Inspection on 20/09/05 for Blackwell Care Centre

This inspection was carried out on 20th September 2005.

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 16/02/06

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 20th September 2005 09:30 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.V251617.R01.S.doc Version 5.0 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.V251617.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Blackwell Care Centre Address Gloves Lane Blackwell Alfreton Derbyshire DE55 5JJ 01538 304506 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.V251617.R01.S.doc Version 5.0 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 centidgrade 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) wich 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 coutersigned 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 15/12/04 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.V251617.R01.S.doc Version 5.0 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 persons present at the inspection were: Mrs L Shipstone, Responsible Individual Mrs C Skinner 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. What the service does well: What has improved since the last inspection? There has been compliance to some of the previous requirements and others were being acted upon, and will be monitored at the next inspection. The staffs’ moral within the home has improved. The staff commented this on, and the inspector had observed this to be the case, since the site visit, which he attended, prior to the registration of the new company. Blackwell Care Centre DS0000064322.V251617.R01.S.doc Version 5.0 Page 6 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.V251617.R01.S.doc Version 5.0 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.V251617.R01.S.doc Version 5.0 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 6 Standard 6 was not applicable. EVIDENCE: The acting manager advised the inspector that no intermediate care was provided. Blackwell Care Centre DS0000064322.V251617.R01.S.doc Version 5.0 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): Standards 7,8,9. 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. EVIDENCE: On examination of 6 care plans (nursing and personal care service users). The care plans were up to date, and had been evaluated at monthly intervals. There was no signature from either the relative or the service user, on the care plans, which identified that they had been consulted regarding the care being provided. On discussing this fact with the acting manager, she informed the inspector that some service users were unable to sign and had no relatives, and some had no relatives, who visited. The inspector informed the acting manager that if no signature could be obtained she should record that fact, but also to look to other people who may support the service user for example care managers, advocates etc. Blackwell Care Centre DS0000064322.V251617.R01.S.doc Version 5.0 Page 10 The acting manager advised the inspector that the new company was looking to introduce a new ‘more professional document’, which was being used, in other homes and included a space for signatures. The administration and storage of medication was monitored and found to be satisfactory. Blackwell Care Centre DS0000064322.V251617.R01.S.doc Version 5.0 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): Standard 15. An alternative choice of meals was available to the service users. The service users commended the quality of meals to the inspector. EVIDENCE: On monitoring the meal provision, the inspector observed that there was a menu blackboard displayed on the corridor, but it had been wiped clean. The acting manager apologised and informed the inspector that she had cleaned the board and forgotten, because of the inspection to complete the menu for today. On visiting the kitchen the inspector spoke to the cook, who explained the meal ordering system. She informed the inspector that the staff obtain the service users choice of meal, at approximately 14.00 hours, for the teatime and dinnertime the following day. She was able to show the inspector a list of the choices, which were available. Also as part of the monitoring process the inspector reviewed the fridge and freezer temperatures and the cleaning rotas. The temperatures were inside the expected temperatures, however there were some omissions in the cleaning Blackwell Care Centre DS0000064322.V251617.R01.S.doc Version 5.0 Page 12 records. The inspector accepted that the kitchen appeared clean at the time of the visit and it was the records that had not been completed rather than the cleaning not being undertaken. The service users advised the inspector that; ‘The food was good’. ‘Always get plenty’. ‘We get what we like’. The care staff confirmed that the ordering system described by the cook, did take place. Blackwell Care Centre DS0000064322.V251617.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not assessed, at this inspection. Blackwell Care Centre DS0000064322.V251617.R01.S.doc Version 5.0 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, 22, 24, 26 The environment had not been maintained to the required standard. EVIDENCE: On touring the building, at this inspection, the following was found: The home was decorated and furnished to an adequate standard, except for rooms 12 and 33, which required redecoration. The sluice room light was not working. The service user with room 10 was using oxygen. No safety notice was displayed. The hairdressing room light cover was missing from the light fitting. Blackwell Care Centre DS0000064322.V251617.R01.S.doc Version 5.0 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): Standard 27 Current staffing levels in place would appear to meet the current dependency needs of service users, accommodated within the home. However the adequacy of the management relating to the supervision of staff remains in question. EVIDENCE: On examination of the duty rotas and discussion with the acting manager, and responsible individual, the inspector established the following: On the am shifts, there were 1 qualified nurse and 6 care assistants. On the pm shifts, there were 1 qualified nurse and 4 care assistants. On the night shifts, there were 1 qualified nurse and 3 care assistants. Providing care to 40 service users (18 nursing needs and 22 personal needs) The acting manager was not supernumerary, but part of the registered general nurse numbers, as stated above, except for today when 2 qualified nurses were on duty. The role of the acting manager and the lack of a registered manager were discussed with the responsible individual. Blackwell Care Centre DS0000064322.V251617.R01.S.doc Version 5.0 Page 16 The inspector informed the responsible individual that on monitoring the care plans and care no issues had been raised, but the previous requirement relating to staff supervision had not been met. Also there had been no application to register a manager. The responsible individual agreed with the inspector and informed him that since she had taken over she was currently on site some time of each day and she had appointed an administrator. Therefore the administrator and herself had taken a considerable amount of the administration from the acting manager. The acting manager supported this comment. The registered person also advised the inspector that she was to review the staffing levels and the service users’ dependency needs, as one of her next priorities, and would be submitting an application for the post of registered manager. Regarding the training issues raised on the last inspection report, these had acted on these. During the discussions with the staff, the inspector was advised that they were satisfied with the care and that staff moral in the home had significantly increased, since the new company had taken over. Blackwell Care Centre DS0000064322.V251617.R01.S.doc Version 5.0 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): Standard 33, 36, 38 The service users were being placed at a potential risk, because of poor practice by staff and lack of supervision. EVIDENCE: With the hairdressing room, there was a trolley containing cleaning substances. The inspector was advised that the cleaner would have placed the trolley into the empty room whilst she went for a break. The inspector accepted that the cleaner had taken some action and not left the trolley on the corridor, but informed the acting manager that as she was aware cleaning substances should be locked away, and not left unattended. Within some of the en-suite facilities the inspector observed pans and urinals, which had not been sufficiently cleansed. The inspector discussed with the acting manager the importance of adequate cleansing to reduce possible infection risk. Blackwell Care Centre DS0000064322.V251617.R01.S.doc Version 5.0 Page 18 Regarding the previous requirements within this section, the following was established: Quality monitoring had occurred within some areas. There had been monitoring of the environment and a relatives / residents meeting had occurred. The acting manager and responsible individual accepted that this monitoring system needed to be expanded and the inspector will monitor the progress on the next inspection. The formal supervision of staff had not commenced because the acting manager was providing more ‘hands on’ registered general nurse input rather than managerial input. This issue has been commented on in the previous section on staffing, but scored 2 in this section. The required certification was shown to the inspector. Blackwell Care Centre DS0000064322.V251617.R01.S.doc Version 5.0 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X 3 X X X 3 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 2 X 2 Blackwell Care Centre DS0000064322.V251617.R01.S.doc Version 5.0 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 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. The register person must ensure that repairs and redecoration are carried out to ensure that the environment meets the required standard. The registered person must appoint a manager. This person must undertake the ‘fit person’ process. (This requirement is part of the conditions of registration.) The registered person must ensure that staff receive formal supervision at least six times a year. The registered person must ensure that cleaning and other substances are kept locked away, not left unattended. DS0000064322.V251617.R01.S.doc Timescale for action 20/10/05 2 OP19 23 20/11/05 3 OP27 8 30/11/05 4 OP36 18 30/09/04 5 OP38 COSHH 20/10/05 Blackwell Care Centre Version 5.0 Page 21 6 OP38 13 The registered person must ensure that the home implements care practices which reduce the possible risk of infection onto service users. 20/10/05 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.V251617.R01.S.doc Version 5.0 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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