Inspection on 16/10/06 for Bretby House

This inspection was carried out on 16th October 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

Bretby House 16/04/08

Bretby House 18/10/07

Bretby House 19/04/07

Bretby House 06/06/06

Bretby House 09/02/06

Bretby House 25/10/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Bretby House 253 Boldmere Road Wylde Green Sutton Coldfield West Midlands B73 5LL Lead Inspector Brenda O’Neill Unannounced Inspection 16th October 2006 09:00 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 Bretby House DS0000064275.V315401.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. Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bretby House Address 253 Boldmere Road Wylde Green Sutton Coldfield West Midlands B73 5LL 0121 373 6562 F/P 0121 373 6562 jd012g3610@blueyonder.co.uk 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) Care First Class (UK) Ltd Care Home 24 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (24) of places Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. The home is registered to accommodate to 24 older people that may include 6 people with dementia. Registration Category 24 (OP) 6(DE)(E). Provide assisted bathing/showering facilities on the first and second floors of the home within twelve months of registration. Provide additional dry goods storage space within eighteen months of registration. Provide a sluice facility within six months of registration. Provide guards of covers to all radiators within the home within six months of registration. Replace or relay the uneven garden path to improve safe access to the garden within six months of registration. In addition to the manager and ancillary staff a minimum of three care staff must be on duty during the waking day and two care staff on night duty. 6th June 2006 Date of last inspection Brief Description of the Service: Bretby House is a large, extended house with parking space available. It is close to public transport routes with Wylde Green station being a short walk away. The home is on a bus route. Boldmere shopping centre is also close to the home. The home provides care and accommodation for up to 24 older people. Accommodation for the residents is spread over three floors with a mixture of single and double rooms, some of which have en-suite facilities. There are several toilets, one shower room and three bathrooms in the home, however not all of these allow for full assistance. Communal areas are located on the ground floor and comprise of one large and one smaller lounge and a dining room. Also located on the ground floor are the kitchen, laundry, office and staff facilities. There is a large and well maintained garden to the rear of the home that is accessed via a ramp. The fees at the home ranged from £314.00 to £346.00 per week. Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second key inspection for the service for 2006/2007 and was carried out by two inspectors over one day in October 2006. During the course of the inspection a tour of the premises was carried out, three resident and two staff files were sampled as well as other care, health and safety and training records. The inspector’s spoke with the manager, two staff members, the proprietor, responsible individual, a visitor and a district nurse. The home had also had a random inspection in August 2006 to assess the progress being made on some of the requirements made following the previous key inspection in June. References will be made to this throughout this report. No complaints had been lodged with CSCI since the last key inspection. Some concerns had been raised by a former member of staff but these were not substantiated. One complaint had been lodged at the home and this had been investigated and responded to appropriately by the proprietor. The issues raised were to be addressed with the staff team at a staff meeting. The complaint was mainly in relation to a resident going to hospital without an escort and the lack of communication between the staff and the relatives. What the service does well: Some of the staff had worked at the home for a considerable amount of time which was good for the continuity of care of the residents. Residents spoken with were very positive in their comments about the staff team and friendly relationships were evident. Appropriate staffing levels were being maintained. It appeared that the health care needs of the residents were being met and the district nurse commented ‘staff follow any instructions given and call the district nurses if the residents need them.’ Routines in the home were minimal and residents could spend their time as they chose. There were no restrictions on visitors to the home within reasonable hours. Visitors were seen to come and go throughout the course of the inspection and appeared to be made welcome by staff. Complaints were being responded to appropriately by the proprietor. Residents were satisfied with the catering arrangements at the home and the menus seen were varied and nutritious. Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 6 Recruitment procedures in the home were robust and safeguarded the residents. There was evidence that staff had received training in a variety of topics relevant to their roles including, adult protection, manual handling and dementia care. What has improved since the last inspection? What they could do better: There needed to be up to date information available for any prospective residents to enable them to make an informed decision as to where they lived. The manager needed to ensure that the copies of social workers’ assessments were obtained prior to the admission of the residents so that the needs of the prospective residents were known by the staff. All residents needed to have care plans in place that they had been consulted about and detailed all their needs and how they were to be met by staff to ensure they were cared for appropriately. Risk assessments needed to be developed further and in place for all residents to ensure any identified risks were documented and systems were in place to minimise them. The medication system needed to be vastly improved to ensure it was safe and the residents received the appropriate medication at the correct times. The daily records for the residents needed to be improved so that they gave an overview of the general welfare of the residents and it could be evidenced that their needs were being met. The keeping of food records needed to be recommenced so that there was evidence that residents diet was satisfactory and that any special diets were being catered for appropriately. Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 7 All new staff needed to have training in line with the specifications laid down by Skills for Care to ensure they were equipped with the necessary skills and knowledge to care for the residents. The home needed to have in place a quality monitoring system based on seeking the views of the residents with a view to continuous improvement. The home was urgently in need of a stable management team to ensure the systems that were in place for ensuring the safety of the residents and good service delivery were applied consistently and that new systems were put in place where the home was failing. An application for the registration of the manager needed to be forwarded to the CSCI so that residents were assured someone was accountable on a dayto-day basis. There were some areas of the management of health and safety that needed to be improved to ensure the home was safe for the residents and staff. These included, updated fire training, checks on the fire alarm and emergency lighting and fire drills. 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. Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 8 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 Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 9 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 and 3. The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents did not have all the necessary information available to them to enable them to make an informed choice about where they lived. The assessment procedures in the home were not being used consistently therefore the needs of the residents were not always known to the staff prior to admission. EVIDENCE: The service user guide for the home had not been completed with all the up to date information. The registered person needed to ensure this was done so that prospective residents had access to all the relevant information about the home. At the time of the random inspection the assessment procedures for new residents had been much improved and copies of the social workers assessments were also being obtained. At the time of this inspection the files for two residents relatively new to the home were sampled. One file included a comprehensive assessment that had been undertaken by staff at the home Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 10 with a summary of the needs to be met at the end. For the other resident the assessment had only been partially completed and there was no summary of needs. There was evidence that social workers had been involved in the admissions as there were initial care plans drawn up by them in place but there was no evidence that the home had obtained a copy of the social worker’s assessments. Three residents’ files were sampled throughout the inspection two of these had copies of the home’s contract with them the other did not. The individual without a contract was in the home on respite care however they still needed to be issued with a contract stating their terms and conditions of residence in the home. Bretby House DS0000064275.V315401.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 in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans did not adequately detail all the needs of the residents and how these were to be met. Risk assessments for residents did not detail how all risks were to be managed or minimised. The medication system was poorly managed and did not safe guard the residents. EVIDENCE: Three resident files were sampled. All included an overview of the residents’ days and their preferred routines. These included residents’ preferences in relation to waking and retiring time, their likes and dislikes in relation to food, where they liked to sit and so on. Two of the files included individual service statements (ISS) that detailed the needs of the individuals and how these were to be met by staff and were quite comprehensive. They also detailed what the individuals were able to do for themselves, for example, ‘confident to carry out own personal hygiene’. It was noted that some of the needs identified on the preadmission assessments were not carried forward to the care plan, for example, one assessment stated needs soft diet this was not mentioned on the ISS and one resident had short term memory loss and again this was not included on the ISS. The third file sampled was for a resident receiving respite Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 12 care and there was no ISS. There was no evidence that the ISS were being reviewed monthly and only one indicated that the resident had been consulted. Two of the files sampled included manual handling, falls, nutritional and tissue viability risk assessments which were generally well detailed. The third file had no risk assessments. It was noted that there was no detail on one manual handling risk assessment of the action to be taken by staff in the event of a fall and on the other the use of a hoist was detailed but the sling size was not included. One of the files included a general risk assessment in relation to the risk of self harm which was appropriate however there was no risk assessment for the individual in relation to how staff would recognise if they were depressed. The individual without any risk assessments was receiving respite care but to ensure any risks were known to the staff and minimised risk assessments still needed to be in place. At the time of the random inspection the content of the residents’ files varied considerably and it was recommended that there was a checklist at the front of each file that was signed and dated as each document was put in place. A contents sheet had been included on the files but there was no space to sign and date when documents were in place. This is an ongoing issue in the home and a system must be put in place to ensure that all the required documentation is on all residents’ files. At the time of the random inspection it was noted that the identified health care needs of the residents, their follow up and monitoring were much easier to track. There were separate recording sheets for visits from health care professionals and these included such things as G.P., district nurse and chiropody visits as well as contact with specialist professionals, for example, community psychiatric nurses. The district nurse visited the home during the course of the inspection and stated: ‘staff follow any instructions given and call the district nurses if the residents need them.’ It appeared that the health care needs of the residents were met but staff needed to be mindful of consistently recording the progress or deterioration of any wounds sustained during any falls. One resident had had a fall and sustained an injury which was tended and dressed but then was not mentioned in the daily reports. It was evident the dressing had either come off or been taken off and that the resident was finding it quite painful. Numerous issues were raised in relation to the safe handling of the medication in the home during the course of the inspection. The keys for the medication trolley and controlled drug cabinet were accessible to all staff. The registered person needed to ensure that one person took responsibility for these on each shift. Staff at the home were not following their own procedures for the administration of medication, for example, the drug trolley was not being taken to the residents but one or two lots of medication were being taken out at a time and the drug trolley left open and unattended. It appeared that medication was not being signed for at the time it was administered. There Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 13 were gaps on the medication administration sheets so it could not be determined if all medication had been issued as prescribed and there was no explanation as to some of the codes being used on the MAR charts. There were excessive amount of medication in the home as staff were ordering repeat medication when it was not needed. It was not possible to audit the medication in all instances due to gaps on MAR charts and some balances of medication not being carried forward. It was evident from the amount of creams left in tubes in the drug trolley that residents had not had this applied as prescribed even though staff had signed to say it had been administered. The acting manager, proprietor and responsible individual were made aware of all the shortfalls and stated they would all be addressed as a matter of urgency. Staff at the home were in the process of undertaking accredited training for the safe handling of medicines and the acting manager needed to start undertaking regular staff drug audits before and after drug rounds to assess the competence of the staff in medicine management. A controlled drug register had been purchased and was in use at the home. The day after the inspection the CSCI was notified that a resident at the home had been given the wrong the medication. Due to this and all the shortfalls noted at the inspection a letter of serious concern was sent to the responsible individual requiring a detailed response of how all the issues would be addressed. No issues were raised by the residents in relation to their privacy and dignity. Staff addressed the residents appropriately and there were friendly relationships evident. Medical consultations took place in the privacy of the residents’ bedrooms. Residents could meet with their visitors in the privacy of their rooms or one of the quieter areas of the home. It was noted that the lock on one of the ground floor toilets was missing. To ensure the privacy of the residents this needed to be replaced. Bretby House DS0000064275.V315401.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 in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There did not appear to be any rigid rules or routines in the home and residents could spend their time as they chose. There was no evidence of any activities being on offer for those residents that wished to take part. There were no restrictions on visitors to the home within reasonable hours. Residents were generally satisfied with the catering arrangements however there were no current food records to evidence that their nutritional needs were being met. EVIDENCE: Routines in the home appeared to be kept to a minimum and residents were free to spend their time as they chose. Preferred daily routines and activities were detailed on the residents care plans however it was difficult to establish if these were observed by the staff as the daily records were very repetitious and did not give an overview of the residents’ days. There were individual activity sheets for the residents but these had not been completed since May 2006. No structured activities were seen during the day of the inspection and residents spoken with said there was little going on in the home. The acting manager stated that there were ongoing activities in the home such as bingo, board games and visiting entertainers. Staff needed to ensure that the daily records gave an overview of the residents’ days to evidence that all their needs, including social, were being met. Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 15 Visitors were seen to come and go throughout the course of the inspection and all appeared to be made welcome. One visitor was spoken with who stated they were happy with the care at the home. There were no restrictions on residents going out with their visitors. Care plans that were complete stated where the residents were able to make choices and where they were to be given choices. Preferred rising and retiring times were also recorded. It was evident from the observations made on the day of the inspection that residents were able to get up when they chose, some residents were having breakfast, others had finished and others were still getting up. It was also evident that residents chose what they wanted to eat for breakfast and several different foods were served. Residents were encouraged to personalise their rooms and personal effects were seen in bedrooms. The menus seen in the home were varied and nutritious however the main meal served on the day of the inspection did not correspond with any of these. The menu board in the dining room stated the meal from the day before therefore it was difficult to know how the residents knew what they were having that day. The records of food being served to the residents had lapsed during October therefore specific diets could not be evidenced, for example, vegetarian and diabetic. One resident informed the inspector she does not have lunch only puddings. In circumstances such as these there needed to be a record to evidence that the individual’s nutritional needs were being met. On the day of the inspection residents were seen to have a variety of foods for breakfast including, several different types of cereal, beans on toast, toast and marmalade and bread and butter. The residents spoken with were satisfied with the catering arrangements at the home. Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 16 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 in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was an appropriate complaints procedure on site and it appeared that any complaints were listened to. Adult protection issues were being recognised and to ensure the residents were protected staff had received training on this topic. EVIDENCE: The policies and procedures on site for complaints and adult protection were not viewed at this inspection as they were seen at the last key inspection and were satisfactory. No complaints had been lodged with the CSCI since the last inspection. Some concerns had been raised by a former member of staff but were not substantiated. One complaint had been lodged at the home and this had been investigated and responded to appropriately by the proprietor. The issues raised were to be addressed with the staff team at a staff meeting. The complaint was mainly in relation to a resident going to hospital without an escort and the lack of communication between the staff and the relatives. No adult protection issues had been raised at the home since the last inspection however it was known that the home had recognised issues in the past and acted on them. Staff had received training in adult protection issues. Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 17 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, 20, 21, 22, 24, 25 and 26. The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was generally well maintained and comfortable some improvements had been made to enhance the comfort and safety of the residents. EVIDENCE: There had been no changes to the layout of the home which was suitable for its stated purpose. There was adequate communal space at the home with two lounges and a dining room. At the time of the random inspection the small lounge had been improved and was cleaner and less cluttered making it a much pleasanter room for the residents and this was being used by some f the residents and this remained so at the time of this visit. It was noted that the vinyl covering two of the armchairs in the large lounge was splitting and could be hazardous for any residents with frail skin. These needed to be recovered or replaced. The uneven paving in the garden had been addressed making it safer for the residents. Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 18 There were adequate numbers of toilets throughout the home and some were large enough for staff to offer assistance. Since the last inspection the bathrooms on the first and second floors had been refurbished and allowed for staff assistance where necessary and both were equipped with bath hoists. On the day of the inspection new flooring was fitted in both these rooms and the inspectors were informed that appropriate chairs for the bathrooms were on order. The home also had a shower but this had a large step up shower tray and was not used by the residents. There was a bathroom on the ground floor that had a medic bath and toilet in it that the inspectors were informed was not used. At the time of the inspection this was being used to store various items but could still be accessed by the residents and would be very hazardous for them. If the toilet was to be used by the residents the room needed to be made safe and all items removed or if it was not to be used it needed to be locked. The built in cupboard in the ground floor bathroom was being used to store food, which was not appropriate, and this was a condition of registration that alternative space for this must be found. The time scale for this had not expired however the issue of this food store had been raised by the environmental health officer and the registered person needed to consult with them about an appropriate time scale for completion. The flooring in the other toilets and bathrooms was in need of replacing however the registered person stated that the home was to have some alterations to the building and this would be done at the same time. Progress on this will be monitored at future inspections. There were some aids and adaptations throughout the home to assist those residents with mobility difficulties including shaft lift, mobile hoist, assisted bathing facilities and a ramp for going into the garden. The home also had an emergency call system. Bedrooms varied in size and the majority of the required furnishings and fittings were evident. The previous manager had begun to audit the rooms for furnishings and fittings against the National Minimum Standards but any shortfalls had not been rectified. If residents choose not to have all of the furnishings and fittings required this needed to be documented in their files. All rooms had a lockable facility and residents were able to have keys to their bedroom doors if they wished. Some bedrooms had had new carpets and new beds however there still remained some bed bases that were worn and needed to be replaced. All the radiators in high risk areas had been guarded and the inspectors were informed the others would be done on a rolling programme. The water temperatures sampled were appropriate. The home was generally clean and odour free the issues raised in relation to infection control procedures at the last key inspection had been addressed Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 19 including, some commodes had been replaced, mops were no longer stored in the toilets and there was suitable storage in the home for clinical waste. The laundry was appropriately located, albeit very small, the proprietors are hoping to extend this in the future. There was a sluice washing machine and a tumble drier installed. Numerous commodes were being used in the home and effective cleaning of the pots can be problematic therefore the home should at their earliest opportunity install a commode pot washer/disinfector. The kitchen was generally clean and tidy with the exception of the oven. The requirement made at the random inspection in relation to replacing the freezer as it was rusting and the fridge seal being split had not been met but the inspectors were informed that new equipment was on order. The fridge and freezer temperatures were not being recorded on a regular basis and it was noted that some boxed foods were being stored on the floor. Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 20 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 in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels were being maintained by a fairly stable staff team. There needed to be evidence on site that new employees were undertaking a suitable induction programme to enable them to care for the residents. Recruitment procedures were robust and safeguarded the residents. EVIDENCE: The rotas at the home evidenced that there were three care staff on duty throughout the waking day plus either a senior care or the manager and two waking night staff. The home also employed cooks and domestic staff. These levels appeared to meet the needs of the residents at the time of the inspection. Relationships between the staff and residents were good and residents were positive in their comments about the staff team. Some of the staff had worked at the home for a considerable amount of time which was good for the continuity of care of the residents. The recruitment records for three staff were sampled and all the required documentation was in place including completed application forms, two written references and CRB checks. The numbers of staff qualified to NVQ level 2 or the equivalent was discussed with the responsible individual. The home had not achieved the required 50 Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 21 however staff were enrolling to undertake the training. There was some evidence that staff undertook some induction training in the home but this needed to be cross referenced to the standards and specifications laid down by Skills for Care to ensure it complied with the requirements and was completed within the timescales given. There was evidence on staff files sampled of ongoing training in the home in such topics as food hygiene, adult protection, manual handling, dementia care and tissue viability. The dates seen for the last fire training in the home indicated that this was out of date and this needed to be addressed as a matter of urgency. Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 22 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 in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home needed a stable management team to ensure the service offered to the residents was safe and continuously improved. An application for the registration of the manager needed to be forwarded to the CSCI so that residents were assured someone was accountable on a day-to-day basis. The home needed to have in place a system for the monitoring the quality of the service offered based on seeking the views of the residents. EVIDENCE: The acting manager that was in post at the last key inspection had moved to another home owned by the same proprietors. A new manager had been recruited but had only been in post for two weeks prior to this inspection and therefore it was difficult to assess his abilities to manage the own the home on an ongoing basis. He did have experience of caring for older people and was Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 23 qualified to NVQ level 3 he was aware that he must be qualified to NVQ level 4 in care and management for his role as manager. The home was urgently in need of a stable management team to ensure the systems that were in place for ensuring the safety of the residents and good service delivery were applied consistently and that new systems were put in place where the home was failing. Numerous issues were raised during the course of the inspection, in particular, the medication system that needed to be improved to ensure the safety of the residents. There were no formal ways of measuring the quality of the service being offered to the residents in place apart from records of staff and resident meetings, which could not be found on the day of the inspection. There needed to be systems in place for monitoring the quality of the service on an ongoing basis based on seeking the views of the residents with a view to continuous improvement. The home did manage some of the finances on behalf of the residents. Some records were sampled and apart from some minor calculation errors were appropriate and all balances of cash held were correct. Some issues were raised in relation to the management of health and safety including fire training for staff and the medication system. It was also noted that the fire alarm was not being tested on a weekly basis and the emergency lighting had not been checked since August 2006 and no records could be found of a recent fire drill. There was evidence on site of the regular servicing of the lift, portable electrical appliances, the fire alarm and extinguishers. The electrical wiring certificate was up to date and the water system had been checked for the prevention of legionella. CSCI were being notified accordingly of any accidents or incidents in the home. The insurance certificate on display in the home was out of date but evidence that this had been renewed was sent to the inspector. Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 24 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 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 2 3 X 2 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 1 Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 25 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(1)Sch 1, 5(1) Requirement The statement of purpose and service user guide for the home must be completed and copies of both documents forwarded to the CSCI. (Previous time scales of 01/04/06 and 31/07/06 not met.) All residents must be issued with a contract/statement of terms and conditions of residence at the point of admission to the home. The registered person must ensure that home’s procedure for the assessment of prospective residents is followed consistently. The registered person must ensure that a copy of the social workers assessment is obtained prior to the admission of any residents to the home. Timescale for action 01/01/07 2. OP2 5(1) 01/12/06 3. OP3 14(1) 01/12/06 Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 26 4. OP7 15(1) All residents must have care plans that detail all their current needs in respect of health and welfare and how these are to be met by care staff. There must be evidence that wherever possible the residents have been consulted about the care plans. Care plans must be reviewed monthly. (Previous time scales of 01/01/06, 01/04/06 and 14/09/06 not met.) All residents must have personal risk assessments undertaken to minimise any identified risks. (Previous time scales of 01/12/05, 01/03/06, 31/07/06 and 14/09/06 not met.) Manual handling risk assessments must be in place for all residents and detail all handling methods and the actions to be taken by staff in the event of a fall. Where a hoist is indicated the sling size must be detailed. (Previous time scales of 31/07/06 and 14/09/07 not met.) All residents must have tissue viability and nutritional screenings and action must be taken to minimise any identified risks. Records of any identified health care needs must how these have been monitored on an ongoing basis. The responsible individual must ensure there is a system in place to ensure all the required documentation in relation to the residents’ care is on all residents’ files. DS0000064275.V315401.R01.S.doc 31/12/06 5. OP7 13(4)(c) 01/12/06 6. OP7 13(5) 01/12/06 7. OP8 12(1)(a) 01/12/06 8. OP8 12(1)(a) 01/12/06 9. OP7 OP8 12(1)(a) 01/12/06 Bretby House Version 5.2 Page 27 10. OP9 13(2) Regular staff drug audits must take place to assess staff competence in medicine management. Appropriate action must be taken when discrepancies are found. One person must take responsibility for the keys to the drug trolley on each shift. The drug trolley must not be left unattended when open. MAR charts must be signed as medication is being administered. There must be no gaps on MAR charts unless for PRN medication. When medication is not administered the appropriate symbol must be used. Any excess medication must be returned to the pharmacist and a signed returns sheet obtained. Any balances of medication that remain in the home at the end of the 28 day must be carried forward to the new MAR chart. Staff must ensure they only obtain repeat prescriptions for what is needed by the residents for the next month. Any prescribed creams must be applied as directed by the doctor. The registered person must ensure that where any resident is administered the wrong medication a thorough 31/10/06 Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 28 11. 12. OP10 OP12 12(4)(a) 12(1)(a) 13. OP15 17(2) schedule 4(13) 14. OP20 23(2)(c) 15. OP21 13(4) 16. 17. OP21 OP21 23(2)(l) 23(5) 18. OP24 16(2)(c,p) 19. OP24 16(2)(c) investigation is undertaken and the outcome is notified to the CSCI to include how this is to be avoided in the future. The lock on the ground floor toilet must be replaced. Staff must record how residents are spending their days to evidence their social needs are being met. (Previous time scales of 01/03/06, 31 /07/06 and 14/09/06 not met.) There must be records of the food being served to the residents in sufficient detail to evidence that the diet is satisfactory in relation to nutrition and choice and of any special diets being catered for. Any lounge chairs that have split vinyl on the seating must be removed/replaced. (Time scale of 01/10/06 not met.) The medic bathroom must be made safe for the residents to use or locked so that they cannot access it. Additional dry goods storage space must be provided. (Time scale not expired) The registered person must consult with the environmental health officer to agree a time scale for the dry goods store to be relocated. The furnishings and fittings in the bedrooms must be audited against the National Minimum Standards and shortfalls rectified. (Previous time scale of 01/05/06, 31/07/06 and 01/10/06 not met.) Any worn bed bases must be replaced in order of priority. 14/11/06 14/11/06 30/11/06 14/11/06 14/11/06 20/03/07 14/11/06 01/12/06 30/11/06 Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 29 20. OP26 13(3) 21. OP26 13(3) A commode pot washer/disinfector must be installed in the home. (Previous time scale of 20/08/06 not met.) Fridge and freezer temperatures must be recorded on a daily basis to ensure they working efficiently. 01/01/07 14/11/06 22. OP28 23. OP30 24. 25. OP30 OP31 26. 27. OP31 OP33 Boxed foods must not be stored on the floor. 18(1)(a) 50 of care staff must be qualified to NVQ level 2 or the equivalent. (Previous time scale of 31/12/06 had not expired.) 18(1)(c) All staff must have induction training as specified by Skills for Care that is completed within the first twelve weeks of employment. (Time scales of 31/07/06 and 30/09/06 not met.) 23(4)(d) The registered person must ensure all staff have their fire training updated. 9(2) The responsible individual for the home must ensure that an application for the registration of the manager is forwarded to the CSCI. 9(1)(b)(i) The manager must be qualified to NVQ level 4 in care and management. 24(1)(a,b) The home must have a system in place for monitoring the quality of the service offered based on seeking the views of the residents. (Previous time scale of 30/06/06 and 30/09/06 not met.) 31/12/06 31/12/06 01/12/06 31/12/06 30/06/07 01/03/07 Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 30 28. OP38 23(4)(c) (v)(e) There must be evidence on site that: The fire alarm is tested on a weekly basis. The emergency lighting is tested on a monthly basis. That fire drills are carried out every six months. 14/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Bretby House DS0000064275.V315401.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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