Inspection on 25/04/05 for Bramble House

This inspection was carried out on 25th April 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

Bramble House 17/09/09

Bramble House 17/09/08

Bramble House 20/09/07

Bramble House 13/11/06

Bramble House 19/06/06

Bramble House 25/10/05

Bramble House 26/10/04

Bramble House 02/06/04

Bramble House 16/12/03

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

CARE HOMES FOR OLDER PEOPLE Acefield Care Home 96a & 98 Stroud Road Gloucester GL1 5AJ Lead Inspector Janet Griffiths Unannounced 25 April 2005 10:30 th 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 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. Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Acefield Care Home Address 96a & 98 Stroud Road Gloucester GL1 5AJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01452 521018 Forestglade Limited Mrs Vivian Grimes Care Home - Personal Care only 30 Category(ies) of Old Age - not falling within any other category registration, with number (30) of places Physical Disability - over 65 years of age (2) Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 26 October 2004 Brief Description of the Service: Acefield Residential Care Home is situated on the outskirts of the city of Gloucester and is within easy walking distance of a local shopping complex. A major building project, completed last year, has joined the large detached house and an adjacent house via a link corridor. The first floor of the main house is accessed either by stairs or currently a stair lift until the shaft lift has been replaced. In addition to the above work, by constructing a conservatory and improving the existing lounge/diner, the communal space has been increased. A small lounge has been designated for smokers. With another extension at the rear of the building, the home is now registered to accommodate 30 elderly service users. This extension consists of four single en-suite rooms, new office space and an assisted bathroom. To complete this work, the kitchen has been enlarged and totally refurbished and a new laundry, sluice and shower room have been built. The area that was previously the adjacent house has also been refurbished and extended to provide two extra bedrooms, one en-suite, an assisted bathroom and toilet and the small smokers lounge. Access to the first floor in this half of the building is via a stair lift. There are four assisted baths and a shower within the home and there are now fourteen rooms with en-suite facilities. The home still has extensive gardens at the rear of the building and adjacent to the conservatory, with orchards, vines and fruit that the chef is able to utilise. Additional carparking space has been created at the front of the building. Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five and a half hours on one day in April 2005 and was brought forward because of a number of concerns and a complaint that had been raised recently and was completed by two inspectors. The inspectors spoke to the manager, deputy manager and most of the staff on-duty as well as a number of service users and one visitor. Whilst one of the inspectors concentrated on viewing the home and speaking with the staff and service users, the second carried out the complaint investigation looking at all the appropriate records for this and in addition, looking at a selection of records to include care plans and staff files. This inspection resulted in 15 requirements, 6 of which are requirements from previous inspections, that remain outstanding. The home is not performing to a satisfactory standard and the CSCI has arranged a meeting with the home to discuss these issues and ensure improvements. What the service does well: What has improved since the last inspection? What they could do better: The home must invest in a training and development programme for all of the staff, from needs identified at regular supervision and appraisal sessions. This must include specific training to care for this client group. A clear line of accountability must be in place and communication systems improved with recorded handover sessions being used. Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 6 Every service user, whether long-stay or respite must have a full assessment completed prior to admission, and reviewed on admission, care planned and regularly reviewed to ensure that individual needs can be met. Daily records must record any significant event of each service user and clear procedures in the event of accidents must be in place. Individual risk assessments must also be completed as well as regular environmental risk assessments to ensure that a safe environment is provided. Recruitment procedures must be improved upon. The complaints procedure does not seem to be viewed with confidence by service users and needs to be reviewed. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 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 standard(s) 1,3,4 Some progress has been made to improve the admission procedure, ensuring that an assessment is either completed by the manager, or in the case of admissions on the respite programme, a social services representative. But there is still not an assurance from the standard of records kept that care needs will be met. EVIDENCE: Information is available in the home in the form of a Statement of Purpose and Service Users Guide, which the inspectors were told, is given to the relatives of each new service user. This was seen and does need review as some information is no longer accurate. It also appeared that this information was not made available for those service users on respite care. At the time of inspection the home had three service users receiving respite care; two were being discharged that day and the third was staying until the middle of May and had been an emergency admission. One relative spoken with as a service user was being discharged said that she was very happy with the care her mother had received. However, a recent complaint received from the relative of another service user receiving respite care, was very unhappy with the care received. Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 9 The inspector also received a phone call during the inspection reporting another incident where a service user had wandered out of the home recently undetected and was found by the police. From speaking with staff, and the issues raised within the complaint it appears that staff are unable to handle difficult situations effectively and have little knowledge in how to deal with situations of challenging behaviour, and untoward incidents and accidents. There is still a concern that inappropriate placements are being made to the home resulting in staff being unable to meet their needs. Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 There has been little progress made on improving arrangements to ensure that the health needs of residents are identified and met. These shortfalls have a potential to place residents at risk. There is no improvement in the quality of record keeping safeguarding risks and the health and welfare of service users. EVIDENCE: Although a brief assessment and some care plans are completed for permanent residents, there are few records kept for those on respite care. There were no photographs of any of the residents on short-term care. A new daily record sheet has recently been introduced with tick boxes to indicate if meals have been taken and whether a resident is continent and have taken their medication. In addition to this care staff make brief records. The records of the resident named in the complaint were seen and two significant incidents when she had an accident and was trying to leave the home via the garden, were not recorded. There was also very little other information regarding the care needs of this resident Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 11 One service user had been receiving attention from the district nurse for a pressure sore, which reportedly has now healed. This service user has been unwell. A pressure- relieving mattress was in place. Others receive blood glucose monitoring each week as they have diabetes. Three of the staff have reportedly been trained to perform this procedure by a district nurse but there is no written evidence to confirm this. One service user was reported as generally deteriorating and was being nursed in bed. She also had a pressure relieving mattress in place and because she was nutritionally at risk she was being fed and given supplements to her diet. The medications were not checked fully on this occasion but a request has been made for the pharmacy inspector to carry out an inspection shortly as there have been a number of problems with the medication procedures in the past. One service user on respite care was spoken with and did voice concerns over his drug administration. He was used to self-administering his medicines at home, but found that some of his tablets were missed or not given at appropriate times following his admission which caused a problems with his condition. His chart was checked and some gaps in recording were found. The deputy manager reported that he had missed one dose only as he only brought two days supply in with him and they had problems getting a new supply. The other gaps she explained as having forgotten to sign for the tablets given. It has been a requirement for some time for staff administering medicines to receive accredited training. The inspector was informed that approximately 12 staff had been enrolled with Swindon College to commence shortly. One issue raised within the complaint related to lack of privacy. Rooms do not have locks but it is recommended that these are fitted to doors to provide privacy ensuring that they comply with fire regulations and allow emergency access to staff. Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 12 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 standard(s) 12,13,15 There continues to be a lack of social activities within the home although visitors are encouraged and links with the community maintained where possible. Nutritious meals are provided. EVIDENCE: An activities organiser has recently been appointed to work four mornings a week. She was not on-duty during the inspection and there appeared to be little stimulation for the residents. This is an outstanding requirement from the last inspection. It was reported that she is currently assessing each resident’s interests (nothing recorded) and is about to arrange a programme of activities. A copy of this programme has been requested. There is a clear need for activities to be better organised, the only two things noted were a drawing of a tree, which was a “birthday tree”, that had been stuck on the wall the previous week; one person who gets picked up once a month by the W.I and two people who go to a day centre every week. Staff did mention bingo and something that sounded a little like reminiscence therapy but the residents’ did not mention any of these. A total of ten residents were spoken with. One said she was very happy at the home; that the food was good and she got on well with other residents and was satisfied with the personal care she received. Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 13 A second said she was very happy at the home and that she got on well with everybody, but like to go out occasionally, as she has very few visitors. A third stated that he thought the staff were “very nice” and that his personal care was “brilliant”. He liked talking to staff and stated that he thought he was always “treated with respect” and in a caring way. Another resident said that she enjoyed the home as everyone has “laugh and a joke”, the food was nice and there was always enough. A married couple said that they felt safe and enjoyed the company, had lots of visitors, the food was good and that there was nothing they were unhappy with. One said that he thought the home was “nice” but said there were “two staff”, who can be a bit “heavy handed, if you know what I mean”. He explained he meant the way they talked to people, which could be too” loud” and a “bit aggressive”. He was later observed having a chat and a joke with a care assistant and they seemed to have a respectful relationship. The last resident spoken with stated that the home was “fairly beareable” but “jolly was not the word” and she would rather be at home. The food was average and “most of the staff were alright” Meals were not looked at in great detail on this occasion. The home does now keep a record of all meals provided and were asked to be more specific about sandwich fillings at suppertime. Cakes were being baked for tea and there was always someone observed being given drinks and biscuits between mealtimes. From the above comments from the residents it appeared that they were happy with their meals. One resident being nursed in bed remarked that she was getting regular food and drinks provided by the staff. The cook on duty said that the food budget was adequate and that there never was a problem getting additional produce if required. She felt the diet provided was very good with a high proportion of fresh items used and very little “budget” items. They provide specialist diets for 5 diabetics, though this seemed to be simply making puddings using “candarel” instead of sugar. There were no vegetarians in the home. There were no written instructions in kitchen about preferences or diets but the cook said that they all knew what individuals liked and disliked. One resident occasionally helps with the washing up but no others are interested. Staff were observed always knocking on doors before walking in and speaking to any residents they came into contact with. Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 14 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 standard(s) 16 & 18 There is a complaints procedure in the home but little evidence that the service users or their relatives feel that their views are listened to or acted upon. Arrangements for the protection of service users are not satisfactory placing them at possible risk of harm or abuse. EVIDENCE: This unannounced inspection was brought forward as a result of a complaint being received by CSCI. Social Services and CSCI have also received a number of concerns over recent months that have been followed up and all appear to have common themes. Several recently reported incidents indicate that service users are at risk in the home; for example, one wandered out of the home onto the busy main road and was found by the police and a second had a fall which involved a lift door that had been propped against the wall when the lift was being repaired. She was reported by the complainant to have multiple bruises and abrasion on discharge which staff were unaware of. This resident also attempted to leave the home and was reportedly brought back against her will. When one resident was asked whether there was anything she was not happy with she became a little evasive and said that just because someone made “one mistake a week they should not get into trouble.” She said that she “would not complain”, smiled and said she did not want to say anything else. Another thought it was “unfair to complain” as the staff all did their best, and would not elaborate on this. One member of staff was very upset and angry that the home was being criticised and said she felt like giving in her notice. Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 15 It was reported that a total of fifteen staff from both day and night duty had attended training on Adults at Risk, but of those spoken with many either didn’t realise that was what it had been or couldn’t remember having it. The home does have a policy on whistle blowing. Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 16 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 standard(s) 19 & 26 The standard of the environment within this home is satisfactory but does not provide service users with a particularly attractive and homely place to live. EVIDENCE: The standard of cleanliness in the home is poor. One cleaner was observed hovering, but when the job was completed, there were still particles of food visible on the floor. Also, when a resident was taken out to have their clothes changed after spilling a drink, the chair was not wiped over. One cleaner was newly appointed but appeared unclear about her duties and the second cleaner was unable to help with this. One relative spoken with in a telephone conversation stated that it was ‘a shabby and depressing home’. Generally the standard of maintenance was satisfactory and there were no obvious areas to be addressed, but two bedrooms, one of which was empty, had odours of urine. Apart from this the rooms appeared reasonably clean and tidy and several were fairly personalised. Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 17 One downstairs bathroom was out of action, but this had only happened 4 days previous and repair had been organised. There were concerns in relation to the complaint investigation over the security in the home and garden as staff were reluctant to allow one service user the freedom to spend time in the garden and a second absconded from the garden undetected. Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 The procedures for the recruitment of staff are still not robust and do not provide the safeguards to offer protection to people living in the home. The training opportunities offered to the staff have been limited to date resulting in an under skilled staff group. EVIDENCE: There were adequate staffing levels on-duty at the time of inspection to meet the needs of the service users, with four care staff in addition to the manager and deputy during the morning and four care staff on the late shift. There was nobody in charge of the shifts during the evenings, and also during the day, in the absence of the manager and deputy, with an ad hoc arrangement of the person who had been at the home the longest being in charge. As this has been raised both in the complaint and concerns raised that no-one appears willing to accept responsibility of a shift there is a need to assign a designated shift leader for each shift and record this on the rotas so that everyone is clear who is responsible. Seven care staff were spoken with during the inspection. One new member of staff stated that she thought the home provided a good standard of care and that the staff were “very caring”, often doing things in their own time and bringing in items and gifts for the residents. Two staff had no concerns at all about the quality of care or the attitudes of staff and felt that the team worked together and that the standard of care was “very good”. Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 19 Staff regularly visit the home in their own time and were very proud of the job they do. Another was positive about the care and the management of the home and the rest of the staff team. The last spoken with said that this is the “best one she has worked in”. She thought the staff team were very caring, committed and worked very hard and she had no concerns about any aspects of the care provided. To date none of the staff have commenced NVQ training although it was reported that at least ten should be commencing training once Learning Direct has found a provider and is helping with finances for this. Most of the staff are a mature staff group and are reportedly apprehensive about commencing this training. Neither could any give examples of any service user specific training they had done, i.e. dementia, managing incontinence. Practice appears to be developed by watching and learning from the established staff members who themselves have had no formal training. Two staff commented upon the fact that when people are deaf you need to speak “loudly”. Nobody has had any training in communication, which is very important in this client group and in view of the concerns/complaint raised on staff communications and attitudes. The only recent training staff had undertaken was for moving and handling, first aid and fire training. Two care and two catering staff were also completing a distance learning nutrition course. Several examples of good interaction between staff and residents were observed with no obvious examples of poor practice, but the staff generally had a limited view of their roles and limited understanding of best practice issues. The staff were genuinely surprised at criticisms and none criticised or made any suggestions for how the home could be improved in any way. All staff appeared well presented and people seemed to be busy, the two times they were stood in a group they were discussing work issues and allocating tasks. Three staff files of newly appointed staff were requested; one could not be found and one did not have a file. CRB and POVA had been checked for two but not the third who had been employed at the home previously. This person stated that she had just started work again at the home after working elsewhere for 6 years and has not provided references or completed a CRB check. The manager was told that this is still necessary. One who had recently been appointed did not have a full career history and had not declared that she had worked in a care home previously or obtained a reference from this employer. The medical questionnaire also needs to be amended to include confirmation of both mental and physical fitness. Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,36,37,38 There is no leadership, guidance and direction to staff to ensure residents receive consistent quality care. This results in some practices that do not promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: The system for handovers is very ad hoc, with no formal handover time or procedure, or prescribed time for writing up notes. This must be organised within work time to ensure that adequate communications between staff are in place. The manager stated that a meeting had been scheduled for the previous week to discuss the complaints but when she arrived for it was informed that the staff cancelled it. One member of staff when asked about staff meetings commented that the home “didn’t need them as everyone knows what they are doing’’. She further stated that the management of the home was “excellent” and that she had no issues or concerns in that area. Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 21 Another member of staff thought staff meetings were very useful. One member of staff stated that she has had an appraisal but no formal supervision, (and didn’t understand what this was). It was reported that all staff had had appraisals completed and these were seen with one exception. A system has been devised for supervision but none have taken place as yet. The staff team are quite loud at times and two people appeared quite brusque in their approach, but this did not seem to be in any uncaring way, simply the way they work. The impression is given that there are a few strong characters in the staff team, and with the lack of training and supervision there is a concern that these staff are to some extent role models for the newer and younger staff members. A full health and safety check was not completed on this occasion but issues recorded elsewhere in this report regarding security in the home and garden and areas of the home being in an unsafe condition and inappropriate action taken with regard to accidents and incidents in the home all raise concerns about the health, safety and welfare of service users in the home. There were also issues raised concerning the records that should be maintained in the home, for example a record of visitors and a photograph of each service user. Neither of these are well maintained. Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 22 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 1 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 1 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 2 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 1 x 2 x x x 2 2 1 Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 23 yes Are there any outstanding requirements from the last inspection? 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 3 Regulation 14 Requirement Ensure that each new service user is only admitted on the basis of a full assessment completed by someone qualified to do so to ensure that their needs can be met by the home. Timescale of 26/11/04 not met. The registered person shall keep under review and where appropriate, revise the statement of purpose and the service users guide and notify the Commission and service users of any such revision within 28 days. The registered person shall ensure that the assessment of the service users needs is kept under review; and revised at any time when it is necessary to do so having regard to any change of circumstances. Each service user shall have a written plan of care that is kept under review in consultation with the service user/their representative where possible. The registered person shall make suitable arrangements for the recording, handling,safekeeping, safe adminsitration and disposal Timescale for action 31/5/05 2. 1 6 31/5/05 3. 4 14(2) 31/5/05 4. 7 15 31/5/05 5. 9 13 31/5/05 Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 24 6. 12 16 7. 13 16 8. 18 13 9. 19 13 10. 11. 26 30 16 18 12. 29 19 13. 36 18 of medications received into the care home. A programme of activities to be arranged in consultation with the service users having regard to their needs (timescale 31/12/04 not met). Consult service users about their social interests and make arrangements to enable them to engage in local, social and community activities (timescale of 31/12/04 not met) The registered person shall make arrangements, by training staff or other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. The registered person shall ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. Ensure that all areas are kept clean and odour free(timescale of 26/11/04 not met). Ensure that persons employed by the registered person receive training appropriate to the work they are to perform and suitable assistance including time off, for the purpose of obtaining further qualifications appropriate (timescale of 26/11/04 not met) The registered person shall not employ a person to work at the care home unless the person is fit to work at the home and the registered person has obtained in respect of that person the information and documents specified in paragraphs 1 to 7 of Schedule 2. Staff supervision and appraisal programme to commence(timescale of D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc 31/5/05 31/5/05 31/5/05 31/5/05 31/5/05 31/5/05 31/5/05 31/5/05 Acefield Care Home Version 1.20 Page 25 31/12/04 not met) 14. 37 17 The registered person shall maintain in respect of each service user a record which includes the information, documents and other records specified in Schedules 3 & 4 A record must be kept of any accident affecting the service user in the care home and of any incident in the care home which is detrimental to the health or welfare of the service user, which record shall include the nature,date and time of the accident or incident, whether medical treatment was required and the name of the persons who were respectively in charge of the care home and supervising the service user. A record of falls and treatment provided to the service user must be kept. 31/5/05 15. 38 17 31/5/05 16. 38 17 31/5/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 7 Good Practice Recommendations The service users plan meets relevent clinical guidelines produced by the relevant professional bodies concerned with the care of older people, and includes a risk assessment, with particular attention to prevention of falls. The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times. The registered person shall establish and promote a procedure for considering complaints made to a registered person by a service user or person acting on the service users behalf and shall be appropriate to the needs of the service user. A recorded staff rota showing which staff are on duty at Version 1.20 D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Page 26 2. 3. 10 16 4. 27 Acefield Care Home 5. 6. 28 32 7. 8. 38 38 any time during the day and night and in what capacity, is kept, for example a designated person in charge for each shift. A minimum ratio of 50 trained members of care staff (NVQ 2 or equivalent) is achieved by 2005. The registered manager communicates a clear sense of direction and leadership which staff and service users understand and are able to relate to the aims and purpose of the home. The registered manager ensures that risk assessments are carried out for all safe working practice topics and that significant findings of the risk assessments are recorded. All accidents and incidents of illness or communicable disease are recorded and reported. Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 27 Commission for Social Care Inspection 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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. Extracts may not be used or reproduced without the express permission of CSCI Acefield Care Home D51_D03_s16357_Acefield_v221755_030505_Stage 4.doc Version 1.20 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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