being conducted and whilst changes were noted in one care plan, no changes to the care plan had been made, identifying the action to be taken and who was to take this action and how this would be done. Care planning files had evidence of risk assessments with regard to manual handling and falls. There was also evidence of regular nutritional assessments and weight checks and pressure ulcer risk assessments. The home operates a key worker system. Care Team Managers (4) work with the key workers who are responsible for 2/3 residents each. Daily recording covered physical health needs with some detail of the individual’s mental health, moods and behaviours. Whilst there was some evidence of input from the people who live in the care home in their initial reviews, this was not seen in their care plans. Within the sampled care planning and record keeping there was evidence of good health care record keeping. Evidence was seen of input from the community psychiatric nursing team, GPs, dentist and chiropodist. Regular appointments and visits were arranged as necessary and the outcome of these appointments were noted and reflected in care plans. This was evident in one of the care plans seen in the case-tracking sample. At the site visit, the inspector was told that two doctors from a local surgery visit the home regularly and District Nurses from this surgery attend the people who live in the home as required, often visiting the home twice a week. In addition, Blackthorns has the service of a visiting NHS dentist and a home eye care visiting service. The services of an occupational therapist or physiotherapist are arranged as needed through the resident’s GP. A survey completed by a GP highlighted some concerns regarding communications between the home and the GP service and the increased use of the GP and DN service. They said that the care home usually sought advice and acted to ensure the improvement of individual health care needs of residents. They spoke of concern assessing particular health care facilities such as physiotherapy and chiropody, acknowledging the lack of these facilities in the NHS and the possibility of transport problems at the home. With the increased in the frailty of the residents and the need for more GP and DN input, the GP spoke of greater demands being put on the GP service. Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 12 A second healthcare professional survey completed by a District Nurse praised the home for providing “a real home setting for its residents.” They spoke of “Blackthorns proactively calls the DN’s when they have clinical concerns about any of their residents” and they said that the home had “good effective systems in place to ensure all residents that need DN attention receive it, providing comprehensive documentation of all visits.” Medication administration, record keeping, storage and stock control were sampled and inspected. A Monitored Dosage System (MDS) is used in the home. Medication is held in an air-conditioned Medication Room in secure medication trolleys or in wall-mounted medication cabinets on each unit. The majority of the people living at the home have their medication held in blister packs although people who come into the home on respite hold their medicines in their individual containers. Medication records and medicines sampled were in good order. The Acting Home Manager said that all staff who administer medication are required to complete the Boots the Pharmacist training course – Care of Medicines and they are required to demonstrate that they are competent. The Acting Home Manager said that medicines are administered by the Care Team Managers of the home. This was observed during the site visit. On the site visit, it was evident that the people living at Blackthorns were able to express their individuality, for there was evidence of personal possessions and photographs in their rooms. During the visit, the inspector was able to observe several occasions when staff treated the people who lived in the home with dignity and respect. One incident involved a resident who was experiencing problems with their glasses. They approached a carer who sensitively dealt with the cleaning the glasses and offered support and guidance in a respectful manner. On another occasion, care staff were seen speaking to a resident offering reassurance and being patience as was required. One person living at Blackthorns said that the staff are “lovely” and they were “very good.” Survey work completed by the Commission resulted in completion and returns from twelve people who use this service. Ten people who live at the home said that they always receive the care and support they needed, whilst two said that they usually receive the care and support they need. One person said that “they look after me very well” and another said, “Staff are very good”. Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 13 The only negative comment received came from survey work completed by relatives, carers and advocates. Out of the six completed and returned, one person had commented that they had seen “other people in their mother’s clothes.” As the survey was completed anonymously, it was not possible to follow this particular issue up with management. It is hoped however, that management will continue to monitor and review laundry arrangements to ensure that this problem does not re-occur. Blackthorns DS0000017771.V343764.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 good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The daily routine and activites in the home were flexible and optional, with people who live at Blackthorns being able to make choices with regard to their social and leisure activities. Family contact and visiting arrangements were open and relaxed, with family links encouraged and promoted. Blackthorns provides a varied and nutritious menu for individuals to select from. EVIDENCE: Throughout the day of the site visit, staff were seen interacting in a positive manner with the people living at the home. They were seen chatting with residents as they went about their tasks and they gave gentle reminders as to what was happening next to give individuals a concept of time. Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 15 Since the last inspection, the home has employed a new Activities Coordinator. They told the inspector that they had commenced employment in March 2007 and that they were employed on arranging activities for 25 hours a week, five days a week. At the site visit, the inspector was able to speak with the Activities Co-ordinator and they gave a detailed account of the activities offered daily. The records held centrally further evidenced this and records seen on individual care plans for three people who live at Blackthorns. The activity sessions take place in the main lounge and all of the residents are invited to attend. Many receive a personal invitation each day from the Activities Co-ordinator and approximately 18 residents attend each day. Photographic evidence was seen of events and activities completed in the home. Potting and planting up seedlings had been a very popular activity and three people spoken to during the site visit had commented on how much they had enjoyed this activity and there were particularly pleased to see their established plants being planted in the garden and in hanging baskets by the home’s gardener/maintenance man. In a large store cupboard in the main lounge, a variety of games and activity equipment was seen. The Activities Co-ordinator said that reminiscences quizzes and games are enjoyed, as are games of football, hoop-la, dominos, cards and board games. Each day the activity session starts with armchair exercise moving on to other chosen activities. Cooking has also been offered recently and as with the gardening activity this had proved very popular. Two residents spoken to during the site visit commented this on. Out of the twelve completed surveys left with the home following the site visit, nine people who live at the home confirmed that there are always activities arranged by the home that they could take part in; two said that there were usually activities arranged by the home for them to take part in and one person said that they “like to sit and watch” the activities on offer. Within the survey work addressed to relatives, carers and advocates, one relative stated that they felt the activities on offer were something, which the care home did well. They highlighted the gardening activity, games and singsongs as being beneficial – “stimulating the mind.” The Acting Home Manager spoke of positively promoting links with family and friends. Relatives and friends are invited to fundraising Coffee Mornings and social events in the home. Blackthorns has an ‘open door’ visiting policy and one relative spoken being able to visit as they and their relative wished and they were able to meet either in their room, in one of the lounges or the main lounge or in garden or enclosed courtyard garden. One visitor in their survey had commented that “The staff are keen to help and make visitors welcome.” Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 16 During the site visit it was evident that people living at Blackthorns were able to move around the home as they wished. They were able to choose whether they wished to attend activities on offer and they were able to sit in their room, in one of the lounges or in the gardens. Evidence was seen of personal possessions in bedrooms. Items such as pictures, ornaments and photographs were seen in the bedrooms. Blackthorns offer a four-week rotation menu with at least two choices offered for lunch and tea. Two choices of the main course and dessert are offered at lunchtime. Menus are planned for breakfast, mid-morning snack, lunch, midafternoon snack, tea and supper. Two cooks cover the week. Whilst menu planning is arranged by head office, the home is responsible for purchasing and ordering food supplies through both local suppliers and wholesale suppliers. Menus were on display around the home in each unit and small kitchenette areas offer facilities for hot and cold drinks throughout the day. Nutrition records are kept for each person living at Blackthorns and it was possible to see the fluid and food intake for each individual. Special therapeutic diets are offered as required, although at the time of the site visit, these were no required. Of the twelve surveys returned and completed by people living at Blackthorns, nine were very complimentary regarding the meals served at the home saying that they always like the meals served. Comments such as “Yes 9 times out of 10” and I “would like smaller portions” were added. Three said that they usually liked the meals at the home. Blackthorns DS0000017771.V343764.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. People who live at Blackthorns benefit from the home’s complaints procedures and safeguarding adult’s arrangements to ensure that they are safe. EVIDENCE: Blackthorns Care Home has complaints/compliments procedure, which is referred to their Service Users’ Guide. Complainants are advised to raise concerns with the home’ s manager either verbally or in writing. Twelve surveys were completed and returned to Commission for Social Care Inspection (CSCI) by the people living at the care home following the site visit. Nine people who live in the home were aware to whom they should raise concerns, with the remaining three people stating that they were sometimes or usually able to speak with someone if they were not happy. One had not answered this question. Six surveys were completed and returned to Commission for Social Care Inspection (CSCI) from relatives following the site visit. Five said that they knew how to make a complaint. One had not answered the question. Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 18 A policy on adult protection and prevention of abuse was seen on a central file in home’s office. Clear detailed procedures were in place with best practice guidance available. The Acting Home Manager – Mrs Suzanne Smith had a clear understanding of these procedures and spoke of adult protection training completed and planned for all staff. Adult protection training is considered as part of the statutory training sessions offered in the home. Ten staff were identified as planned to attend this training in June 2007. Blackthorns DS0000017771.V343764.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, 22 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. Overall, Blackthorns provides a safe environment that is accessible to the people who live at the home. It is homely, whilst requiring decoration and refurbishment. EVIDENCE: Blackthorns care home was generally clean and tidy. There were no offensive smells found on the day of the site visit. New handrails had been fitted in the corridors and a new call bell system had been installed. Overall however, the premises are looking tired and worn. Paintwork was chipped and marked, whilst fitted bedroom furniture was dated and requiring some attention e.g. new door and drawer knobs. Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 20 Redecoration, refurbishment of bedroom accommodation and communal areas is still to be completed. At the site visit building work was ongoing to convert the day centre accommodation of the Warrens on the lower ground floor into seven new bedrooms with en-suite facilities. In this area there will be a bathroom, treatment room and toilet and lounge area. The planned completion date is 15th June 2007. At the site visit the inspector was informed that redecoration and refurbishment of each unit was due to commence. Following the site visit a schedule of this work was sent to the Commission for Social Care Inspection (CSCI). This states that the work is to commence in the Larkspur Unit on 18th June 2007, finishing 6th July 2007; Honeysuckle Unit commencing 9th July 2007 finishing 27th July 2007; Primrose Unit commencing 30th July 2007 finishing 18th August 2007 and Poppy Unit commencing 20th August 2007 finishing 7th September 2007. Redecoration and the fitting of new carpets, furniture and curtains and the installation of a hearing loop system in the main lounge are to commence 10th September 2007 finishing 21st September 2007. It is hoped that this work is progressed and completed as planned for currently the home’s accommodation is clearly in need of upgrading, decoration and refurbishment. This was recognised by staff and management and commented on by three people who live at the home and were spoken with during the site visit. One relative in their survey made comments regarding the accommodation. They said that they believed redecoration, new carpets and furniture was “in hand.” At the site visit the inspector was able to speak with a domestic carer who is responsible for laundry. They told the inspector that two people provide laundry cover over seven days, with additional cover for holidays and sickness. The home has two washers and two dryers, both industrial models. In addition to an iron and ironing board, the home has a roller press and a hand press and ironing board. Marking and labelling of clothes was considered with laundry staff and the difficulties were acknowledged when clothing came into the laundry unmarked. The experience highlighted by one survey completed by a relative when their relative’s clothing was seen on another resident is something the home needs to guard against. Comments seen in the survey work completed by Commission for Social Care Inspection (CSCI) spoke of their relative’s clothes being “clean”. Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 21 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. People who use this service do not benefit from staffing levels, which have been calculated to meet their individual needs. People who live at the home are protected by the home’s recruitment practices and training. EVIDENCE: The Acting Home Manager – Mrs Suzanne Smith was unclear as to the assessed dependency needs of people living at Blackthorns and the calculations required to ascertain staffing levels in the home. At the site visit these were found to be the Acting Home Manager or a Deputy Manager with a Care Team Manager and six care staff on duty 7 00am to 2 00pm; one Care Team Manager and five care staff on duty 2 00pm to 10 00pm with one Care Team Manager and two night carers. In addition there are three to four domestic staff, one laundry person and two cooks on duty each day. These were as were detailed on the staff deployment rota. Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 22 As noted at previous inspections the afternoon and evenings have reduced staffing levels and so activities or individual support offered to the people who live at Blackthorns are limited. The Acting Home Manager was advised to review the individual dependency levels of the people living at Blackthorns to have a clearer understanding of the level of staffing required in the home at all times. The home is registered to accommodate people with dementia and whilst their physical needs may not be scored as “high dependency” by the home, their emotional, behavioural and mental health needs may rate them as “high dependency”. Continual assessment will be required to ensure that their changing needs are met. Fourteen staff out of twenty-seven care staff have obtained a National Vocational Qualification (NVQ) level 2 or equivalent. The home has therefore achieved a minimum ratio of 50 trained members of care staff with this qualification. Staff recruitment files for two care staff members were sampled and inspected. They were found to meet requirements as detailed in the National Minimum Standards – Standard 29. Staff files sampled had evidence of induction training records, both in-house and as developed by Skills for Care. Blackthorns DS0000017771.V343764.R01.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 the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Blackthorns benefits from clear management structure. An application for registration as the registered manager has been submitted to the Commission. People who use this service do not benefit from a developed quality assurance and quality monitoring system. People who use this service benefit, from safeguarding cash held in safe custody. Safe working practices are promoted through ongoing training. Health and safety certification and insurances promotes a safe working environment. Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 24 EVIDENCE: At the time of the site visit Blackthorns had no registered manager. Mrs Suzanne Smith is the Acting Home Manager and has made an application for registration. A date for a Fit Person Interview has been arranged. Mrs Smith confirmed that she had over twenty-three years in working in care work. During her work at Blackthorns she has completed a NVQ level 2 in care and has a NVQ Assessors Award. Mrs Smith confirmed that she is planning to complete the Registered Manager’s Award by September 2007 and is looking to obtaining a NVQ level 4 in care. Management structure within the home had clear lines of accountability. Both staff and the people who live in the home had a good sense of the structure and direction of the leadership in the home. Runwood Homes plc have an Annual Development Plan. The inspector was told that this has not been updated since the last inspection. However, an inhouse survey was completed in October 2006 and as a result of this quality and monitoring, action had been taken. Namely an increase in activities offered in the home and more choice in the food served. In addition a survey on the catering arrangements in the home had been completed in April 2007. Topics covered were choice, drinks and the serving of hot meals. Mrs Smith said that she plans to share the results with the residents and relatives who took part, displaying the results on a central notice board. Further survey work had recently been conducted by the home and these had been distributed to the people who live in the home and their relatives. Mrs Smith said that she is planning to feedback the results to residents and relatives at a planned coffee morning. Copies of reports following visits by the registered provider (Regulation 26 visits/reports) were sampled and inspected. Reference was made to the last Commission for Social Care Inspection (CSCI) inspection report and the Annual Development Plan. Of the three people living at Blackthorns involved in this case tracking. Two had their money held in the home. The monies and records were inspected and these were found to be in good order. The homes policies and procedures support the health and safety of service users and staff supporting them. The certificates relating to equipment and services to the home were in place and updated as required. Records of hot Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 25 water temperatures were seen and inspected and water temperatures were found to be around 43°C. The previous inspection highlighted the need for staff training with regard to infection control and an in-house training package has been developed and used in the home. Regular monthly fire drills are now completed and recorded for all staff, including night staff. An audit is undertaken to ensure that all staff are involved in this training. A training matrix detailed basic training opportunities completed since January 2006 to January 2007, with additional planned training, which had been run and is to be run in 2007. Courses offered included First Aid, Moving and Handling, Health & Safety, Food Hygiene, Fire Awareness and Dementia Care. The majority of care staff have completed all of these courses. Blackthorns DS0000017771.V343764.R01.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X 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 2 X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Blackthorns DS0000017771.V343764.R01.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 OP7 Regulation 15, Schedule 3(1)(b) Requirement People who use the service must be assured that their care plans detail about what actions are required to meet their individual’s needs, who is to take this action and how this was to be done. People who use the service must be assured that the shortfalls identified in the report with regard to redecoration, refurbishment and maintenance are addressed. This is a repeat requirement for the 5th time. People who use the service must be assured that the needs of people with hearing impairment are met through the provision of a loop system. This is a repeat requirement for the 5th time. People who live at the care must be assured that there is an effective staff team to support their individual needs and assessment. DS0000017771.V343764.R01.S.doc Timescale for action 14/08/07 2. OP19 12 (1)(a) 21/09/07 3. OP22 23(2)(n) 21/09/07 4. OP27 18(1)(a) (b) 14/08/07 Blackthorns Version 5.2 Page 28 5. OP31 8(1)(a)(b) 6. OP33 24(2)(c) There must be a qualified, competent and experienced registered manager at the care home to make sure that people who use services receive a good service. An effective quality assurance and quality monitoring system must be introduced to ensure a through review of the care and services offered in the care home. This is a repeat requirement. 14/08/07 14/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Blackthorns DS0000017771.V343764.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Blackthorns DS0000017771.V343764.R01.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. 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