Inspection on 05/11/07 for Bole Hill View

This inspection was carried out on 5th November 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

Bole Hill View 20/10/08

Bole Hill View 03/10/06

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

CARE HOMES FOR OLDER PEOPLE Bole Hill View 2 Eastfield Road Crookes Sheffield S10 1QL Lead Inspector Sue Turner Key Unannounced Inspection 5th November 2007 08:10 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 DS0000067344.V349780.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. DS0000067344.V349780.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bole Hill View Address 2 Eastfield Road Crookes Sheffield S10 1QL Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0114 2683960 0114 2683960 jane.myers@sct.nhs.uk None Sheffield Care Trust vacant post Care Home 20 Category(ies) of Dementia - over 65 years of age (20) registration, with number of places DS0000067344.V349780.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Three of the DE(E) beds may instead be used as DE. Where additional services are provided eg day care, outreach, escort duty, staffing for this must be over and above that required for the registered service. 3rd October 2006 Date of last inspection Brief Description of the Service: Bole Hill View is situated in the Crookes area of Sheffield. Local amenities are accessible and there is a regular bus service. The building is single storey and the majority of bedrooms are single. Bole Hill View has two double rooms that can accommodate married couples or be used for single individuals. Bathrooms and toilets are close to bedrooms and there are a number of comfortable sitting areas and a comfortable dining area. The home provides respite care to people living with dementia. At the time of this inspection there was one permanent service user remaining who has lived at the home for several years. The manager stated that the current range of fees is £321.75 - £359.00 per week. There are additional charges for hairdressing, chiropody, newspapers, toiletries and outings. The home has a Statement of Purpose and a Service User Guide which is displayed in the home and available to people and their relatives. Information about how to raise any issues of concern or make a complaint was also on display. DS0000067344.V349780.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection carried out by Sue Turner regulation inspector. This site visit took place between the hours of 8.10 am and 5:00 pm. Jane Myers is the acting manager and was present during the visit. Prior to the visit the manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. Questionnaires, regarding the quality of the care and support provided, were sent to people staying in the home, their relatives and any professionals involved in peoples care. The Commission for Social Care Inspection (CSCI) received one questionnaire from a person using the service, three from relatives and one from a professional. Comments and feedback from these have been included in this report. On the day of the site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, check the homes policies and procedures and talk to six staff, one relative and four people. The inspector checked all key standards and the standards relating to the requirements outstanding from the homes last inspection in October 2006. The progress made has been reported on under the relevant standard in this report. The inspector wishes to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. What the service does well: People living in the home said that the care they were receiving was good. They made comments such as: “I’ve been here a few times and I like it”. “We always get a good meal”. “I’m getting used to it here”. DS0000067344.V349780.R01.S.doc Version 5.2 Page 6 “The staff are friendly, good and helpful”. One health professional said: “I have no reservations about recommending the home to patients and relatives” and “There is generally a high level of care”. Relatives said: “The home provides a safe environment, looking after clients physical needs, for example washing and feeding”. “Everyone is very kind and helpful and seem genuine in their care for our father”. “Staff always have the time to discuss relatives care and wellbeing”. “We are very pleased with all aspects of the care at Bole Hill View”. “The staff I meet are very caring and understanding. They make my mother feel at home”. The inspector observed that people were well dressed in clean clothes and had received a very good standard of personal care. People’s health care was monitored and access to health specialists was available. People confirmed that staff were always respectful towards them. People said that they had a choice of food and that the quality of food served was “very good”, “good” and “alright”.” There was a complaints procedure and Adult Protection procedure in place, to promote peoples safety. People said they had confidence in the homes manager and staff, who would listen to any concerns and take them seriously. People said that they felt safe living at the home. The home was clean and tidy. No unpleasant odours were noticeable in the home. People living in the home and their relatives said that the home was always kept “clean” and “spotless”. A staff training record was in place, and individual training records were maintained. Mandatory training took place, to equip staff with the essential skills needed. DS0000067344.V349780.R01.S.doc Version 5.2 Page 7 Staff supervision took place, to support and give guidance to staff on an individual basis. Systems were checked and serviced to maintain a safe environment. What has improved since the last inspection? The acting manager had been in place for a year. She had made progress and actioned the majority of the requirements issued at the last inspection. Although pre assessment information received had improved, there still needed to be further work carried out to ensure that people and their relatives were confident that the staff could meet individual needs. Procedures had been put in place, which ensured that staff had access to appropriate support when crisis situations arose which could have placed people at risk. A photograph had been place in each persons care file, their weight was being monitored and people had signed their contracts. All care plans had been reviewed each month. Details of accidents were recorded in people’s daily notes and individual accident records were completed in full. Medication at the home was stored securely. Staff that administered medication confirmed that they had undertaken training in medication administration; to equip them with the skills needed to carry out the procedure safely. All staff had attended training in adult protection and were aware of their responsibilities in dealing and reporting any concerns. The temperature in all parts of the home was comfortable and being maintained at a minimum of 21°c. The missing headboards had been replaced and all areas of the home were free from offensive odour. Accurate and up to date records were being of people’s finances income and expenditure. People’s files were stored securely. A risk assessment had been completed for the very heavy fire door. Consultations had taken place with the fire service that permitted the fire doors on the corridor to be held open. DS0000067344.V349780.R01.S.doc Version 5.2 Page 8 Staff had received fire instruction in the last six months and were due to attend further fire training given by the fire officer. The managers confirmed that any additional moving and handling equipment that was necessary was provided upon request. What they could do better: The Statement of Purpose and Service User Guide should be reviewed and updated. The design of the guide should be revised to make it easier for people to read and more appealing to look at. The home offers respite care to people with dementia. Some people stay at the home on a regular basis, others may stay only once. It is essential that before people are admitted into the home, their needs have been assessed. People’s needs should be assessed by both a social worker and by staff from the home. This would then ensure that the home could meet individual needs. As part of an assessment people should be given the opportunity to visit and assess the quality, facilities and suitability of the home. People should also be given the opportunity for staff to meet them in their own home or current situation if different. The care needs, wishes and preferences for each person should be clearly recorded in their care plan. These should also contain specific information on the staff action required to meet personal care needs. Staff should be provided with training regarding managing challenging behaviour to ensure that they are confident and competent in this area. Care plans should then include what action staff should take when faced with challenging behaviour including aggression and violence. Individual risk assessments should be reviewed and updated so that peoples health, safety and welfare is maintained, Leisure activities should be more readily available. The recruitment of an activities worker would aid this. People said they enjoyed watching television. A TV with a bigger screen and a better reception should be provided for the main lounge. Thought should be given about how people could be orientated to date, time and place. The rolling programme of re decoration should continue so that all floor coverings, bedrooms and communal areas are adequately maintained, clean and in good condition. DS0000067344.V349780.R01.S.doc Version 5.2 Page 9 A review of the staffing levels should be undertaken. The varying numbers and diversity of the people accommodated should be considered within the review. Full recruitment checks must be carried out for all staff. This information should then be available at the home for inspection purposes. Records should be up to date, accurate and available for inspection. In line with the homes policy bathroom water temperatures should be checked and recorded weekly. Any action necessary should be taken, following the completion of the fire risk assessment. 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. DS0000067344.V349780.R01.S.doc Version 5.2 Page 10 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 DS0000067344.V349780.R01.S.doc Version 5.2 Page 11 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): Standards 1, 3, 4 and 5. Standard 6 is not applicable to this home. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provided information to inform people about their rights and choices. Pre admission information was not adequate. This did not assure that the home was able to meet people’s health, cultural, social and care needs. EVIDENCE: The homes Statement of Purpose (SOP) and Service User Guide provided useful information about the home and what services they could and could not provide. However some information in the SOP was out of date, documents still referred to the National Care Standards Commission (NCSC) and this had changed to the Commission for Social Care Inspection (CSCI) in April 2004. DS0000067344.V349780.R01.S.doc Version 5.2 Page 12 The Service User Guide, although informative was not set out in a way that people could easily read or refer to. Pages were loose and some were left blank. The print was small and not pleasing to read. Considering that the home accommodates people with dementia some pictures and colour would make the guide more user friendly. Assessments were carried out by a social worker prior to admission to the home. Staff said that although this had improved the assessments did not always have enough information and did not reflect the needs of the person. The inspector looked at the information provided for three people. Full needs assessments had been completed for all three. However useful information about a persons individual needs was insufficient. This made it very difficult for the staff to assess if peoples needs could be met whilst they were staying in the home. One person’s information detailed very little about his/her ethnic origin, beliefs and preferences. This person’s social and cultural need could therefore not be met. Added to this the person had dementia and their only family contact was working abroad. The inspector spoke at length to the manager about the need for people to be assessed by both the social worker and the homes staff. It was not usual practise for the staff to visit people at home or in hospital to meet with them and carry out an assessment. Although trial visits to the home sometimes took place, again this was not the norm. DS0000067344.V349780.R01.S.doc Version 5.2 Page 13 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 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person had a plan of care, however these did not include sufficient detail to ensure that peoples individual needs were being met. Medication procedures protected people’s health and welfare. People and their relatives were complimentary about the way staff promoted their privacy and dignity. EVIDENCE: Three peoples care plans were checked. One person had been admitted into the home the day before. His/her care plan was not completed and would be difficult to complete due to the little information known about the person prior to their admission. As the service provides respite care it is imperative that as much information as possible is gathered at the pre admission point. In many cases admission DS0000067344.V349780.R01.S.doc Version 5.2 Page 14 takes place because family and carers need a break or are taking a holiday. This means that they are often unavailable to contribute to a care plan once the respite stay has begun. Two other care plans seen did not clearly state how the persons health, emotional and social needs were met. Daily notes were completed but again these did not always link with what was recorded in the care plans and reviews. Staff said that people that stayed in the home could be quite challenging. However there were no details or guidance in the care plans about how staff should approach people who displayed challenging behaviour and aggression. Reviews had been completed either monthly or upon re admission to the home. In many areas the reviews said “same as last month”. When these were looked at alongside the care plans they did not correlate. There was no evidence to confirm that people and/ or their relatives were involved in drawing up and reviewing the care plans. Individual assessments had been completed which identified the risk of people falling and any moving and handling issues. One falls risk assessment had not been reviewed and updated for over twelve months. One moving and handling assessment had not been reviewed and updated since May 2007. The care plans identified that a range of health professionals visited the home to assist in maintaining peoples health care needs. People said that GP’s, dentist, opticians and chiropodists also visited the home as requested. One relative said: “Staff are always quick to attend to any of our fathers physical ailments and to inform relatives of his treatment and progress”. Medicines were securely stored in locked trolleys within locked cupboards. Medicine Administration Records (MAR) checked were completed with staffs’ signatures. Staff said they had completed an in-depth training programme. This gained them the competencies needed to administer medications. There was evidence that managers and trained staff were auditing medication administration procedures. Staff spoken to were aware of the need to treat people with dignity and respect and were observed interacting in a friendly and pleasant way. One health care professional said: “The care service always respects individuals’ privacy and dignity”. DS0000067344.V349780.R01.S.doc Version 5.2 Page 15 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, 14 and 15. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were able to maintain contact with family and friends ensuring that they continued to be involved in community life. A limited range of activities was on offer, further activities would promote choice and maintain peoples interests. Meals served at the home offered choice and ensured people received a healthy balanced diet. EVIDENCE: People were seen to be “getting up” at various times during the morning. One relative spoken to said they were able to visit at any time and were made to feel welcome. Relatives surveys said: DS0000067344.V349780.R01.S.doc Version 5.2 Page 16 “My mother has dementia and is unable to telephone me. I phone her often and am never refused to talk to her by staff”. “I think this home is better than the one Nan used to go to, everyone is really friendly”. The inspector saw that people received varying amounts of staff interaction and stimulation. Staff were very busy attending to ‘tasks’. Staff did attempt to involve people in a game of bingo or dominoes, but this seemed a token gesture and wasn’t planned into the day. People said that they enjoyed watching television. The lounge was large and the television was placed in the corner of the room. The reception on the TV was very poor and the screen was small. People who had impaired vision would have found it very difficult to see the television. The home didn’t employ an activities worker or a laundry person and these tasks were the responsibility of the carers. Staff rotas were difficult to cover due to vacancies and long-term sickness, resulting in activities being the first thing that would be disregarded. The inspector discussed with the manager the need for an activities worker, to enhance people’s social life and reduce the burden on carers. One relative said: “There could probably be occasional visits by entertainers to cheer up the people in the home”. It was noticeable in the home that there was not enough information that may help people with orientation. Few clocks were displayed and the information board contained only the date. A board containing information such as the weather, the place where the people were living, or a news item, may help people with orientation to time and place. The inspector sat with people at breakfast. People were asked their preferences of food and drinks and were served in a friendly manner. Tables were set nicely with tablecloths, matching cutlery and crockery and condiments. When talking about the meals provided people said such things as: “The meals are pretty fair, depending on whose cooking”. “I get a cup of tea when I want and I’m very happy at Bole Hill View”. “Some things I like, some I don’t, which is just like at home” “We always get a good meal, but I can’t get on with the porridge” “The food is very good, with a lovely variety”. DS0000067344.V349780.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures were in place and people and their relatives felt confident that any concerns they voiced will be listened to. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure that people were protected from abuse. EVIDENCE: People and their families had been provided with a copy of the homes complaints procedure, which was also on display in the entrance hall. This contained details of who to speak to at the home and who to contact outside of the home to make a complaint should they wish to do so. People said that they felt very comfortable in going to any member of the staff or management team, knowing that any concerns they may have would be addressed without delay. The home kept a record of complaints, which detailed the action taken and outcomes. The home had received one complaint since the last inspection; this had been investigated by the manager and any appropriate action taken as necessary. CSCI had not received any complaints about the home. Staff spoken to were clear how to respond and record any complaints received. DS0000067344.V349780.R01.S.doc Version 5.2 Page 18 An adult protection procedure was in place. Staff had undertaken formal training on adult protection, which had equipped them with the skills needed to respond appropriately to any allegations. People spoken to said that they felt safe living at the home. One person said: “If I’m unhappy about something there are plenty of people I can speak to, if I wanted to complain I would ask to speak to the lady in the office”. DS0000067344.V349780.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24 and 26. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The rolling programme of refurbishment and decoration had improved many areas of the home. So that everyone is able to live in a comfortable and safe environment the programme of refurbishment needs to be ongoing. EVIDENCE: A rolling programme of refurbishment and redecoration was underway. The manager said that six bedroom carpets had been replaced. The home was in the main clean and tidy. Lounge and dining areas were domestically furnished and a tour of the building identified that some areas of the home were in need of minor repair. DS0000067344.V349780.R01.S.doc Version 5.2 Page 20 Lounge, dining room and corridor carpets were stained and marked. This had been identified at the last inspection. The manager said that they had attempted to clean the carpets but this hadn’t improved their appearance. She said the dining room carpet was to be removed and a more suitable floor covering was to be fitted. Money had yet to be identified to replace the lounge and corridor carpets. These carpets looked very unsightly. Some homely touches were provided, however some bedrooms, communal rooms, bathrooms and toilets looked quite bare. The majority of people who use the home return back home after a short stay. Many bedrooms seen didn’t look homely and the inspector and manager discussed some possible solutions and ideas to make the bedrooms and communal areas more appealing. No unpleasant odours were noticeable in the home and relatives said that the home was always kept “clean and tidy”. Controls of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. DS0000067344.V349780.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Consideration should be given to how the diversity of people cared for, can affect the adequacy of the staffing levels. Recruitment records were not available, which could result in information obtained for some staff being insufficient to adequately protect the welfare of people staying at the home. Staff had completed training, including induction, which ensured that they had the competences to meet people’s individual needs. EVIDENCE: The manager said that agreed staffing levels within the home were being maintained. Three carers and one team leader worked throughout the day. The home could accommodate up to twenty people, on the day of the inspection twelve people were in residence. Staff said that they were able to provide basic care but no more on some occasions when the home was to capacity. Carers were also expected to cover the laundry and activities. A day centre on site also had an impact on staffing levels. DS0000067344.V349780.R01.S.doc Version 5.2 Page 22 It was recognised that staff sickness had played a significant part in the staff shortages, however staff said that there had also been delays in recruitment of new staff, which had added to the problem. To the credit of the staff and managers of the home a good level of care for people had been maintained. Seven care staff had achieved NVQ Level 2 or above in care. A number of care staff had also commenced the training. This did not meet the required minimum of 50 of the staff team trained to NVQ Level 2 in Care. Staff interviewed said that when they started work they received induction training in the first two months of their employment. Three staff files checked identified that the member of staff had received induction training when they commenced work. Staff were able to talk about the various training courses that they had attended, which included all of the mandatory training, for example, Moving and Handling, Food Hygiene, Adult Protection, First Aid and Fire. Some other topics had been delivered by the Sheffield Partnerships for Older Peoples Projects (POPP’s) team. Staff said that they would benefit from receiving training in how to deal with people who have challenging behaviour. The inspector asked to see the recruitment records for three people recently employed at the home. Two of the three people had been re deployed within the organisation. For these people evidence of their recruitment checks was not available. The manager was confident that all checks had been undertaken. However she tried to obtain this information and it was unclear where this was held. The importance of this information being available for inspection was reiterated to the manager. Following the inspection the manager forwarded evidence of completed CRB checks. The inspector did not see other recruitment information. DS0000067344.V349780.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36, 37 and 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Changes to the management at the home continued to cause some uncertainty and instability. The quality assurance system needed further development to ensure that the home was run in the best interests of everyone. People’s monies were safely handled, which ensured that finances were accurate and safeguarded. In the main people’s health and safety had been promoted and protected. DS0000067344.V349780.R01.S.doc Version 5.2 Page 24 EVIDENCE: The acting manager was experienced in the care of older people and those with dementia. The manager was positive about the inspection process and committed to improving the service. Staff said that morale at the home was very low. They said that they had always worked well together as a team. As there had been so many changes over a short period of time they said they were feeling de skilled and demoralised. Staff were able to recognise that some changes made were for the better. The inspector spoke to the manager about how staff were feeling. She acknowledged that the last twelve months had been difficult for some staff. The manager said she was inspired to continue to make improvements and improve the atmosphere within the home. The inspector discussed the homes quality assurance process with the manager. The manager said that she had begun to look at ways in which to ensure quality at the home was maintained. She had designed a survey/questionnaire that was to be sent to people and their relatives that would give them the opportunity to comment about the service provided at the home. Staff and carers meetings were regularly held and minutes of these meetings were seen. The responsible individual visited the home on a regular basis, a report was written following the visits. This report highlighted that the temperature of the hot water was not being checked as required by the homes policy. This was also a requirement issued at the last inspection. The home handles money on behalf of some people. This was checked for three people. Account sheets were kept, receipts were seen for all transactions and monies kept balanced with what was recorded on the account sheet. Formal staff supervision, to develop, inform and support staff took place at regular intervals and staff said that they found this useful and beneficial. On the day of the inspection a number of records that were requested were not available. Some were provided at a later date. This was partly due to the home moving from Local Authority systems and to Sheffield Care Trust systems. However the inspector believes that the managers should take more responsibility in ensuring that records and systems are organised in a way that makes them more easily accessible. DS0000067344.V349780.R01.S.doc Version 5.2 Page 25 Equipment at the home was serviced and maintained. Fire records evidenced that fire alarm checks took place each week. A fire risk assessment had been completed. There was no information in the risk assessment that clarified if any action needed to be taken following the completion of the risk assessment. DS0000067344.V349780.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 2 2 2 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 3 X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 2 2 DS0000067344.V349780.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 OP3 Regulation 14 Requirement Assessments received prior to admission to the home must accurately reflect people’s needs. Before people are admitted into the home the registered person must be able to demonstrate the homes capacity to meet the persons assessed needs. People must be given the opportunity to visit and assess the quality, facilities and suitability of the home. People must be given the opportunity for staff to meet them in their own home or current situation if different. The care needs, wishes and preferences for each person must be recorded in detail in their care plan. Plans of care must contain specific information on the staff action required to meet personal care needs. (Previous timescale of 10/11/06 not met) DS0000067344.V349780.R01.S.doc Timescale for action 17/12/07 2. OP4 14 17/12/07 3. OP5 14 17/12/07 4. OP7 15 05/11/07 Version 5.2 Page 28 5. OP7 15 Care plans must include what action staff should take when faced with challenging behaviour including aggression and violence. (Previous timescale of 10/11/06 not met) To ensure that peoples health, safety and welfare is maintained, individual risk assessments must be reviewed and updated. People must have the opportunity to exercise their choice in relation to social and leisure activities. Arrangements must be implemented to ensure that people are orientated to date, time and place. All floor coverings must be adequately maintained, clean and in good condition. (Previous timescale of 10/11/06 not met) Agreed staffing levels must be reviewed. The registered provider must be satisfied that staffing levels are adequately maintained. The varying numbers and diversity of the people accommodated must be considered within the review. Full recruitment checks must be carried out for all staff. This information must be available at the home for inspection purposes. Consideration must be given to staff comments about training regarding managing challenging behaviour, and action taken to ensure that they are confident and competent in this area. (Previous timescale of 10/11/06 not met) DS0000067344.V349780.R01.S.doc 05/11/07 6. OP7 14 05/11/07 7. OP12 16 17/12/07 8. OP12 16 17/12/07 9. OP19 OP26 26 01/01/08 10. OP27 18 01/01/08 11. OP29 19 05/11/07 12. OP30 18 10/01/08 Version 5.2 Page 29 13. OP37 17 14. OP38 23 15. OP38 13 Records required by regulation for the protection of people must be up to date, accurate and available for inspection. In line with the homes policy bathroom water temperatures must be checked and recorded weekly. (Previous timescale of 10/11/06 not met) The fire risk assessment must be fully completed. Any action necessary must then be taken. 05/11/07 05/11/07 05/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The Statement of Purpose and Service User Guide should be reviewed and updated. The design of the guide should be revised to make it easier for people to read and more appealing. Daily notes should ‘link’ to the information recorded in the care plans and reviews. Care plans should detail who has contributed to the care plan. There should be a television with a bigger screen and better reception. Bedrooms and communal areas should be made to look more homely and appealing. A minimum ratio of 50 of carers should have completed NVQ Level 2 or equivalent. Records should be arranged so that they are easily accessible. 2. 3. 4. 5. 6. 7. OP7 OP7 OP12 OP19 OP24 OP28 OP37 DS0000067344.V349780.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000067344.V349780.R01.S.doc Version 5.2 Page 31 - 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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