Inspection on 06/06/06 for Bretby House

This inspection was carried out on 6th June 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 16/10/06

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 6th June 2006 08:45 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.V294626.R01.S.doc Version 5.1 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.V294626.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bretby House Address 253 Boldmere Road Wylde Green Sutton Coldfield West Midlands B73 5LL 0121 373 6562 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 Old age, not falling within any other category registration, with number (24) of places Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. The home is registered to accommodate up to 24 older people. 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 nine 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. That one named person who is diagnosed as having Dementia at the time of admission can be accommodated and cared for in this home. 9th February 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. Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 5 The fees at the home ranged from £320.00 to £365.00 per week. Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was carried out by two inspectors over one day in June 2006. During the inspection a tour of the premises was carried out, three resident and two staff files were sampled as well as other care and health and safety documentation. The inspectors spoke with the manager, two members of staff and five of the seventeen residents. Prior to the inspection the inspector received a completed pre inspection questionnaire that included information about the home, residents and staffing and some completed relative and resident comment cards. What the service does well: What has improved since the last inspection? The interaction between the staff and the residents had improved and were much more respectful. The systems in place for the assessment of residents prior to admission had improved. The home had their own assessment documentation which covered all the required areas and would when fully completed detail the residents’ needs. Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 7 The systems in place for care planning had improved and those sampled were quite detailed and gave information about the residents’ needs and how they were to be met by staff. Several risk assessments had been put in place for the residents identifying where they were at risk and how these risks were to be minimised. Some improvement was still required. The staff had received training in adult protection issues and there was better recognition when incidents arose in the home. Recruitment procedures for new staff had improved and safeguarded the residents. There had been some improvements in the health and safety of staff and residents including, the purchase of a hoist to assist with manual handling, the hot pipe work had been guarded, staff had stopped using wheelchairs without footrests. What they could do better: There needed to be up to date information available for prospective residents to enable them to make an informed decision as to whether the home could meet their needs. 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. Care plans needed to be updated as the resident’s needs changed and reviewed at least monthly to ensure that staff were working with the most up to date information and could meet the residents’ current needs. Staff needed to ensure that the food served to the residents was prepared and in a form that they could eat to ensure they were receiving an adequate diet. Risk assessments needed to be developed further to ensure any identified risks were documented and systems in place to minimise them. The manger needed to ensure that there were no gaps on the medication administration sheets so that it could be determined if the residents had received their medication or not. There were some issues in relation to health and safety that needed to be addressed to ensure the home was an entirely safe environment for the residents to live in. 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. Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 8 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. 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.V294626.R01.S.doc Version 5.1 Page 9 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.V294626.R01.S.doc Version 5.1 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 The quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. There was no updated information available for prospective residents to enable them to make an informed decision as to whether the home could meet their needs. The assessment procedure had improved but the manager needed to ensure all the relevant information was known about residents prior to admission to ensure the home was able to meet any identified needs. Prospective residents were able to visit the home prior to admission. EVIDENCE: The manager of the home was still in the process of updating the statement of purpose and service user guide. It is proposed that the home will have a welcome pack available for all prospective residents but this was not completed at the time of the inspection. Three resident files were sampled. One of the files was for a person admitted to the home since the last inspection. This evidenced that the assessment procedure had improved. The home had their own assessment documentation, Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 11 which covered all the required areas however it had not been fully completed for the individual in question. All the relevant boxes were ticked but there was little additional information to clarify what help was needed by the person. Also at the end of the documentation there should have been a summary of identified needs and this had not been completed. There was a copy of the social workers assessment and information from the previous residence, which detailed a lot of the person’s needs however these had not been received at the home until the day of admission. The manager needed to ensure that the needs of prospective residents were known prior to admission so that a judgement could be made as to whether the home could meet the identified needs. There was evidence that residents could visit the home prior to admission. The files sampled included a document entitled contract and this detailed the fees to be paid but not the room to be occupied, there was no space to sign the contracts and it made a lot of referrals to the welcome pack for information which was not available at the time of the inspection. The manager of the home had applied to the CSCI for variations to enable them to continue to care for two residents with dementia which was a requirement made following the last inspection. Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 12 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, 10 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The systems in place for care planning had improved but these needed to be used for new residents within a reasonable time after admission. Residents were at risk as not all risks had been documented and management plans had not been put in place. To ensure the medication system was entirely safe some issues needed to be addressed. The interactions between staff and residents were more respectful. EVIDENCE: Three care files were sampled. Two of these included care plans entitled ‘Individual Service Statements’ (ISS). These were quite well detailed and included information about the individual needs of the residents and how they were to be met by staff, for example, to what extent they could care for themselves, incontinence needs, preferred waking and retiring times, preferred leisure activities and so on. There were also overviews of the residents’ days included on the files which included details of residents’ preferred routines. One of these was quite detailed in relation to the resident’s sensory disability and detailed how the needs in relation to this were to be met at meals times Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 13 however there were also additional needs on the ISS. The manager needed to ensure that the documents were cross referenced so that staff were aware of all needs. It was also noted that one ISS stated the individual was mobile however from other documentation it was evident they were not. Another ISS was sampled due to some observations made during the lunch time meal this mentioned the resident’s dentures and she clearly did not have dentures. The manager needed to ensure that ISSs were reviewed at least monthly and updated as needs changed to ensure they reflected all the current needs of the residents. There was no evidence to suggest that residents had been consulted about their care plans. One of the files sampled was for a resident who had lived at the home for almost three weeks and no care plan had been drawn up. The manager had written a brief overview of her needs on the day of admission however there was adequate information available on the file for an interim care plan to have been put in place. All three files sampled included manual handling risk assessments however these varied in what they included. One was very comprehensive and included what actions were to be taken by staff in the event of a fall, another did not detail the actions to be taken in the event of a fall and the other one had been updated as the individual was immobile but did not include the sling size to be used with the hoist. It was also noted, from another risk assessment, that this person was to be turned by night staff but there were no details of the handling methods to be used. Issues were raised at the last inspection in relation to the handling methods being used by staff. This appeared to have been resolved as the home had purchased a hoist. All the files sampled included falls risk assessments but only one included any personal risk assessments. One of the residents had a sensory disability which would have presented risks and it was evident from daily records that another resident had some challenging behaviours that needed to be assessed and strategies put in place for staff to manage the behaviours. All three files sampled had nutritional screenings included and wherever possible the weights of the residents were being monitored. It was noted that one nutritional assessment had not been completed appropriately and if it had been would have indicated cause for concern. The inspectors determined this by the observations made during the lunchtime meal. Only two files had tissue viability screenings. Where a risk had been identified on one of the tissue viability screenings details for managing this had been included. It was also evident from daily records that where a resident had developed pressure ulcers the district nurses were visiting the home to give treatment. As at the last inspection it was difficult to track that the identified health care needs of the residents were being met. There was a separate sheet for recording doctors’ visits but these were not always completed and any details on the daily records were lost as time went on, for example, it was documented that a resident had broken their dentures but there was no Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 14 documented evidence found that these had been repaired. The inspectors were assured this had been done. It was strongly recommended that the doctors visit sheets were amended to include all professional visits and were kept with the daily records to ensure ease of access for staff. There was evidence of regular chiropody treatment be obtained for the residents. Medication continued to be administered via a monitored dosage system. Some issues were raised that the manager needed to address. There were some gaps on the medication administration sheets (MAR) and it could not be determined if the medication had been given or not, not all balances of medication held in the home had been brought forward to the new MAR sheets therefore it was not possible to audit these and where residents could have one or two tablets the numbers given were not evident and therefore the amounts remaining could not be audited. A controlled drug cabinet had been purchased since the last inspection. The book being used for the recording of controlled medication appeared to be causing some confusion, sometimes there were two signatures other times three and it could not be determined that they had always been checked. The home needed to purchase a specific controlled drug register, which would be easier to follow and complete as it would be specifically designed for the task. The medication fridge was still located in the kitchen and not in the medication room. The manager stated she had started to complete staff drug audits to assess staff competence. The interactions between staff and residents had improved since the last inspection and no disrespectful comments were heard throughout the course of the day. Residents appeared to be able to have privacy when they wished. They were able to spend time in their rooms and medical consultations took place in private. Bedrooms doors were lockable and residents could have keys if they wished. Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 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 were some activities 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. Staff needed to ensure that the foods served to the residents were in a form that could be eaten by them. EVIDENCE: There did not appear to be any rigid rules or routines in the home and residents were able to spend their time as they chose. Residents spoken with were generally content. There were some documented activities in the activities diary these included bingo, armchair exercises, memory game, films and board games. There was also evidence of one to one activity at times, for example, cards and scrabble. The recording of activities had lapsed for the eight days prior to the inspection therefore it could not be determined if any activities had taken place during this period. There was also evidence that meetings had been held with the residents in relation to the range of activities. Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 16 Several visitors were seen to come and go throughout the course of the inspection and all appeared to be made welcome. There were no restrictions on residents going out with their visitors and there was some evidence that staff had started to take the residents out the local shops and café. Residents were being encouraged to make every day choices and this had improved since the last inspection, for example, choice of drinks and more alternatives on the menu. Care plans that were complete stated where the residents were able to make choices and where they were to be given choices, for example, for a resident with a sensory disability the colour of the clothes available for her to choose. Preferred rising and retiring times were also recorded. Residents were encouraged to personalise their rooms and personal effects were seen in bedrooms. All the residents spoken with stated they were satisfied with the food being served to them and described it as ‘good’. The inspectors joined the residents for lunch and the meal was well cooked and presented. The menu was on a board in the dining room and alternatives were available for those who did not like the meal on the menu. It was noted that one of the residents had difficulties chewing meat due to the lack of dentures and did not eat any at all. This was not identified in her care plan or nutritional risk assessment. Staff needed to ensure that the food served to residents could be eaten by them and if they needed any food soft it needed to be documented in the care plan and the cook informed. The menus in the home had recently changed to summer menus and appeared varied and nutritious. Food records were being kept but did need to reflect if the residents were not eating certain foods. The inspectors spoke with the cook who was aware of the likes and dislikes of the residents and was able to confirm that any diabetic diets were being catered for. Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 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 complaints procedure had been amended since the last inspection as required. The home had not received any complaints since the last inspection. Some general concerns had been raised with the CSCI but these were not substantiated at this inspection. The home was keeping a complaints log. It was recommended that any minor complaints/concerns were also logged. There were adult protection procedures on site and a copy of the multi agency guidelines for adult protection had been obtained. The adult protection procedures for the home still needed to include the address and telephone numbers of the CSCI and the local social services office. Since the last inspection staff had undertaken training in adult protection and there was a greater awareness of the issues. One issue had been raised by the manager and acted upon appropriately and the appropriate guidelines followed. Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 18 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, 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 the residents appeared comfortable. Some issues needed to be addressed to ensure the home was safe for the residents. EVIDENCE: There had been no changes to the layout of the home, which was generally suitable for its stated purpose. Since the last inspection the entrance hall and main staircase had been redecorated and was much brighter. The requirements made by the fire officer at the most recent visit had been met apart from one for which the time scale had not expired. Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 19 The stair carpet that was raised at the last inspection as it was frayed had not been addressed. There was adequate communal space at the home with two lounges and a dining room. The smaller lounge was beginning to get quite cluttered with storage of pressure cushions and bits and pieces, the curtains were torn, the skirting board under the radiator was very dirty and the thermostatic control had broken off the radiator. One of the conditions of registration for the home was that the uneven path must be replaced or re-laid to improve safe access to the garden this had not been done and the time scale had expired. This issue was discussed with the registered individual a little after the inspection and it was explained that as the residents were going into the garden this needed to be addressed as a matter of urgency. There were adequate numbers of toilets throughout the home and some were large enough for staff to offer assistance. The home had three bathrooms and one shower room. The inspectors were informed that the medic bath was not used, the shower had a large step up shower tray and one bathroom had only a domestic type bath. There was one bathroom on the first floor that had a bath hoist seat but this room would not have allowed for full assistance from staff. One of the conditions of registration for the new proprietors was that assisted bathing/showering facilities were provided on the first and second floors of the home. The time scale for this condition had not expired and the proprietor was in the process of obtaining quotes for this work to be carried out. When the bathroom on the first floor is altered the proprietor must ensure that opaque glass is fitted to the window to ensure the privacy of the residents and that the blind is replaced as it is very old and quite dirty. It was also noted that a plastic garden chair that was quite rough was being used in this bathroom and this needed to be replaced with appropriate seating. Also both end panels on the bath needed to be repaired. The built in cupboard in the ground floor bathroom was being used to store food, which was not appropriate, and again this was a condition of registration that alternative space for this must be found. The time scale for this had almost expired and if more time was needed a variation needed to be submitted to the CSCI for this. The flooring in the bathroom on the first floor was beginning to lift again and needed to be made safe and in the majority of the bathrooms and toilets the vinyl was still not sealed around the edges and this needed to be addressed. There were some aids and adaptations throughout the home to assist those residents with mobility difficulties including shaft lift and a ramp for going into the garden. There was only one very small handrail in one of the ground floor corridors. As stated previously the assisted bathing facilities in the home were inadequate. The manager stated she had completed an audit of the aids and adaptations and some additional equipment had been purchased. It was pleasing to note that the use of wheelchairs without footrests had stopped. Bedrooms varied in size and the majority of the required furnishings and fittings were evident. The majority of the rooms had only one chair and there Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 20 was not always access to bedside lighting. The manager stated she 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 of the bedroom carpets had been replaced however one in particular was noted as being quite worn and shabby and needed to be replaced. It was also noted that several bed bases were stained and worn and needed to be replaced in order of priority. Bedrooms were personalised to the occupant’s choosing. There was central heating throughout the home and some of the radiators had been guarded however there were still several that had not and this needed to be addressed as a matter of urgency. This was a condition of registration and the time scale for completion had expired. Some of the guards were needed as a matter of priority due to the positioning of the radiators, for example, next to beds. This issue was discussed with the registered individual for the home and she was to forward a variation, she also informed the inspector that quotes were being obtained for this work. It appeared that all hot water outlets had thermostatic mixer valves fitted. The shower had been taken out of use as at the last inspection it was running well in excess of 43 degrees. The hot pipe work in the ground floor toilet had been boxed in since the last inspection. All bedrooms were naturally ventilated and window restrictors had been fitted where appropriate. The home was generally clean and odour free however some issues were raised in relation to infection control procedures in the home these were: • Any rusting commodes needed to be removed from use. • Mops must not be stored in toilets when not in use. • There must suitable storage in the home for clinical waste or a safe system in place for transferring it to the outside bin. • Bins for use by staff must be foot operated. • The badly soiled pressure ring in the bathroom needed to be removed. • Dressings prescribed for residents must not be used for other residents. 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. Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 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. Training in safe working practices was being updated on an ongoing basis. 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 submitted with the pre inspection questionnaire evidenced that adequate numbers of staff were on duty at the home and that there had been little staff turnover since the last inspection. 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. All the residents spoken with were very positive in their comments about the staff team. The recruitment files for the two newest members of staff were sampled. Both files included all the required information and all the appropriate checks had been obtained prior to them commencing their employment. It was recommended that the manager maintained records of any interviews with prospective staff and included any discussions she had about gaps in employment. Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 22 The pre inspection questionnaire detailed that only three of the eighteen staff employed had achieved NVQ level 2 or the equivalent. The requirement for this is 50 . The induction records for the two new staff were seen. The checklist for one of the staff had been completed in one day and covered a vast amount of topics. The other staff member had only some of the topics ticked off but had only started her induction the day before the inspection. The manager did have a copy of the Skills for Care induction standards but there was no evidence that these were being used for the new staff. All staff had training records in place and these evidenced that the home were updating all the regulatory training in safe working practices. Training had been undertaken in manual handling, adult protection, health and safety and fire procedures. Future planned training included safe handling of medicines, further manual handling, dementia care and NVQ level 2. Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37, 38 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 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. 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 manager of the home had been in post since January 2006 and several improvements had been made, for example, better systems were in place for assessment and care planning however further improvements were required. The manager had several years experience of caring for older people and had gained a good knowledge of the residents at the home. She had undertaken her Registered Manager’s Award and was undertaking her NVQ level 4 in care. Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 24 There were no formal ways of measuring the quality the service of the offered to the residents in place apart from records of staff and resident meetings. 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 for the residents and a much improved system for documenting this had been put in place at the last inspection. No issues were raised on the pre inspection questionnaire and it stated that one of the residents continued to handle their own finances. There had been an improvement in notifying the CSCI of any accidents or incidents in the home since the last inspection. The responsible individual for the home had started to produce the required reports on the conduct of the care home on a monthly basis. Some issues were raised in relation to health and safety that needed to be addressed, for example, the guarding of radiators and infection control. Staff were receiving training in safe working practices. The in house checks on the fire system were up to date. There was evidence on site that the majority of the equipment on site had been serviced with the exception of the bath hoist, emergency call system and the lift. The information in relation to the call system and the lift were faxed to the inspector after the inspection and also information that the bath hoist had been condemned and that this had been taken out of use, therefore no requirements have been made in relation to these issues. Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 25 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 1 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 1 2 X 2 1 2 STAFFING Standard No Score 27 3 28 1 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X 3 2 Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 26 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 scale of 01/04/06 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. (Previous time scale of 01/04/06 not met.) The registered person must ensure that a copy of the social workers assessment is obtained prior to the admission of any residents. For individuals who are selffunding the registered person must ensure the home’s assessment documentation is fully completed and identifies the needs of the individual. All residents must have care plans that detail all their current needs in respect of health and DS0000064275.V294626.R01.S.doc Timescale for action 31/07/06 2. OP2 5(1) 31/07/06 3. OP3 14(1) 31/07/06 4. OP7 15(1) 14/08/06 Bretby House Version 5.1 Page 27 welfare and how these are to be met by care staff. (Previous time scale of 01/04/06 partially met.) 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 and 01/04/06 not met.) Care plans must be cross referenced to the daily overviews and risk assessments. All residents must have personal 31/07/06 risk assessments undertaken to minimise any identified risks. (Previous time scale of 01/12/05 and 01/03/06 not met.) There must be clear guidelines for staff to follow for the management of any challenging behaviours. (Previous time scale of 01/03/06 not met.) Manual handling risk assessments must detail all handling methods and the actions to be taken by staff in the event of a fall and where a hoist is indicated the sling size must be detailed. All residents must have tissue viability assessments. (Previous time scales of 01/12/05 and 01/03/06 partially met.) Nutritional risk assessments must be appropriately completed to reflect the individual Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 28 5. OP7 13(4)(c) 6. OP7 13(5) 31/07/06 7. OP8 12(1)(a) 31/07/06 8. OP8 12(1)(a) 9. 10. OP9 OP9 13(2) 13(2) 11. 12. OP9 OP9 13(2) 13(2) 13. OP12 12(1)(a) 14. 15. OP15 OP19 16(2)(i) 13(4)(c) 16. OP20 23(2)(d) (h)(m) concerned. Records of any identified health care needs must detail how these have been followed up and monitored. (Previous time scale of 01/03/06 not met.) There should be no gaps on MAR charts unless for PRN (when required) medication. The balances of any medication held in the home at the end of a MAR chart must be carried forward to the next MAR chart. The home must purchase a controlled drug register. The medication refrigerator must be located in the medication room and the maximum, minimum and current temperatures recorded on a daily basis to ensure that the medicines are stored within their product licences. (Previous time scales of 04/11/05 and 01/03/06 not met.) Staff must record how residents are spending their days to evidence their social needs are being met. (Previous time scale of 01/03/06 partially met.) Staff must ensure that the foods served to residents are in a form that can be eaten by them. The stair carpet must be made safe or replaced. (Previous time scale of 01/03/06 not met.) The small lounge: • Must not be used for storage. • The curtains must be repaired or replaced. • The skirting board must be thoroughly cleaned. • The thermostatic control DS0000064275.V294626.R01.S.doc 31/07/06 01/07/06 01/07/06 31/07/06 01/08/06 31/07/06 01/07/06 01/07/06 01/07/06 Bretby House Version 5.1 Page 29 17. OP20 13(4)(c) 18. OP21 23(2)(l) on the radiator must be repaired. The uneven garden path must be 01/07/06 replaced or re-laid. (Previous time scale of 20/03/06 not met.) Additional dry goods storage 31/07/06 space must be provided. (Previous time scale had not expired.) If additional time is required for this work a variation must be forwarded to the CSCI giving details. The vinyl flooring in the 31/07/06 bathrooms and toilets must be adequately sealed or the vinyl replaced. (Previous time scales of 01/12/05 and 01/05/06 not met.) Assisted bathing/showering 20/09/06 facilities must be provided on the first and second floors of the home. (Previous time scale given had not expired.) The garden chair being used in 14/07/06 the bathroom must be replaced with more appropriate seating. The bath panels in the first floor bathroom must be repaired. 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 not met.) The bedroom carpet identified during the inspection must be replaced. Worn and stained bed bases must be replaced in order of priority. 19. OP21 23(2)(b) 20. OP21 23(2)(j,n) 21. OP21 23(2)(c) 22. OP24 16(2)(c,p) 31/07/06 23. OP24 16(2)(c) 31/08/06 Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 30 24. OP25 13(4)(c) All radiators must be covered or guarded. (Previous time scale of 20/03/06 not met.) An application to vary the time scale for this condition of registration must be forwarded to the CSCI. A commode pot washer/disinfector must be installed in the home. (Previous time scale had not expired.) • Any rusting commodes must be removed from use. • Mops must not be stored in toilets when not in use. • There must suitable storage in the home for clinical waste or a safe system in place for transferring it to the outside bin. • Bins for use by staff must be foot operated. • The badly soiled pressure ring in the bathroom must be removed. • Dressings prescribed for residents must not be used for other residents. 50 of care staff must be qualified to NVQ level 2 or the equivalent. (Previous time scale of 01/06/06 not met.) All staff must have induction training as specified by Skills for Care that is completed within the first twelve weeks of employment. The responsible individual for the home must ensure that an application for the registration of the manager is forwarded to the DS0000064275.V294626.R01.S.doc 31/07/06 25. OP26 13(3) 20/08/06 26. OP26 13(3) 31/07/06 27. OP28 18(1)(a) 31/12/06 28. OP30 18(1)(c) 31/07/06 29. OP31 9(2) 31/07/06 Bretby House Version 5.1 Page 31 30. OP31 31. OP33 CSCI. (Previous time scale of 01/04/06 not met.) 9(1)(b)(i) The manager must be qualified 30/06/06 to NVQ level 4 in care and management. (Previous time scale given had not expired.) 24(1)(a,b) The home must have a system in 30/06/06 place for monitoring the quality of the service offered based on seeking the views of the residents. (Previous time scale given had not expired.) 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. 2. 3. Refer to Standard OP8 OP16 OP29 Good Practice Recommendations It is strongly recommended that the doctors visit sheets are amended to include all professional visits and that they are stored with the daily records. It is strongly recommended that any minor complaints/concerns be logged. It is strongly recommended that records be kept of employment interviews. Bretby House DS0000064275.V294626.R01.S.doc Version 5.1 Page 32 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.V294626.R01.S.doc Version 5.1 Page 33 - 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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