Inspection on 16/02/06 for Blackwell Care Centre

This inspection was carried out on 16th February 2006.

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

Blackwell Care Centre 25/07/06

Blackwell Care Centre 20/09/05

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

CARE HOMES FOR OLDER PEOPLE Blackwell Care Centre Gloves Lane Blackwell Alfreton Derbyshire DE55 5JJ Lead Inspector Ivan Barker Unannounced Inspection 16th February 2006 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 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. Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Blackwell Care Centre Address Gloves Lane Blackwell Alfreton Derbyshire DE55 5JJ 01773 863388 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) Ambiance Care (Blackwell) Limited Vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1. The registered person must comply with Regulation 13(4) Standard 38, and ensure that the water expelled from the hot taps is 43 degrees centigrade 2. The registered person must comply with Regulation 16, Standard 24, and provide adjustable beds for service users assessed as high dependency and requiring nursing care. 3. The registered person must comply with Regulation 23, Standards 19 and 21, and ensure that repairs are carried out to the 2 baths, (Parker and Island bath) witch are currently in need or repair. Should the baths be beyond repair new baths must be provided. 4. The registered individual (Mrs Shipstone) must have a satisfactory CRB check countersigned by the CSCI. 5. The registered person must appoint a registered manager. All the conditions stated above to be complied with by 30th November 2005. Date of last inspection 20th September 2005 Brief Description of the Service: Blackwell Care Home is a purpose built home registered for 40 service users in the category of older people, situated in the village of Blackwell. The home can admit service users with personal care and nursing needs. Service users bedrooms are all single occupancy and have the benefit of ensuite facilities. The care home provides a pleasant environment for the service users and accommodation is provided on two floors. There is passenger lift and staircase access to the first floor facilities. There are spacious communal areas, many with views of the grounds of the home, which are accessible to the service users. Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Only a limited number of the National Minimum Standards were examined at this inspection (with emphasis on several of the ‘key standards’), and the previous requirements. The person present at the inspection was: Mrs J Potter, Acting manager. Within this inspection, which occurred over a four and half hour period, the inspector toured the building, spoke to service users and staff and examined the care plans and other documentation. He spoke with 5 service users, and staff during the inspection. Unfortunately no relatives were visiting at the time of the inspection. Compliance to the Conditions stated above, has almost been achieved and these should be removed, when a registered manager is in post. What the service does well: What has improved since the last inspection? Since the last inspection there has been a change of acting manager. It was recognised that the previous acting manager was in a ‘holding position’ because the proposed manager was on maternity leave. The new acting manager is now in post, and now able to drive forward initiatives, which may have been restricted to the other acting manager. Also as the new manager has applied for the post of registered manager, this could offer some management stability to the home. Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 Page 6 There has been compliance to three of the six requirements. Assurances have been given to complete the remaining three requirements. 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. Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 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 Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Accurate assessments will allow the home to be aware of the service users needs prior to admission, and give them the opportunity to plan how to meet these needs. EVIDENCE: The inspector was shown evidence that all service users were assessed prior to their admission to the home, by the Acting manager or senior member of staff. Assessments from the Care managers or the hospital staff were received by the home, prior to admission. The acting manager advised the inspector that she was still to implement the new documentation, which he had seen at the previous inspection. She explained that the new document when implemented would provide a more extensive assessment record of the service user’s needs. Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 7 and 10 Accurate care plans contribute to the delivery of care, however all parties should be aware of the intended care and ‘sign up’ to the care provision. Service users were allowed to make choices and their privacy was upheld. EVIDENCE: Standards 7,8 and 9 were assessed at the previous inspection. A Requirement regarding Standard 7 was listed for the service users or relative to sign the care plans, which would evidence that the document had been shared with them. However this requirement had not been met. The acting manager advised that this would be achieved when the new documentation was introduced, which was expected to be, by the end of April 2006. Regarding Standard 10, through observation and discussions with service users and staff, it was established that these standards were being met. Staff were observed to knock on the doors before entering. The inspector was informed that both the service users and staff were called by their first names. Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 Page 10 One service user informed the inspector that the staff were ‘helpful and respectful’. Another service user informed him that they ‘ let you get up when you want’. Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13 and 14. Various activities were organised within the home, which would provide stimulation to service users and enhance their quality of life. EVIDENCE: The acting manager advised the inspector that the home now had the position of an activity co-ordinator. The co-ordinator was introduced to the inspector. She was able to demonstrate by the production of displays, programmes etc, that activities occurred both inside and outside of the home. She expressed to the inspector her commitment to the post and her intention to enhance the quality of service users’ lives through the provision of activities and outings. The inspector discussed the possibility of keeping records of activities and outings in which each service user had participated. The acting manager advised the inspector that this record would be part of the new documentation, being implemented by the end of April. Service users were able to access the local village, being accompanied by staff or their relative or visitor. Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 Page 12 There was no restriction on visiting and visitors were able to visit in the communal areas or the service user’s own room, should the service user wish. The inspector discussed the provision of activities with 4 service users. He was informed that they were satisfied with the activities and outings and all commended the efforts of the co-ordinator. Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): As far as could be established the home took complaints seriously and acted upon the issues. The staff received training, on Adult Protection, which if implemented should make them more aware of Adult Protection issues and how to act should an allegation occur. EVIDENCE: The complaints procedure was displayed, and contained all the relevant information. The complaint book was examined and no complaints were outstanding. No one during the inspection asked to see the inspector to voice any complaints. The inspector received only positive comments regarding the home. Regarding Adult Protection, it was established by the examination of the training records that staff had attended adult protection training. The acting manager advised the inspector that she was to contact the Local Authority to discuss further training in Adult Protection. Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 There had been compliance to the requirements. EVIDENCE: The key standards were examined at the previous inspection. All the requirements that were raised regarding this section had been acted upon and resolved. Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 28, 29, 30. The necessary documentation designed to protect the service users were not in the staff files. The necessary checks had not been undertaken and service users may be placed at risk. Staff had received moving and handling, fire and training. An up to date workforce will contribute to the delivery of care. EVIDENCE: On examination of 4 staff files the inspector established that the files did not contain the required information as detailed within Schedule 2 and 4. Some files did not contain Criminal Record Bureau checks and some only had one reference. The acting manager advised the inspector that since the new company had taken over, a more constructive monitoring system, regarding the obtaining and logging of information had been implemented. However the administrator was yet to complete the exercise, but had recorded all the shortfalls within the staff files. Her analysis had found that, 9 people who were without CRB checks, had been employed by the previous owner of the home. The acting manager assured the inspector that the analysis had only been compiled on the 15th February, the day prior to the inspection, and therefore had not been acted upon. It was agreed that as a matter of urgency, these 9 staff should have a POVA check, to be completed by the end of the week, and CRB checks to be commenced within the next two days, and supervision of these staff to occur, until a satisfactory check was received. This proposed action was accepted by the acting manager. Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 Page 16 On examination of the training records relating to Moving and Handling and Fire, the records indicated that staff had received both Moving and Handling and Fire training. Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31 and 35. The management of the home does not comply with the requirements of the Care Homes Act, as a registered manager was not in post. The staff did not receive formal supervision, which may affect the staffs’ ability to deliver the care, and the acting manager being aware of the capabilities of her staff. EVIDENCE: Since the last inspection there has been a change of acting manager. It was recognised that the previous acting manager was in a ‘holding position’ because the proposed manager was on maternity leave. The new acting manager is now in post, and now able to drive forward initiatives, which may have been restricted to the other acting manager. Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 Page 18 A registered manager was not in post. The current acting manager had made an application to register as the manager. The Commission for Social Care Inspection was processing this application. Whilst the inspector appreciated that the application has been submitted and being processed, because the process has yet to be completed, the requirement has been repeated within this report. Also it should be noted that this requirements forms part of the conditions of registration. On requesting to examination the staff supervision records, which the inspector raised as a shortfall within his previous inspection, he was advised that the process of formal supervision had not yet started. Therefore as this was raised as a requirement within the last inspection, but received assurances from the acting manager that this issue would be addressed, the requirement was repeated. Regarding the service users’ personal monies the home operated a basic credit and debit system for a few service users. All previous requirements regarding Standard 38 had been acted upon. Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 Page 19 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 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 2 X X Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Timescale for action 30/04/06 2. OP27OP31 8 3. OP36 18 The registered person must ensure that the care plans are up to date, evaluated monthly and signed by the service user, relative, or a person acting on their behalf. (Revised timescale) The registered person must 30/11/05 appoint a manager. This person must undertake the ‘fit person’ process. (This requirement is part of the conditions of registration.) The registered person must 16/05/06 ensure that staff receive formal supervision at least six times a year. (Revised timescale for the process to have commenced and for staff to have received at least one supervision) The registered person must ensure that all staff are checked against all the required checks within Schedule 2 and 4, which includes the requirement to obtain CRB checks. 4 OP28OP29 Schedule 2 and 4 16/03/06 Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 Page 21 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 Blackwell Care Centre DS0000064322.V286046.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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