Inspection on 18/10/07 for Bretby House

This inspection was carried out on 18th October 2007.

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 19/04/07

Bretby House 16/10/06

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 Key Unannounced Inspection 18th October 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000064275.V351870.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. DS0000064275.V351870.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 Vacant post 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 DS0000064275.V351870.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. 19th April 2007 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 people living in the home 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 are in use. Communal areas are located on the ground floor and comprise of one large lounge/diner and two further lounges. 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. DS0000064275.V351870.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this key inspection over one day in October 2007. During the course of this visit a tour of the premises was made, three staff and three files for the people living in the home were sampled as well as other care and health and safety records. The inspectors had lunch with the people living in the home and made observations of the care being offered to them throughout. The inspectors spoke with the proprietor, responsible individual for the home, acting manager, three staff members and six of the people living in the home. Prior to the inspection a completed Annual Quality Assurance Assessment had been returned to the Commission which gave some additional information about the home. The inspector also received one completed comment card from a person living in the home and two from relatives. A random inspection was also undertaken at the home in August 2007. This inspection was undertaken to assess the progress being made by the home in meeting the requirements made following the key inspection in April. Areas looked at during this inspection were care plans, risk assessments, daily records and fire records. Some progress had been made on these areas and they are commented on in this report. Some concerns had been raised with the commission prior to the random inspection. These were looked into during the random inspection and are commented on under the complaints section of this report. The home had logged one complaint and information about this had been relayed to the Commission. This was managed well and investigated thoroughly. The acting manager of the home had recently raised an adult protection issue with social care and health and the Commission into the conduct of one of the staff. What the service does well: Despite being a very busy time of day when the inspection commenced the home was calm and the atmosphere very relaxed. No rigid routines were seen during the course of the inspection. The records showed that the health care needs of the people living in the home were being met and advice from professionals was sought when necessary. The system in place for administering medication was well managed and ensured the people living in the home received their medication as prescribed. DS0000064275.V351870.R01.S.doc Version 5.2 Page 6 Visitors were seen to come and go during the inspection and were made welcome by staff. Friendly relationships between staff and visitors were evident. The menus were varied and nutritious and offered choices at each meal. The people living in the home were satisfied with the meals being served. There was an appropriate complaints procedure in the home and complaints were well managed. The staffing levels in the home were appropriate for the needs of the people there. The home was generally well maintained and the people living there appeared very comfortable. What has improved since the last inspection? What they could do better: A comprehensive assessment must be carried out prior to admission to ensure that the needs of the people being admitted to the home are known to staff. Where there are any identified risks for the people living in the home there must be management plans in pace detailing how these are to be minimised. DS0000064275.V351870.R01.S.doc Version 5.2 Page 7 Information on any risk assessments needed to be consistent and cross reference to each other where applicable to ensure staff had all the necessary correct information. Staff must ensure that appropriate assistance and encouragement is given at meal times and that the people living in the home are given adequate time to eat their meals. To ensure that the people living in the home were safe all accessible radiators needed to be guarded and COSHH substances stored securely at all times. All the appropriate checks needed to be undertaken and documents obtained for new employees prior to them commencing their employment to ensure the people living in the home were safeguarded. To ensure new staff were equipped with the necessary skills and knowledge to care for the people living in the home induction training needed to be in line with the specifications laid down by Skills for Care. To ensure the standards in the home were acceptable to the people living there the home needed a quality monitoring system in place based on seeking their views. 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. The summary of this inspection report can be made available in other formats on request. DS0000064275.V351870.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 DS0000064275.V351870.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The necessary information was available for people wanting to live in the home to enable them to make an informed choice about where they lived. The assessment procedures in the home needed to be improved to ensure the needs of the people moving in were known to the staff prior to admission. EVIDENCE: The new service user guide had been completed and printed. The amendments that had been required following the last key inspection had been addressed. The document was available for anyone who may be thinking of moving into the home and copies were to be issued to all the people living in the home. It was noted that the contract/ license agreement in the service user guide was different from the contract being issued to people moving into the home at the time of the key inspection. If the document in the service user guide is the new contract that is to be used this should be issued to all the people living in DS0000064275.V351870.R01.S.doc Version 5.2 Page 10 the home and those being admitted so that they are all aware of the current terms and conditions of their stay at the home. The assessments for two residents recently admitted to the home were sampled. The staff at the home had undertaken their own pre admission assessments. The form used for the assessments was quite thorough and it was evident from these that the individuals had been spoken to and asked a number of questions about their lives and any difficulties they were having. However the forms had not been fully completed for either of the individuals. It is important that the forms are fully completed, in particular the summary of needs at the end, to enable the staff at the home to make an informed decision as to whether they can meet the needs of the individuals being admitted to the home. Only one of the files sampled included a copy of the social workers assessment which gave some detailed information about the needs of the individual. The two individuals confirmed that they had visited the home prior to admission to assess the facilities available to them. There were no records being kept of pre admission visits. It was recommended that records were kept of pre admission visits that detailed how the visit had gone and if any issues had arisen that needed to be addressed. Both the files sampled included copies of contracts/statements of terms and conditions however these had not been completed or signed. DS0000064275.V351870.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans and risk assessments for the people living in the home had improved. Further improvements were required to ensure they detailed all the needs of the people living in the home and how any risks were to be minimised. The medication system was well managed and safeguarded the people living in the home. EVIDENCE: At the time of the random inspection in August 2007 the manager had only been in post for a short period of time however she had begun to update and improve the care plans, which were entitled individual service statements (ISS). At the time of this inspection there had been a vast improvement in the ISSs. Three files were sampled. Two for people recently admitted to the home and one for an individual that had been living in the home for three months. All the files included ISSs. Areas covered in the ISSs included, washing and dressing, DS0000064275.V351870.R01.S.doc Version 5.2 Page 12 bathing and showering, mobility, social and religious needs, communication, activities, medication and sleeping and rising. Some of the ISSs also included diet. The ISSs were quite comprehensive and included some good detail of what the individuals were able to do for themselves and where they needed assistance from staff and what this assistance was. For example, ‘will wash her own hands and face if given a flannel and towel’ and ‘refuses to go to bed, staff to make comfortable in the chair and encourage to go to bed later’. Two of the individuals had dementia and there was clear detail on the ISS of how this affected them particularly in relation to communication for one. There was also good detail of how to cater for a diabetic diet on one of the ISSs. Some further improvements to the ISSs were suggested to the manager. For example, one stated ‘check once or twice during the night’ this needed to be discussed with the individual exactly what they wanted and then detailed so that night staff knew exactly when they were to check. One of the ISSs did not mention the individuals diet at all. Also one of the ISSs had been updated as the person had fallen which left them at risk at night when using the commode. A risk assessment had been undertaken for this but this had not been mentioned in the ISS. The ISS needed to be cross referenced to the risk assessment. It was evident from one of the ISSs and the observations made that there were issues over the dietary intake of one of the individuals. This was detailed to some extent on the ISS, in the nutritional assessment and personal risks. For example, ‘needs encouragement but won’t accept assistance. Need to give small portions but often. Food to be cut up’ was on the ISS. The nutritional assessment stated she was high risk, ‘eats well with encouragement’ and so on. The personal risk assessment stated for poor appetite staff to log and monitor food intake, small portions often, offer foods to build up appetite. When speaking to the acting manager it was evident the individual was offered specific foods throughout the day, for example, chocolate and there were specific ways of encouraging her to eat, for example, putting the food on the fork or spoon and letting her pick it up. None of this was recorded and staff did not encourage in the way described during lunchtime. The acting manager needed to ensure that either the ISS or the risk assessment was specifically detailed and that they were cross referenced to each other so that staff knew exactly how to encourage the individual to eat. It was also strongly recommended that the individual had separate food and fluid records that detailed all that they ate and drank so that it could be easily ascertained if their intake was adequate. The G.P. did make a planned visit to this person on the day of the inspection and the manager asked for a referral to the dietician but the G.P. did not think this was necessary at this time. At the time of the random inspection the acting manager had begun to address the shortfalls in the risk assessments. Further improvements had been made at the time of this inspection. All files included manual handling, nutritional and tissue viability assessments and two included personal risk assessments. One DS0000064275.V351870.R01.S.doc Version 5.2 Page 13 of the manual handling risk assessments stated a different sling size to the falls risk assessment and one did not give a sling size but it was detailed on the falls risk assessment. The acting manager needed to ensure that all risk assessments cross referenced to each other and that the information was consistent. The format being used for the tissue viability assessment did not have a key that showed what the score indicated therefore it could not be ascertained if management plans were needed or not. One of the nutritional assessments indicated that a specific management plan needed to be in place (as detailed above). The personal risk assessments that were in place were quite comprehensive. These included ongoing urine infections, use of a commode and managing aggressive behaviour and all included details of how the risks were to be managed. At the time of the random inspection the accident records indicated that one of the people living in the home was having several falls. A requirement was made that the records be regularly audited to establish if there were any patterns to the falls. The acting manager had been doing this and the number of falls the individual was having had reduced. The recording of the health care needs of the people living in the home were being recorded in more detail at the time of the random inspection and the outcomes of any professional visits were recorded. This progress had been sustained. It was evident that the people living in the home received the necessary professional input from G.P.s, chiropodists, opticians, district nurses, community psychiatric nurses and so on. The acting manager had introduced a new system for daily records. These were now being done under five separate headings, continence, concerns, well being, activities and personal care. The recordings varied in content and some were still very repetitive. Further improvements were needed to ensure they gave an overview of the individuals, there general well being and how they were spending their days. Medication continued to be well managed. All medication was recorded when received and copies of prescriptions and photographs of the people living in the home were with the corresponding MAR (medication administration record) chart. All staff that were administering medication had received training. It was recommended that there was a sample staff signature sheet with the MAR charts so that it could be determined who had administered the medication at any time. One minor discrepancy was found when undertaking the audit of the medication where it appeared one tablet had been administered and not signed for. Controlled medication was being administered and recorded appropriately. DS0000064275.V351870.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. 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 the people living there could spend their time as they chose. The suitability of the activities being offered needed to be discussed with the people living in the home to ensure they met with their expectations. There were no restrictions on visitors to the home within reasonable hours. People living in the home were satisfied with the food being served to them the food records evidenced that their nutritional needs were being met. EVIDENCE: As at the last two inspections despite being a very busy time of day at the start of the inspection the home was very calm and relaxed and there were adequate numbers of staff on duty. It was evident throughout the inspection that the people living in the home were able to get up when they wished. Friendly relationships between the staff and the people living in the home were evident throughout the inspection. People living in the home were able to spend their time as they chose and were seen wandering freely around the home, sitting chatting to each other, DS0000064275.V351870.R01.S.doc Version 5.2 Page 15 watching television, taking part in a colouring activity and a floor game. There was a weekly activities programme on display in the home. Activities recorded in individual records included church service, sing a long, watching television, skittles, hoop game, watching a DVD and progressive mobility. The records did not include any comments on if the activity was enjoyed or otherwise. An issue raised on one of the completed surveys was the appropriateness of the activities on offer and that all the people living in the home were offered the same activities despite their abilities. As at the last inspection it was recommended that activities were discussed with the people living in the home, collectively and individually, to ensure they are meeting their expectations. Visitors were seen to come and go throughout the inspection and were made welcome by staff. Relationships between the visitors and the staff appeared good. Daily records showed that the people living in the home had visitors at varying times throughout the day and they could go out with them when they wished. The people living in the home were able to make choices on a daily basis, for example, when to get up and go to bed, what to wear and what to eat and how to spend their time. The inspectors were of the opinion that some of the people living in the home could have been offered more independence at meal times, for example, tea pots, milk jugs and sugar bowls on tables for them to help themselves. Individuals were encouraged to personalise their rooms to their liking and personal possessions were observed in the rooms seen. There were rotating menus in the home and the food records generally reflected the meals being served. Although the menus detailed the vegetables to be served the food records did not always detail what was served. Also when sandwiches were served for tea the food records did not always detail what the fillings were. The inspectors observed staff asking people what they would like prior to meals and there was a list of their likes, dislikes and diets in the kitchen. At the time of the last key inspection issues were raised about meal times, for example, all meals were served on small plates, no one was asked if they wanted more to eat, puddings were served before people had finished their meal. The inspectors had lunch with the people living in the home and generally the issues had been addressed. The meal was well cooked and presented nicely and the majority of the individuals appeared to enjoy it. Larger plates were being used and people were asked if they wanted seconds. Only one person had their pudding put on the table before they had finished their main meal. Staff were on hand to offer assistance if required, for example, one person with a sight impairment was told what was on their plate and where. As stated previously the manager had discussed with the inspectors how one of the people living in the home should be encouraged to eat as they would not allow staff to feed them. This did not happen at this DS0000064275.V351870.R01.S.doc Version 5.2 Page 16 meal and the individual was not allowed much time before the meal was removed. Staff needed to ensure the appropriate encouragement was offered at meal times and that meals were not rushed. It was recommended to the acting manager that more independence be offered at meal times to those people that were able to pour their own tea, help themselves to vegetables and so on. Since the last inspection the dining area had been relocated. Half of the large lounge at the rear of the home had been changed to the dining area. The area was very pleasant, had been redecorated with new flooring, furniture and lighting. The area was a little crowded and it was recommended that the possibility of having a dining table in the lounge at the front of the home for the people who were more able be explored. The other lounge at the front of the home did have a dining table and some meals were served in there. DS0000064275.V351870.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. 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. To ensure the people living in the home were safeguarded staff received training in adult protection issues and any issues were acted on appropriately. EVIDENCE: The complaints and adult protection procedures have been viewed on several occasions and found to be appropriate. Some concerns have been raised with the Commission since the last key inspection and these were looked into during the random inspection. The issues were about the circumstances surrounding an incident in the home when one person fell and knocked over another. The issues raised were about the lack of staff in the home at the time. This was addressed straight away however the proprietor was informed should a situation like this occur again staff cover must be maintained until the manager returns to the home. Other issues raised were about the tumble drier being broken and there was washing hanging around the home and bare bulbs in the wall lights at the home. A recommendation was made at the time that a second tumble drier be purchased and this had been done at the time of this inspection. A requirement was made following the random inspection in relation to the DS0000064275.V351870.R01.S.doc Version 5.2 Page 18 exposed light bulbs. This had been resolved at the time of this inspection as all the lighting in the lounge had been renewed. The home had logged one complaint and information about this had been relayed to the Commission. This was in relation to the theft of some money from one of the people living in the home. This was appropriately reported to the police and social care and health under the home’s adult protection procedures. The police visited the home and spoke with the individual concerned but were unable to pursue the issue. The proprietor repaid the money. No further thefts have occurred. It was recommended that staff record any minor complaints or ‘niggles’ that the people living in the home make to evidence they listen to them and take action. The acting manager of the home had recently raised an adult protection issue with social care and health and the Commission into the conduct of one of the staff. This resulted in a referral to the POVA register. The acting manager is clearly aware of her responsibilities to report any allegations of abuse. Staff at the home had had training in adult protection issues. DS0000064275.V351870.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There had been further improvements to the environment enhancing the comfort and facilities available to the people living there. Some issues needed to be addressed to ensure the people living in the home were entirely safe. EVIDENCE: The home was suitable for its stated purpose, was generally well maintained and safe. There had been some significant improvements made to the communal areas of the home since the random inspection. The dining room which was at the front of the home had been changed to a lounge. The dining area had been relocated to half of the large lounge at the rear of the home. There is also another lounge at the front of the home. All the lounges and dining area had been decorated and a lot of new furniture had also been purchased. Two of the DS0000064275.V351870.R01.S.doc Version 5.2 Page 20 lounges and the dining area had also had new flooring and the lighting had been changed in the lounge/diner. All the communal areas were very comfortable and bright. All the corridors and stairs throughout the home had been redecorated and new carpet had been fitted on the stairs and some corridors, other corridors on the ground floor had had hard flooring fitted. The home also has a large garden which was generally well maintained. At the time of the last key inspection the bottom of the garden was badly overgrown and could have been hazardous for anyone who wandered in this area. At the time of this inspection this was in the process of being cleared. There were adequate numbers of toilets throughout the home and some were large enough for staff to offer assistance. The flooring in the toilets on the ground floor of the home had been replaced as required at the last inspection however this was still needed in some of the other toilets. There were assisted bathing facilities on the first and second floors of the home. The medic bathroom on the ground floor had been closed off for some time as it was hazardous. Therefore there was no bathing or showering facility on the ground floor. It is planned that the medic bathroom will be converted into a walk in shower. There had been an ongoing issue at the home about there being a built in cupboard in the medic bathroom where food was stored. This had been resolved at the time of this inspection and all food was being stored in the kitchen. There were some aids and adaptations throughout the home to assist those people 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. It was strongly recommended that hand rails are fitted in the corridors throughout the home. Due to the relocation of some of the furnishings in the home some of the radiators had become accessible to the people living in the home and these were not guarded. This needed to be addressed to ensure no one could be burnt. Some bedrooms were seen on the day of the inspection. They 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 (NMS) but any shortfalls had not been rectified. If individuals choose not to have all of the furnishings and fittings required by the NMS this should be documented in their files. All rooms had a lockable facility and the people living in the home were able to have keys to their bedroom doors if they wished. Three further bedrooms had had new carpets however there still remained some bed bases that were worn and needed to be replaced. DS0000064275.V351870.R01.S.doc Version 5.2 Page 21 The home was generally clean and odour free, with the exception of one bedroom where the flooring was due to be replaced. Some minor issues were raised in relation to infection control e.g. fresh foods must be dated when frozen and one rusting commode was seen in a bedroom. It was also noted that COSHH substances had been left out in the kitchen. These must be stored securely when not in use. The laundry was appropriately located, albeit very small, the proprietor has had planning permission to build a new laundry. There was a sluice washing machine and two tumble driers installed. There were ongoing problems with the large tumble drier being out of action. This was on a contract to the home and the suppliers were waiting for a part before it could be repaired. This was causing difficulties for the home as wet washing was building up and must be addressed as soon as possible. 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. DS0000064275.V351870.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. 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 to ensure the needs of the people living in the home could be met. It was not evidenced that employees were undertaking suitable induction training to enable them to care for the people living in the home. Recruitment procedures needed to be improved to ensure the people living in the home were safeguarded. EVIDENCE: There had been some staff turnover since the last key inspection. The home was advertising for care, domestic and laundry staff. Some had been appointed but were experiencing some delays in obtaining the necessary police checks. The rotas showed that there were three staff on duty until 9pm and then two waking night staff. The manager’s hours were usually supernumery to the care rota an exception being when staff were off sick at short notice. The home employed two cooks one worked during the week the other at weekends. A worker from another home owned by the same proprietor was undertaking domestic cover for the home. The interactions between the staff and the people living in the home were good and the individuals spoken with stated staff were ‘kind’ and ‘helpful’. DS0000064275.V351870.R01.S.doc Version 5.2 Page 23 The home employed fourteen care staff and the inspectors were informed that eight of these had NVQ level 2 or the equivalent and the others had been registered to undertake the training. It was known from previous inspections that staff had undertaken a variety of training including manual handling, fire safety, first aid, dementia care, challenging behaviour, adult protection and so on. However it was difficult to assess which staff had undertaken all the required training as there was no training matrix for the home. The manager showed the inspector the training that was planned to take place in the home, manual handling the day after the inspection, first aid and adult protection also in October and infection control and health and safety in November. Food hygiene training was still to be booked. The files for three new staff were sampled. Only two of these included any evidence of induction training and this had only been partially completed. The induction programme seen was in line with the specifications laid down by Skills for Care but it needed to be completed within the first twelve weeks of employment. The recruitment records for three new staff were sampled. The records showed that only one of the staff had all the required checks completed prior to them being employed. For one a CRB from a previous employer had been accepted and even though this was very close to when the person started work at Bretby it was not acceptable and a new one needed to be applied for. For the other staff member their POVA first check had been received five days after their employment commenced. It was also noted that for one employee the references had not been received prior to them commencing work. These issues are unusual for this home as they have not had issues over recruitment in the past. These must be addressed to ensure the people living in the home are fully safeguarded. DS0000064275.V351870.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There had been a noticeable improvement in the home since the appointment of the manager. Further improvements were required to the system in place for monitoring the quality of the service offered. The health and safety of the people living in the home and the staff were generally well managed. EVIDENCE: The home had been without a permanent manager for a considerable amount of time and this was having an effect on the service being offered at the home. A new acting manager was appointed to the home in July. At the time of the random inspection in August some improvements were evident. At the time of this inspection further progress had been made on meeting the requirements following the last key inspection particularly in relation to care planning and risk assessments. The acting manager had a lot of experience of working with DS0000064275.V351870.R01.S.doc Version 5.2 Page 25 older people and the running of a residential home. She had her NVQ level 4 in care and was going to register to undertake the Registered Manager’s Award. Although she had only been at the home for three months she had gained a good knowledge of the needs of the people in her care. She was very committed to improving the standards in the home and very receptive to what the inspectors were saying. One of the completed surveys that had been returned to the Commission stated ‘the new manager seems to have a better understanding.’ The home did have a quality monitoring process in place. At the time of the last key inspection there was evidence that the responsible individual for the home had undertaken a quality audit of the home. The findings of this were not supported by that key inspection and there was no action plan in place to address any shortfalls that had been noted. The inspectors were informed that no further audits had been undertaken. Clearly improvements had been made in the home and a quality audit should be undertaken with the involvement of the people living in the home to identify where further improvements are required and how they will be addressed. There was some evidence that the acting manager was having meetings with staff and the people living in the home. The meetings with the people living in the home showed they had been consulted about such things as the colour schemes and the change of use of the communal rooms. Staff meeting minutes showed that a variety of care issues were discussed, for example, infection control and bathing. The home continued to manage some of the finances on behalf of the people living there. Some records were sampled. The written records were appropriate and recorded all income and expenditure and all balances of cash held were correct. It was noted that receipts were not available for the most recent chiropody treatment. The acting manager stated this was due to her not having them with her at the time of her visit. The acting manager was aware she had to get these and keep them. At the time of the last key inspection some issues were raised in relation to health and safety. Records on site detailed that the weekly fire alarm and monthly emergency lighting checks had lapsed and no evidence could be found on site of an up to date fire drill. At the time of the random inspection these issues had been resolved and at the time of this inspection records continued to be up to date. At the time of the random inspection a fire risk assessment had been carried out by an outside contractor and some actions were identified. Some of these had been addressed at the time of the random inspection but a requirement was made in relation to those outstanding. At the time of this inspection this had been addressed. There was evidence 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. No evidence could be found that the emergency call system had been serviced. The Commission DS0000064275.V351870.R01.S.doc Version 5.2 Page 26 was being notified of any accidents in the home as required and notifications in relation to any incidents of challenging behaviour were had improved. DS0000064275.V351870.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 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 3 2 2 X 2 2 2 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 DS0000064275.V351870.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(a) (b) Requirement There must be a comprehensive assessment undertaken of the needs of people wanting to use the service prior to them being admitted to the home. A copy of the social worker’s assessment must be obtained where they have been involved in the admission process. This will ensure the staff at the home know the needs of the people being admitted prior to admission. All residents must have personal risk assessments undertaken to minimise any identified risks. (This has been outstanding since 01/12/05) This will ensure that residents are not exposed to any unnecessary risks. There must be specific management plans in place for staff to follow where there are concerns over the dietary intake of any of the people living in the home. DS0000064275.V351870.R01.S.doc Timescale for action 30/11/07 2. OP7 13(4)(c) 30/11/07 3. OP8 12(1)(a) 13(4)(c) 30/11/07 Version 5.2 Page 29 4. OP8 12(1)(a) This will ensure that the nutritional needs of the people living in the home are met. There must be a system in place to indicate what the score on the tissue viability assessment indicates and when a management plan is needed. Information on risk assessments must be consistent and they must cross reference to each other where applicable. 30/11/07 5. OP15 12(1)(a) This will ensure people are cared for safely. Appropriate assistance must be 18/11/07 offered to the people living in the home at meal times. Staff must ensure the people living in the home are given enough time at meal times to eat their meal. This will ensure people have their nutritional needs met. Any worn bed bases must be replaced in order of priority. (This has been outstanding since 30/11/06) This will ensure the residents are comfortable. Radiators that are accessible to the people living in the home must be guarded. This will ensure the people living in the home are safeguarded. All COSHH substances must be stored securely. Good infection control procedures must be followed at all times. DS0000064275.V351870.R01.S.doc Version 5.2 Page 30 6. OP24 16(2)(c) 31/12/07 7. OP25 13(4)(c) 31/12/07 8. OP26 13(4)(c) 18/11/07 9. OP29 19(1) This will ensure the people living in the home are not exposed to any unnecessary risks. All the appropriate checks must be undertaken and documents obtained prior to new staff commencing their employment. This will ensure the people living in the home are safeguarded. All staff must have induction training as specified by Skills for Care that is completed within the first twelve weeks of employment. (This has been outstanding since 31/07/06) 18/11/07 10. OP30 18(1)(c) 30/11/07 11. OP33 This will ensure new staff have the necessary skills and knowledge to care for the people living in the home. 24(1)(a,b) The home must have a system in 31/12/07 place for monitoring and improving the quality of the service offered based on seeking the views of the people living in the home. (This has been outstanding since 30/06/06). This will ensure that standards within the home are acceptable to the people living there. There must be evidence on site that the emergency call system has been serviced. This will ensure the safety of the people living in the home. 12. OP38 13(4)(c) 30/11/07 DS0000064275.V351870.R01.S.doc Version 5.2 Page 31 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 OP2 Good Practice Recommendations It is strongly recommended that the contract in the service user guide is issued to all the people living in the home and that it is signed and dated at the time of issue. This will ensure individuals are aware of the terms and conditions of their stay. It is recommended that the outcome of any pre admission visits to the home are documented. This will ensure any issues are highlighted at early stage. Care plans should be further developed to ensure they included all the needs of the people living in the home, for example, frequency of night checks and dietary preferences. This will ensure person centred care is offered. It is strongly recommended that where there are concerns about the food and fluid intake of any of the people living in the home individual intake charts are used. This will enable closer monitoring of food and fluid intake. There should be a specimen staff signature sheet with the MAR charts so that it can be determined who has signed for medication. It is strongly recommended that activities are discussed with the people living in the home, collectively and individually, to ensure they are meeting their expectations. To ensure the independence of the people living in the home is maintained ways of offering more independence at meal times should be explored. It is recommended that all minor concerns and complaints raised by the people living in the home are recorded to show that they are listened to and that concerns are acted on. To promote good infection control the flooring in the toilets on the first and second floors of the home should be replaced. It is recommended that handrails are fitted along all the corridors in the home to aid the mobility of the people living there. Not all the bedrooms had all the furniture and fittings detailed in the National Minimum Standards. This should be discussed with the people living in the home to ensure DS0000064275.V351870.R01.S.doc Version 5.2 Page 32 2. 3. OP5 OP7 4. OP8 5. 6. 7. 8. OP9 OP12 OP15 OP16 9. 10. 11. OP21 OP22 OP24 12. OP26 13. OP30 the furnishings meet with their needs. 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. There was no training matrix available for the whole staff team. This should be reviewed so that it is easy to identify what training has been undertaken or is required by staff. DS0000064275.V351870.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45 – 46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000064275.V351870.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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