Inspection on 11/09/06 for Breach House

This inspection was carried out on 11th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Breach House 03/11/05

Breach House 07/07/05

Breach House 25/01/05

Breach House 09/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Breach House Holy Cross Lane Belbroughton Stourbridge West Midlands DY9 9SP Lead Inspector N Andrews Unannounced Inspection 09:10 11 and 14 September 2006 th th 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 Breach House DS0000018495.V311406.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. Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Breach House Address Holy Cross Lane Belbroughton Stourbridge West Midlands DY9 9SP 01562 730021 01562 730021 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) Miss Karen Ann Hucker Mr Michael Gordon Hucker, Mrs Hilary May Hucker Mrs Julie Anita Head Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (26), of places Physical disability over 65 years of age (26) Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home provides a service for older people but may also accommodate one named person under the age of 65 who has dementia. 3 November 2005 Date of last inspection Brief Description of the Service: Breach House is a large, detached property that was formerly a farmhouse. The premises have been adapted and extended for their present purpose as a residential care home for older people. The property occupies a level site and is situated in a rural area in approximately two acres of ground at the end of a long driveway on the edge of the village. The service users are accommodated in single bedrooms, some of which are large enough for two people, on three floors. Twenty-four of the bedrooms have an en-suite facility. The home has a passenger lift to enable the service users who are accommodated on the first and second floors to access their bedrooms more easily. One bedroom is served by a stair lift. There are two lounges, a dining room and a conservatory. The home provides communal bathroom and toilet facilities. The garden is attractive and well maintained and there is adequate car parking space near the front of the building. The home operates as a family business and a registered manager is employed to be responsible for the day-to-day running of the home. At the time of the inspection two service users were in hospital and one of the other 24 service users was in receipt of short-term respite care. One person was attending the home two days each week for day care. The fees range from £1349.00 to £1780.00 per month. Breach House DS0000018495.V311406.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 that took place over the course of two days. The home was inspected against the key National Minimum Standards and time was spent with the registered manager and, in part, the registered provider assessing the home’s response to the requirements that were made as a result of the previous inspection. Various records and a number of policies and procedures that the home is required to maintain were inspected. A tour of the premises was also made. Individual discussions were held with three service users, two members of staff and the relative of one of the service users. As part of the inspection ‘Comment Cards’ were also issued to the relatives of the service users. Five Comment Cards were completed and returned. The comments contained in the Comment Cards are reflected in this report. What the service does well: What has improved since the last inspection? Since the previous inspection several of the service users’ bedrooms had been redecorated and the first and second floor corridors had been redecorated and re-carpeted. The main lounge had been repainted and the conservatory had been refurbished. The work to upgrade all of the fire doors and to fit protective covers to all of the radiators had been completed. Breach House DS0000018495.V311406.R01.S.doc Version 5.2 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. Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5 The quality outcome in this area was good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their relatives had an opportunity to visit the home prior to admission and each service user was provided with a written contract. However, the statement of purpose and service users’ guide did not include all of the required information to enable prospective service users to make a fully informed choice about the home. The form that was used to assess prospective service users did not cover all of the relevant aspects of care to enable the staff to prepare a full and accurate care plan to ensure that all of the service users’ care needs were met. EVIDENCE: The registered manager stated that all the service users were given an information pack containing a copy of the home’s statement of purpose and service users’ guide on admission. Three of the service users with whom discussions were held confirmed that they had received copies of the home’s statement of purpose and service users’ guide. A copy of the home’s statement of purpose was made available for inspection. It was pleasing to note that the statement of purpose contained relevant information including a Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 9 ‘Residents Charter’. However, it did not include all of the required information and needed to be amended in a number of places as follows, • The reference to ‘mental’ illness on page 1 should be changed to ‘dementia’ illness. • The reference to ‘Elderly care (I), Mental infirmity (MP/E) and Physical frailty (PH/E)’ on pages 2 and 8 must be changed to reflect the correct service user categories contained in the home’s Certificate of Registration. • The address of the registered provider must be included in accordance with Schedule 1.1. • A statement that the home is not registered to provide nursing care must be included in accordance with Schedule 1.7. • The reference to ‘10’ days in paragraph 18 on page 7 must be changed to 5 days in accordance with Standard 5.3. • The reference to the Registration and Inspection Unit on page 8 must be changed to Commission for Social Care Inspection. • The arrangements made for respecting the privacy of the service users must be included in accordance with Schedule 1.18. Some of the information provided in the statement of purpose was repeated. It would be helpful if the document was revised accordingly. A copy of the home’s service users’ guide was made available for inspection. The service users’ guide contained relevant information. However, it did not include all of the required information and needed to be amended as follows, • The reference to ‘Elderly care (I), Mental infirmity (MP/E) and Physical frailty (PH/E)’ on page 17 must be changed to reflect the correct service user categories contained in the home’s Certificate of Registration. • A reference to the terms and conditions in respect of accommodation to be provided for service users, including as to the amount and method of payment of fees must be included in accordance with Regulation 5 (1)(b). • A statement that a copy of the home’s most recent inspection report is kept in the home and is available for perusal on request must be included in accordance with Regulation 5 (1)(d). • The service users’ guide should include the service users’ views of the home and information about how to contact the local social services and health care authorities in accordance with Standards 1.2 and 1.3, respectively. The registered manager stated that all the service users were given a statement of terms and conditions of residence (contract) on admission. A copy of the contract was made available for inspection. It was pleasing to note that the contents were satisfactory. The registered manager stated that, in the majority of cases, she was responsible for carrying out the care needs assessment of prospective service users prior to their admission. Occasionally, the deputy manager accompanied Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 10 the registered manager. A copy of the form used by the home to assess the needs of prospective service users, was made available for inspection. The assessment form was called ‘Prospective Client Assessment Sheet’ and contained headings for recording relevant information. However, the assessment form did not include a reference to, • religious and cultural needs. The assessment form must be amended in order to include a reference to the above issue. The format of the assessment form should also be expanded to ensure that there is sufficient space to record details of all the information required. Prospective service users are invited to make an introductory visit to the home prior to admission in order to share a meal with the current service users, to view the home and to meet the staff. Two of the service users with whom discussions were held confirmed that they had made a pre-admission visit to the home. The home’s contract stated that ‘the first eight weeks after admission will be regarded as a trial period’. The registered manager stated that the home did not normally admit service users in an emergency. However, emergency admissions had occurred in the past and had been successful. The home’s policy and procedure in respect of emergency admissions was referred to in the home’s statement of purpose. Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 11 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): 7, 8, 9 and 10 The quality outcome in this area was good. This judgement has been made using available evidence including a visit to this service. The home provided a care plan for each service user and these were reviewed regularly. There was evidence to show that the service users’ healthcare needs were being met and that they were treated with dignity and respect. However, the care plans did not include all of the required information and accredited training in the administration of medication had not been undertaken by all the staff. EVIDENCE: The registered manager stated that all of the service users had a care plan. A copy of the home’s care plan form was made available for inspection. The care plan contained a reference to most of the aspects of care listed in Standards 7.2 and 3.3. However, it did not include a reference to the following aspects of care, • communication, • foot care, • personal safety and risk, • carer and family involvement and other social contacts/relationships. The care plan must be amended to include all of the above issues. The care plans in respect of four service users were inspected. The care plans contained clear, relevant information and there was evidence to show that they were Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 12 reviewed monthly. The care plans contained risk assessments on falls, nutrition, moving and handling and pressure areas. However, the care plans in respect of two service users had not been signed by the service users or their relatives. The registered manager stated that all of the service users were registered with GP’s in two local surgeries in Hagley and Belbroughton. None of the service users had any pressure sores. It was confirmed that the staff were aware of what to look for in order to prevent pressure sores developing. The home provided pressure relieving mattresses and cushions and sheepskin protection for heels. It was confirmed that the district nurses were supportive and that the home enjoyed a good relationship with them and other visiting professionals e.g. the continence adviser. MUST nutritional screening was undertaken on admission and a record of the service users’ weight was maintained. The service users were weighed every month and if there were any concerns a weight-monitoring chart is introduced. An aroma therapist visited the home and she also provided hand massage. The service users’ records contained details of checks carried out by the GP, dentist, optician and chiropodist. Service users with hearing problems were referred to the GP. The service users with whom discussions were held expressed their satisfaction with the arrangements made for their health care. The relative of a service user who was a frequent visitor to the home stated in one of the Comment Cards ‘I am more than impressed with the standard of care provided. It is excellent’. The home used the NOMAD monitored dosage system for the administration of medication. The home had secure facilities i.e. a treatment room, for the safe storage of medicines. Medication for external use was stored separately from internal medicines. A controlled drug cupboard was used for the safe storage of controlled drugs. A controlled drug register was used for recording the administration of controlled drugs. The record of administration for controlled drugs contained the signatures of two members of staff. A dedicated fridge was provided for storing medication that required cool storage. A list of signatures was maintained in respect of the staff members that were involved in the administration of medication. The list needed to be updated. The medication administration records (MAR Charts) were accurate and up to date. The MAR Chart entries that were handwritten were signed by two members of staff. The home maintained a record of the medication that was returned to the surgery. The registered manager stated that the home had a positive relationship with the dispensing surgery. Appropriate notices were displayed in the treatment room. The staff supervised one service user who selfadministered insulin. The staff did BM monitoring. One senior member of staff and two newly appointed members of staff from abroad who were not yet involved in the administration of medication had not undertaken accredited training in the administration of medication. The keys providing access to the storage of medication was restricted to the senior on duty and the registered manager who also had a set of keys. The policy and procedure for the Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 13 administration of medication was clear and well written. However, it contained an out of date reference to the National Care Standards Commission (NCSC). This should be replaced with a reference to the Commission for Social Care Inspection (CSCI). The policy and procedure should also include details of the procedure to be followed in the event of an error in the administration of medication. The service users with whom discussions were held were content with the arrangements that had been made for the administration of their medication. The registered manager had developed a code of practice, a copy of which was issued to all new members of staff. The code of practice included a reference to some of the principles that underpin good residential care i.e. choice, fulfilment, independence, privacy and rights. The discussions that were held with two members of staff revealed that they understood the importance of respecting the service users’ privacy and dignity. Their responses to the questions that were asked reflected the good practice outlined in Standard 10. The home had a mobile handset that enabled the service users to make and receive telephone calls in private. Several of the service users had their own telephone in their bedroom. Mail is given to the service users unopened. However, in some cases the service users’ relatives had asked for the post to be kept in the office until they collected it. This was done in order to prevent the service users from becoming worried about any matters that may cause them anxiety. It was confirmed that the service users always wore their own clothes. The three service users with whom discussions were held confirmed that the staff treated them with respect and that their right to privacy was upheld. One service user said, ‘I’m very happy with the service from the home’. Another service user said, ‘The staff are very thoughtful. They always knock the bedroom door’. Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The quality outcome in this area was good. This judgement has been made using available evidence including a visit to this service. The service users were satisfied with the range of social and leisure activities provided by the home and were able to maintain contact with their relatives and friends with whom contact was encouraged. The service users were helped to exercise choice and control over their lives. The home provided wholesome and nutritious food. EVIDENCE: The home employed a person specifically to promote the social activities for the service users. The home provided a range of social and leisure activities, both internal and external. The activities included outings to the garden centre and pub, videos, manicures, Bingo, a visiting singer and guitarist and reminiscence sessions lead by members of staff. The home had recently held a ‘summer sizzler’ and other special events e.g. birthdays, were also celebrated. A hairdresser visited the home every week. None of the service users attended a place of worship. However, a representative from the Anglican Church led a Communion Service at the home once a month. A choice of food was offered and service users were able to exercise choice in regard to what time they had breakfast and where they ate their meals. The registered manager stated that relationships between the service users’ were positive. The service users were informed verbally about social and leisure activities. Information about forthcoming events was placed on notice boards, included in Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 15 a monthly newsletter and discussed in service users meetings that were held approximately every three months. The home also had an ‘Events Folder’ that contained details about activities and forthcoming events. A ‘Residents and Families Information File’ was available in the main corridor that contained a ‘welcome letter’, a list of activities, the dining arrangements, a statement of the home’s aims and objectives, a copy of the ‘residents charter’, a copy of the home’s statement of purpose and service users’ guide, the most recent inspection report and the service users’ views of the home. The service users with whom discussions were held expressed their satisfaction with the range of activities provided and confirmed that they were consulted about the food and their personal preferences and routines. They also confirmed that they were free to get up and go to bed when they wished. The relative of one service user expressed her satisfaction with the way in which her mother had improved during the period of her residence in the home. She said that her mother ‘socialised more and was much more alert’. She also commented positively on the ‘good atmosphere’ within the home and said, ‘The television isn’t on all the time which is a good thing’. The registered manager stated that visitors were welcome at all reasonable times. Visitors were asked to contact the home beforehand if they intended to visit after 9.00 pm. Service users were able to receive their visitors in private. The registered manager stated that the service users’ choice about those whom they wished to see or not see would be respected. The service users with whom discussions were held confirmed that their visitors were made welcome and were always offered a cup of tea. The relative of one service user also confirmed that she was made to feel welcome and that the staff were pleased to see relatives. The statement of purpose stated that the home had an ‘Open House’ policy towards visitors and ‘encourages relatives, friends and others i.e. voluntary organisations, to visit the home during the day’. The registered manager stated that the service users were encouraged to retain responsibility for their own finances and to make decisions regarding various aspects of their care. The service users that were spoken to during the inspection confirmed that they were able to exercise choice in daily living. The home issued information leaflets to the service users and their relatives at the time of admission about the Care Aware Advocacy Service. The home also provided leaflets from the NHFA Care Fees Advisory Service on ‘Meeting the Cost of Care’. The bedrooms that were seen during the inspection contained evidence to show that the service users were enabled to bring personal possessions with them. The contract stated that ‘Items of personal furniture may be brought into the Home by the Resident at the discretion of the Proprietors etc’. The registered manager stated that the service users were able to access the records held about them by the home. The home’s statement of purpose contained a reference to ‘The Right of Access to all Personal Records’. Details of the Care Aware Advocacy Service and the service users’ entitlement to bring personal possessions with them when they are admitted should be referred to in the service users’ guide. Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 16 The home operated a four-week menu and maintained a record of the food provided. The record was inspected and found to be balanced and nutritious. The food that was observed being served during the inspection was wholesome, well presented and sufficient in quantity. The meal times were appropriately spaced throughout the day i.e. breakfast was served between 9:00 and 9:15 am, lunch was served between 12:30 and 12:40 pm and the tea time meal was served between 5:00 and 5:15 pm. Drinks and biscuits/cakes were provided mid-morning and mid-afternoon and supper was served between 9:00 and 9:30 pm. The service users were consulted on a daily basis about the food they wished to have the following day. A choice of food was available. Eight service users were diabetic and their dietary needs were catered for appropriately. None of the service users required liquefied meals or special diets for cultural, religious or medical reasons. The registered manager stated that none of the service users had any difficulties in swallowing. The risk assessment in respect of one service user who had epilepsy needed to be more specific about the action to be taken in the event of choking during a seizure. It was noted that tests were carried out on two service users who had high levels of cholesterol. One service user required staff assistance at meal times and another service user needed to be encouraged to eat. The food for two service users was served in dishes to enable them to retain their independence whilst eating and another service user used adapted cutlery that she had brought with her when she was admitted. However, the service users’ comments about the food were not altogether positive. One service user said, ‘The food is not always as good as I’m used to, it’s acceptable, I’d like better food, I’m reasonably happy here, apart from the food it’s like a hotel’. Another service user stated, ‘The food is quite good. I would like more green vegetables’. One service user felt that there were ‘too many sandwiches’. The comments by the service users about the food were not regarded as so detrimental as to result in this Standard not being met. However, it is recommended that all the service users are consulted about the food in order to identify any improvements that can be made. Breach House DS0000018495.V311406.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): 16 and 18 The quality outcome in this area was good. This judgement has been made using available evidence including a visit to this service. The home had a satisfactory complaints procedure and the service users felt confident about making complaints. However, the home’s policy and procedure for the protection of service users from abuse and the relevant training for the registered manager and deputy manager did not fully ensure the safety of the service users. EVIDENCE: The home had a satisfactory complaints procedure that was referred to in the statement of purpose, service users’ guide and, more briefly, in the contract. A copy of the complaints procedure was also included in the folder of information issued to new service users at the time of admission. The home maintained a record of the complaints made against the home. The last entry was dated 31 July 2003. A copy of the complaints procedure that was on display near to the main entrance included information that was out of date. The registered provider addressed this matter immediately. A requirement was made as a result of the previous inspection that information must be available in the complaints procedure that complainants can contact the Commission for Social Care Inspection at any time. The requirement had been implemented. The service users with whom discussions were held stated that they felt confident about making a complaint and that any complaint made would be dealt with appropriately. One service user confirmed that she had a copy of the complaints procedure in her bedroom. The home had a policy and procedure on the protection of vulnerable adults from abuse. The registered manager stated that a copy of the policy and Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 18 procedure had been given to each member of staff. The policy and procedure must be amended in order to ensure that all alleged or suspected incidents of abuse are responded to appropriately without having to obtain the prior consent of the suspected victim. The same policy and procedure must also state clearly that all cases of alleged or suspected abuse will be referred without delay to the CSCI in accordance with Regulation 37. The registered manager was advised that, in different places in the policy and procedure, it would be more appropriate to change the word ‘should’ to ‘will’ in order to ensure a more robust approach to dealing with any issues of abuse that may arise. A copy of the home’s ‘whistle blowing’ policy was made available for inspection. The policy must include a clear statement that members of staff may refer any concern to an outside agency e.g. the CSCI, without having to exhaust the home’s internal mechanisms first in accordance with the provisions of the Public Interest Disclosure Act 1998. The home had a video on ‘Abuse in Care Homes’ that was used in staff training exercises. The registered manager confirmed that the staff had undertaken training in basic awareness of adult abuse. Whilst this training is sufficient for care staff, it is important that the registered manager and deputy manager undertake training on the protection of vulnerable adults from abuse at a management level. The home had a copy of ‘No Secrets’. The registered manager confirmed that no incidents of alleged or suspected abuse had occurred within the home or had otherwise come to her attention since the previous inspection. The registered manager also confirmed that she had had no reason to be concerned about the way in which any of the service users had been cared for or any reason to refer any member of staff for consideration for inclusion on the POVA register. The registered provider was aware that any member of staff whose name appeared on the POVA register or who posed a potential risk to service users must be suspended from duty immediately. The home had a policy on ‘Aggression towards Staff’ and on ‘Physical Restraint’. The home’s policy in respect of insuring the service users’ personal belongings was referred to in the contract. The home had a policy that precluded staff involvement in assisting in the making of or benefiting from service users’ wills. This was referred to in the policy on ‘Acceptance of Gifts’, a copy of which was given to staff as part of their induction. The home’s policy on service users’ money and financial affairs should include advice on personal insurance and preclude staff involvement in assisting in the making of or benefiting from service users’ wills and this information should be reflected in the service users’ guide. Breach House DS0000018495.V311406.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): 19 and 26 The quality outcome in this area was good. This judgement has been made using available evidence including a visit to this service. The service users lived in a clean, comfortable and well-maintained environment. A small number of issues relating to some aspects of the environment required attention. EVIDENCE: The home was on a level site with ramped access at both the front and rear of the premises. The property, a former farmhouse, had been adapted for its present purpose as a residential care home. There was a passenger lift to enable the service users to gain easier access to the accommodation on the first and second floor. A stair lift had also been installed to enable one service user to gain access to accommodation in another part of the premises. The registered manager kept a maintenance book in which she recorded items that needed to be repaired and/or renewed. The registered provider stated that similar issues were also recorded in the reports that were prepared in accordance with Regulation 26. It was also stated that the same matters were being included in the home’s development plan. However, in order to demonstrate the home’s proactive approach to the maintenance of the Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 20 premises a programme of routine maintenance and renewal of the fabric and decoration of the premises should be introduced. The programme could form part of the home’s development plan. The grounds were tidy and attractive. It was confirmed that the home employed a gardener for 15 hours per week. A requirement was made as a result of the previous inspection that contained four elements. Two elements of the requirement had been implemented and two elements had not been implemented. The two elements of the requirement relating to the provision of a lock and the upgrading of the flooring in the corridor that had not been implemented still stand. The Fire Safety Officer had visited the home on 19 September 2005. It was confirmed that all seven of the recommendations that had been made as a result of the visit had been implemented. The Environmental Health Officer had visited the home on 9 March 2005. It was confirmed that all five of the recommendations that had been made as a result of the visit had been implemented. It was noted that there was exposed pipe work in the ceiling in the dining room. The registered manager stated that there had been a leak and gave an assurance that the registered providers were in the process of repairing it. Standard 22 was not fully assessed during this inspection. However, during the tour of the premises, it was noted that there were no handrails in parts of the main corridors. Handrails are an essential provision in all homes that are registered for older people and people with a physical disability. The premises were clean, hygienic and free from unpleasant odours. The home had a satisfactory laundry that was appropriately sited off the main corridor on the ground floor. The laundry contained hand-washing facilities. The laundry floor finishes were impermeable and these and the wall finishes were readily cleanable. The home had an infection control policy and policies and procedures on clinical waste, cleaning of spillages and communicable diseases. The policies and procedures that were made available for inspection were satisfactory. The registered provider stated that it was intended to review all of the policies and procedures annually as part of the home’s quality assurance system. All of the home’s policies and procedures had been dated by the registered manager when they were reviewed. However, they should be signed and dated by the registered manager when they are introduced and when they are reviewed. The laundry contained an industrial washing machine that had the specified programming ability to meet disinfection standards. The service users with whom discussions were held spoke positively about the standard of cleanliness throughout the home. They confirmed that the staff wore aprons and gloves when necessary. One service user said that his room was cleaned every day. A Comment Card completed by the relative of one service user contained the comment, ‘The home is clean, tidy, attractive and always smells sweet’. The bathrooms and toilets for communal use were provided with paper towel and liquid soap dispensers. Breach House DS0000018495.V311406.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): 27, 28, 29 and 30 The quality outcome in this area was good. This judgement has been made using available evidence including a visit to this service. The service users’ needs were being met by staff who were competent and appropriately trained. However, the staff recruitment procedure did not fully protect the service users. EVIDENCE: The home had recently encountered some staffing difficulties following the departure of three members of staff. However, these problems had been largely overcome by the appointment of two new full-time members of staff from abroad. A copy of the home’s staff rota was made available for inspection. The staff duty rota showed that the home was adequately staffed. In addition to the registered manager, the home employed a deputy manager for 37.5 hours per week, four senior care assistants (days) for a total of 152.5 hours per week, three senior care assistants (nights) for a total of 103 hours per week, two care assistants (nights) for a total of 52.5 hours per week i.e. 5 nights and four care assistants (days) for a total of 103.5 hours per week. At the time of the inspection, one of the three senior care assistant posts (nights) was vacant. Members of staff that were already employed by the home were helping to cover the night duty. The home deployed two members of staff to be on waking duty at all times during the night. Two members of staff were employed for a total of 56.5 hours per week for housekeeping duties. The home employed two members of staff to cover the catering duties i.e. one fulltime kitchen manager for five days per week (35 hours) and one part-time cook for two days per week (14 hours). The staff rota showed that some staff worked long shifts from 7:00 pm to 7:30 am i.e. over 12 hours, and from 7:30 Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 22 am to 9:00 pm i.e. over 13 hours. The registered manager gave an assurance that these occasions were always informed decisions and only occurred in highly exceptional circumstances. Nevertheless, this practice should be discontinued. The staffing arrangements must ensure that staff remain alert at all times particularly during the night in order to attend to the needs of the service users and to respond appropriately in the event of an emergency. The service users with whom discussions were held spoke positively about the staff. One service user said, ‘I always get treated with courtesy. The carers are very good’. Another service user said, ‘The staff are very good indeed. The staff do come and help us and they are always very careful’. Another service user said, ‘I’m very pleased with the care and kindness. I think the staff do a wonderful job’. One service user confirmed that she was checked during the night by the night staff and said, ‘You know you’re cared for, you’re sure of help at night’. Two of the Comment Cards that were completed by the relatives of service users contained positive comments about the kindness, helpfulness and friendliness of the staff. One relative stated, ‘The staff try to accommodate everything that is asked for’. It was pleasing to note that the deputy manager and two of the senior care assistants (days) had completed the NVQ level 2 and NVQ level 3 training. The two newly appointed senior care assistants from overseas had undertaken nurse training in their country of origin. The nurse training was regarded as the equivalent of at least the NVQ level 2 training. Two senior care assistants (nights) and two care assistants (days) had also undertaken the NVQ level 2 training. Therefore, a total of nine of the thirteen members of staff currently employed by the home had completed the NVQ level 2 training or equivalent. This is a commendable achievement and exceeds the target of 50 of the number of care staff with NVQ level 2 as laid down in the National Minimum Standards. The files of five members of staff were made available for inspection. The files of three members of staff contained all of the information that was required. However, the files of two members of staff recruited from abroad did not contain all of the required information. However, the files did not contain an application form, two relevant written references or a POVAfirst or CRB disclosure check. The registered manager subsequently confirmed that a criminal record check that was equivalent to a CRB disclosure had been carried out in the country of origin in respect of the staff recruited from abroad. In addition, it was also confirmed that an application form and two written references had been provided. The law requires all staff working in the home to be CRB checked including staff recruited from abroad. The registered providers could carry out reasonable vetting of staff from overseas by following the advice available on the CRB’s website (www.crb.gov.uk http:/www.crb.gov.uk ). There is always the possibility that staff recruited from abroad may have either been in this country before or lived in this country for longer than their documentation states. The home’s procedure for recruiting staff from abroad should be at least as rigorous as the Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 23 procedure for recruiting other staff, including the completion of an application form and obtaining two written references. The registered persons are referred to the CSCI ‘Policy and Guidance (for providers and CSCI staff)’. It was confirmed that the staff had been issued with a copy of the code of conduct and practice set by the General Social Care Council. The staff files contained evidence to show that the staff had been provided with a contract and a job description. The home used a TOPSS (Skills for Care) training pack for induction and foundation training. There was one member of staff undertaking the training. The home also provided it’s own induction training. The registered manager stated that members of staff were placed on the NVQ level 2 training course as soon as possible. The home had a staff training and development file. Each member of staff had their own individual training and development assessment and profile. A copy of the home’s staff training matrix was provided. The training matrix indicated that the majority of staff had received training on at least three paid days during the past year. The registered manager stated that a key worker system was in operation. However, the service users with whom discussions were held were not aware of it. The registered manager acknowledged that further work was needed in order to develop the key worker system. The registered manager stated that all of the staff received a copy of the home’s staff induction folder that contained a number of different policies. The home also had a folder that was kept in the staff room that contained information on health issues e.g. strokes, dementia, diabetes and pressure care. The home produced a staff newsletter every month. Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 24 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): 31, 33, 35 and 38 The quality outcome in this area was adequate. This judgement has been made using available evidence including a visit to this service. The home had a competent and experienced manager and was being run in the best interests of the service users. However, the systems for monitoring the quality of the service did not fully promote the service users’ safety and welfare. EVIDENCE: The registered manager was competent and had appropriate experience and skills to manage the home. It was confirmed that she had obtained NVQ level 4 in health and care and was in the process of completing the Registered Managers’ Award (RMA) training. The registered manager said that she hoped to complete the RMA training by the end of December 2006. The registered manager had undertaken relevant training in a number of areas, including abuse awareness. However, she had not undertaken training in the protection of vulnerable adults from abuse at a higher level. This training is regarded as essential for all senior managers. The registered manager had also not undertaken any training in person centred planning. The registered manager Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 25 provided evidence to show that she had undertaken a Fire Wardens Course run by Hereford and Worcester Fire Brigade in August 2003. The registered manager impressed as being conscientious and hard working. The service users, staff and the relative of one service user with whom discussions were held spoke positively about the registered manager and confirmed that she was approachable and supportive. One service user described the registered manager as ‘very attentive’. A copy of the registered manager’s job description was made available for inspection. The general content that described the duties and responsibilities of the post was satisfactory. However, the job description contained out of date references to the Registered Homes Act 1984 and the Regulations e.g. in paragraphs 2, 5.4, and in several places under section 6. The job description could also include a reference to other duties of a registered manager that are not mentioned e.g. carrying out and recording risk assessments and maintaining and reviewing the home’s policies and procedures in accordance with the National Minimum Standards. The registered manager felt well supported by the registered providers. The registered persons had worked hard to introduce systems for maintaining good communication within the home. The registered manager prepared a written report for the registered provider every week and a more detailed report every month. Copies of these reports were kept in the home’s quality assurance folder. Service satisfaction questionnaires had been introduced in August 2006 for service users, their relatives and visiting professionals. Health and safety meetings and staff meetings were held every three months. Senior staff meetings were held every several months; the last one had been held in April 2006. The registered manager stated that it was intended to participate in ‘Having your say’, a training exercise organised by the County Council to promote service users’ involvement in their care and to enable them to have a greater influence over the way in which the service is delivered. A requirement was made as a result of the previous inspection that a quality assurance system must be developed that included all of the elements of Standard 33. However, the requirement had not been fully implemented and still stands. The home did not have a fully operational quality assurance system or an annual development plan. A number of the home’s policies and procedures had not been signed. The registered manager stated that it was intended to introduce a programme to review all of the home’s policies and procedures. The service users were encouraged to maintain control of their own finances. No one connected to the running of the home acted as an appointee or agent on behalf of any of the service users. The majority of the service users received support from their relatives in dealing with their financial affairs. The registered manager stated that personal allowances were held in safekeeping by the home in respect of twelve service users. The money was kept in individual packets in a safe. Access to the safe was restricted to the registered manager and deputy manager. A record was maintained in regard to the service users’ individual amounts. The accounts maintained in respect of Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 26 several service users were checked at random. One discrepancy of £10.00 was found in favour of the service user. The registered provider should carry out regular audits of the service users’ money as part of the home’s quality assurance system. Standard 36 was not fully assessed on this occasion. However, there was evidence to show that staff supervision meetings were held on a regular basis. The registered manager stated that supervision meetings were being held at the required frequency, i.e. at least six times a year. However, it was noted that the forms that were used to record the discussions held during the supervision meetings did not cover the three issues referred to in Standard 36.3. Risk assessments had been carried out and recorded in respect of most of the safe working practice topics covered in Standard 38.2 and 38.3. The two exceptions that were identified were in regard to the security of the premises and food hygiene. It was noted that the accident record sheets were out of sequence, were not always given a report number and did not tally with the list at the front of the folder in which they were kept. The record sheet for one accident was missing. The home’s electrical appliances, boilers, stair lift, passenger lift and bath hoists were satisfactorily serviced and maintained. The home had a health and safety policy and the necessary documentation relating to COSHH and RIDDOR. The registered manager confirmed that Trent Water had carried out checks for Legionella bacteria in the water on 13 September 2005. Safety procedures and notices were posted at various appropriate locations around the home. A copy of the home’s Employers Liability Insurance Certificate provided by Norwich Union was displayed. The certificate was valid until 26 February 2007. A requirement was made as a result of the previous inspection that there must be at least one member of staff with a valid accredited First Aid at Work (four day course) certificate on duty day and night and that care staff must receive training in dementia care. The registered manager confirmed that she and six members of staff had undertaken basic first aid training in July 2006. A further six members of staff were awaiting the training. It was clear that the home had responded positively to the first part of the requirement by providing basic first aid training. However, it is still regarded as important for the registered manager and deputy manager to undertake First Aid at Work training. It was also confirmed that all the staff had watched a video on dementia care and that five members of staff would be attending a training day on dementia care on 10 November 2006. It was, therefore, also clear that the home had responded positively to the second part of the requirement although it had not been fully implemented. Some staff had not undertaken any recent training in moving and handling. It was noted that the additional condition as stated in the home’s Certificate of Registration namely that ‘the home provides a service for older people but may also accommodate one named person under the age of 65 who has dementia’ Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 27 was no longer applicable. A new Certificate of Registration that reflects the home’s current circumstances will be issued by the CSCI. Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 28 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 2 3 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 29 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 OP1 Regulation 4 Requirement The statement of purpose must be amended so that it includes all the information detailed in Regulation 4 and Schedule 1 in accordance with the guidance given on this report. The service users’ guide must be amended to include all the information detailed in Regulation 5 and Standard 1 in accordance with the guidance given in this report and copies given to all current and prospective service users and/or their relatives. The form that is used by the home for assessing the needs of prospective service users must be amended in accordance with Regulation 14 and Standard 3 and the guidance given in this report. The service user plans must cover all aspects of care as set out in Standards 7.2 and 3.3 and be agreed and signed by the service user whenever capable and/or their representative (if any). DS0000018495.V311406.R01.S.doc Timescale for action 31/10/06 2 OP1 5 31/10/06 3 OP3 14 31/10/06 4 OP7 15 31/10/06 Breach House Version 5.2 Page 30 5 OP9 13,18 6 OP18 12,13 7 OP18 18 8 OP19 13 9 OP22 13,23 10 OP29 19 11 OP31 18 12 OP33 24 13 OP36 18 All the staff who are involved in the administration of medication must receive accredited training that includes basic knowledge of how medicines are used and how to recognise and deal with problems in use and the principles behind all aspects of the home’s policy on medicines handling and records. The home’s policy and procedure on the protection of vulnerable adults from abuse and the home’s ‘whistle blowing’ policy must be amended in accordance with the guidance given in this report. The registered manager and deputy manager must undertake training in the protection of vulnerable adults from abuse. The floor covering in the corridor must be attended to and the communal toilets must be fitted with door locks that ensure privacy but enable emergency access. (Previous timescale 31/12/05 not met). Handrails must be provided in the corridors for service users who are infirm or physically disabled. An enhanced disclosure check from the Criminal Records Bureau must be obtained for all new staff prior to their commencement of employment. The registered manager and deputy manager must undertake appropriate training in the protection of vulnerable adults from abuse. A quality assurance system must be developed in line with all the elements of Standard 33. (Previous timescale 31/12/05 not met). Supervision of care staff must DS0000018495.V311406.R01.S.doc 31/12/06 31/10/06 31/12/06 31/12/06 31/12/06 30/09/06 31/12/06 31/12/06 31/12/06 Page 31 Breach House Version 5.2 14 OP38 13 15 OP38 17 16 OP38 13,18 include all aspects of care practice, philosophy of care in the home and career development needs. Risk assessments must be carried out and recorded for all the safe working practice topics covered in Standards 38.2 and 38.3 including the security of the premises and food hygiene. The records relating to accidents within the home must be completed in full and accurately maintained. The registered manager and deputy manager must undertake training in First Aid at Work (four day course). 31/10/06 30/09/06 31/12/06 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 OP9 Good Practice Recommendations The home’s policy and procedure on the administration of medication should be amended to include a reference to the CSCI and the procedure to be followed in the event of an error in administration. Details of the advocacy service and the service users’ entitlement to bring personal possessions with them when they are admitted to the home should be included in the service users’ guide. The views of the service users on the quality and variety of the food provided should be obtained in order to make any necessary improvements. The home’s policy on service users’ money and financial affairs should include advice on personal insurance and preclude staff involvement in the making of or benefiting from service users’ wills and be reflected in the service users’ guide. A programme of routine maintenance and renewal of the DS0000018495.V311406.R01.S.doc Version 5.2 Page 32 2 OP14 3 4 OP15 OP18 5 OP19 Breach House 6 7 8 9 10 11 12 OP27 OP29 OP31 OP31 OP33 OP35 OP38 fabric and decoration of the premises should be produced and implemented with records kept. The practice of staff working long shifts continuously without a break should be discontinued. A job application form should be completed by all members of staff prior to their appointment including members of staff recruited from abroad. The registered manager and deputy manager should undertake training in person centred planning. The registered manager’s job description should be amended in accordance with the guidance given in this report. A development plan for the home should be introduced based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users. The registered provider should carry out regular audits of the service users’ financial accounts as part of the home’s quality assurance system. The home should continue to provide training in dementia care and moving and handling to ensure that all the staff are trained to an appropriate level. Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Breach House DS0000018495.V311406.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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