Inspection on 09/02/06 for Bretby House

This inspection was carried out on 9th February 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 06/06/06

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 9th February 2006 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 Bretby House DS0000064275.V280489.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.V280489.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.V280489.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 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 or 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. 25th October 2005 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.V280489.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by two inspectors over one day in February 2006 and was the second of the two statutory inspections for 2005/2006. To get a full overview of all the standards assessed during this inspection year this report should be read in conjunction with the report written following the inspection on the 25th October 2005. The home had changed hands in September 2005 and this should be taken into account when reading this report. During this visit a tour of the home was carried out, three resident and three staff files were sampled as well as other care and health and safety records. The inspectors spoke with the acting manager, the registered individual, the senior care assistant and five of the twenty-four residents. What the service does well: What has improved since the last inspection? There had been some consultation with the residents about the routines in the home and as a result of these more flexibility had been introduced in relation to breakfast time and whether residents had their breakfast in bed or not. There had also been some consultation with the residents about their preferred activities. The practice of using powdered milk in the home on an ongoing basis had stopped and the records of food served to the residents had been further developed. The records for the management of finances on behalf of the residents had improved and included all the relevant information and details. Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 6 A manager had been appointed to oversee the home on a daily basis. The cleanliness and general hygiene in the home had improved. The kitchen was much cleaner than at the time of the last inspection and a new dishwasher had been installed. A new washing machine had been installed with a sluice cycle, several commodes had been replaced and a new bin had been purchased for the storage of the clinical waste. The safety of the residents had improved including. The flooring in the bathroom and bedrooms that was a tripping hazard had been addressed, some of the radiators had been guarded, the worn armchairs had been removed from the lounge and the water system was being checked for the prevention of legionella. Staff had had their fire training updated and a fire drill had taken place. What they could do better: The acting manager must ensure that any prospective residents have a full assessment of their needs prior to admission and that a copy of the assessment has been obtained from the placing authority so that staff are able to make an informed decision as to whether the home can meet the identified needs. The acting manager and the registered individual must ensure that any future admissions are within the registration category or submit an application for variation to the CSCI detailing how the needs of individual will be met. The care planning system in the home needed to be vastly improved to ensure all the residents’ needs were detailed and included the actions to be taken by staff to meet them. All residents needed to have personal and manual handling risk assessments that detailed how staff were to minimise any identified risks. Where challenging behaviours had been identified strategies for managing these needed to be in place. Staff needed to ensure they complied with the manual handling regulations to ensure they did not put themselves or the residents at risk. Staff needed to ensure they were respectful to the residents at all times and that further consideration was given to helping them exercise choice and control over their daily lives. The acting manager and responsible individual for the home needed to ensure staff were trained in and able to recognise potentially abusive situations so that residents were not left at risk. Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 7 Staff employed at the home needed to undertake structured induction training to ensure they were equipped with all the necessary skills and knowledge to fulfil their roles. The acting manager needed to develop some methods for monitoring the quality of the service offered at the home based on seeking the views of the residents with a view to continuous improvement. Several issues in relation to the health and safety of the residents and staff were raised at this inspection that needed to be addressed as a matter of urgency including, fire prevention, the temperature of the water in the shower, and unguarded radiators. The assisted bathing facilities in the home needed to be improved to ensure they were adequate for the needs of the residents. An application for the registration of the manager needed to be forwarded to the CSCI. 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.V280489.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 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 needed to be improved to ensure the identified needs of any prospective residents could be met. The acting manager must demonstrate to the CSCI that the home is able to meet the needs of any prospective resident assessed as being outside the registration category prior to admission. Prospective residents were able to visit the home prior to admission. EVIDENCE: The responsible individual for the home informed the inspectors that she was in the process of updating the statement of purpose and service user guide for the home. A copy of both of these documents needed to be forwarded to the CSCI when completed. Three resident files were sampled. Two included copies of the initial care plans drawn up the social worker but these had very little detail about the individual needs of the residents and one of these had been faxed to the home on the day of admission. Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 10 The other file did not include any information from the social worker. There was evidence that two of the residents had visited the home prior to admission and a brief assessment undertaken by staff. These included very little detail of the individuals’ needs. The acting manager must ensure that all prospective residents have a full assessment of their needs prior to admission and that a copy of the assessment undertaken by the placing authority has been obtained so that an informed decision as to whether the home can meet the identified needs can be made. It was clearly detailed in two of the files that the residents had vascular dementia which was outside the registration category of the home. The acting manager and the registered individual must ensure that any future admissions are within the registration category or submit an application for variation to the CSCI detailing how the needs of the individual will be met. There was no evidence that any of the residents had been issued with a contact/statement of terms and conditions of residence at the home. Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The care planning system in the home needed to be vastly improved to ensure all the residents’ needs were detailed and included the actions to be taken by staff to meet them. Residents were at risk as there were no documented risk assessments detailing how any identified risks were to be minimised. The medication system was generally well managed and safe. Staff needed to ensure they were respectful to the residents at all times. EVIDENCE: The three files sampled evidenced that there had been no improvement in the care planning system at the home since the last inspection. One of the files included two generic care plans for diet and toileting and the only additional information was that the individual needed encouragement to eat savoury foods. Another file included two generic care plans for personal hygiene and toileting, the additional information on one of these stated ‘can shave himself to a good standard’. The generic plans stated such things as toilet before and after meals, needs assistance with toileting and assistance of one carer. The third file sampled did not include any care plan. Due to the lack of information on the files it was difficult to determine how the staff knew how to care for the residents in question and if their needs were being met. Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 12 These issues were discussed with the registered individual and the acting manager and they stated a new package was being put together to address the issues. All residents must have care plans that detail all their needs and how these are to be met by staff. Residents or their representatives must be consulted about their care plans and they must be reviewed monthly. There was no evidence on any of the files sampled of any risk assessments for the residents. This was of concern to the inspectors as there was evidence on the daily records of challenging and aggressive behaviour, residents wandering, falling and going into other people’s bedrooms. There were no nutritional or tissue viability screenings and one of the residents clearly had some issues over diet. All residents needed to have personal and manual handling risk assessments that detailed how staff were to minimise any identified risks and where there were any challenging behaviours strategies for managing these needed to be in place. It was also evident from discussion with the acting manager and the documentation on a Regulation 37 notification to the CSCI that staff were not complying with the Manual Handling Regulations when lifting residents and this was putting themselves and the residents at risk of injury. The inspector was informed that a hoist was on order for the home and this needed to be in situ at the earliest possible opportunity. There was some evidence on the daily records of personal and health care needs being met however in some instances this was difficult to track. Examples of this included a mention that a resident had been taken to the doctors by a relative but it did not state what for or what the outcome was, on another occasion the daily notes referred to some difficulties with a catheter and that the doctor would be contacted in the morning but there was no evidence that this had been carried out. The systems in place for administering medication were only partially assessed during this visit. Medication was administered via a monitored dosage system and only senior staff and night staff were administering it. Two of the requirements made at the last inspections had been met in relation to two staff signing for controlled medication and ensuring all external preparations were labelled and dated when opened. The home was still in need of a controlled drugs cabinet and they needed to relocate the medication refrigerator. Some of the boxed medication was audited and generally the balances were correct however one of the controlled medications were two tablets short and it could not be determined how this had happened. The acting manager needed to undertake staff drug audits before and after a drug round to ensure the competency of the staff. Residents appeared to be able to have privacy when they wished. They were able to spend time in their bedrooms if they wished, medical consultations took place in the privacy of their bedrooms or another small room on the ground floor of the home. Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 13 All bedrooms had locks on the doors and a lockable facility. During the course of the inspection it was noted that staff did not always address the residents in a respectful manner their responses to the residents and the tone of voice used was not always appropriate. Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Some of the routines in the home had become more flexible and some consultation had taken place with the residents about their preferred activities. Further consideration needed to be given to helping the residents exercise choice and control over their lives in every day issues. There were no restrictions on visitors to the home within reasonable hours. The records of food served to the residents evidenced a varied and nutritious diet was offered. EVIDENCE: The residents seen and spoken with were generally content and some of the routines that had existed in the home, for example, early breakfast in bed, had been changed. Residents had been consulted about whether they wanted breakfast in bed or not, as this was being served very early, some had chosen to change and get up for breakfast others continued to have breakfast in their bedrooms at a time they preferred. The responsible individual stated that there had been some consultation with the residents about their preferred activities and that some activities had been taking place, for example, cards, dominoes and music and movement. A larger television and DVD player had been purchased for the home to enable the residents to watch films. There was no evidence on the daily records sampled of any activities having taken place in the home. Staff needed to ensure they recorded how residents were spending their days to evidence their social needs were being met. Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 15 There was some evidence that residents were encouraged to make some choices, for example, when to get up and go to bed, what to eat and how they spent their time. Residents were encouraged to personalise their bedrooms to their choosing and personal effects were seen in their rooms. Further consideration needed to be given to enabling residents to make choices in their every day lives. For example, during the course of the inspection when serving a drink to the residents, staff made it, poured it out and added the sugar in the kitchen; the drinks were then just handed around the lounge with no choices available. One of the residents commented that that was the second cup of tea she had had that day with sugar in and she did not take it. Whilst having a drink biscuits were given out by staff but no choice was offered even though there was a selection available, two biscuits were just handed to the residents. One of the residents also commented she was not allowed to go out and this may have been for health and safety reasons however it was the inspectors’ opinion that she could have been taken out for a walk by staff. Another resident commented that staff did not like you to go to your room in the afternoons but did not know why. Visitors were seen to come and go throughout the course of the inspection and they appeared to be made welcome by the staff. There were no restrictions on visiting during reasonable hours. The residents spoken with were satisfied with the catering arrangements at the home. The records of foods served to the residents had improved since the last inspection and they evidenced a varied and nutritious diet was offered to the residents. The practice of using powdered milk on an ongoing basis in the home had stopped. The dining room was bright and generally well furnished and decorated but only allowed for 18 people to be seated comfortably. Since the last inspection a dining table had been put in the other lounge to enable more people to sit at a table for their meals if they wished. Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The complaints procedure needed to be amended to ensure that complainants were aware they could refer a complaint to the CSCI at any point. It appeared that any complaints made to the manager were listened to but she needed to ensure the outcome of the complaint was documented and that the complainant had had feedback. Issues of adult protection were not being recognised by staff, which left the residents at risk. EVIDENCE: There was a complaint procedure on site but this needed to be slightly amended to ensure that complainants were aware that a complaint could be referred to the CSCI at any point. The registered individual was in the process of redrafting the complaints procedure and was aware this must be included. Since the last inspection one very minor anonymous complaint had been lodged with the CSCI, which had been passed back to the proprietor to address, and one complaint had been lodged at the home by one of the residents. The acting manager had investigated this complaint and the inspectors saw the documentation in relation to this. The investigation was quite thorough but it could not be determined if the complaint had been upheld or not or if the resident had received any feedback. The registered individual had rewritten the adult protection procedures for the home and these complied with the multi agency guidelines. They needed to be slightly amended to ensure they included the address and telephone numbers of the local social care and health office and the CSCI. It was also recommended that a copy of the multi agency guidelines be obtained. Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 17 It was of great concern to the inspectors that the daily records were detailing incidents that were clearly adult protection and where there was the potential for residents to be harmed by another resident. This had not been recognised as adult protection by the acting manager or the staff. No risk assessments had been put in place to try to avoid this happening. This was fully discussed with the registered individual and the acting manager and an immediate requirement was left at the home for the issues to be referred to social care and health. This also highlighted an urgent training need for the staff at the home. The inspector was informed that adult protection training had been booked to take place shortly for all staff. There were policies and procedures on site for managing aggression and restraint. These were adequate however it was recommended that the restraint policy be further developed to include examples of what can be deemed as restraint. Bretby House DS0000064275.V280489.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 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 since the last inspection, which was generally suitable for its stated purpose. There was still an issue at the home with staff wedging fire doors open and several wedges were seen during the inspection. If residents want to have their bedroom doors open they must be fitted with a self-closing device. It was also noted that parts of the carpet on the stairs were worn and fraying and this was a potential tripping hazard and needed to be addressed. There was adequate communal space at the home with two lounges and a dining room. One of the lounges had a television, video and music centre, the other lounge tended to be used more as a quiet area for the residents. Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 19 This lounge had been rearranged since the last inspection as it had been very overcrowded and a dining table had been put in there. This room now had a much more homely feel. The damaged armchairs had been removed from the larger lounge. There was a large well maintained garden to the rear of the home that was accessible to the residents. One of the conditions of registration for the home was that the uneven path must be replaced or relaid to improve safe access to the garden. 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 never 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 medic bathroom had been cleared of all the unnecessary clutter since the last inspection making the toilet more accessible to the residents. The built in cupboard in this 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 flooring in the bathroom on the first floor had been made safe however 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 and although there were wheelchairs available some of these were still being used without foot rests which was dangerous practice. As stated previously the assisted bathing facilities in the home were inadequate. 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 was not always access to bedside lighting. The bedrooms should be audited for furnishings and fittings against the National Minimum Standards and any shortfalls rectified. 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 since the last inspection and others had been made safe. Bedrooms were personalised to the occupant’s choosing. There was central heating throughout the home and some of the radiators had been guarded since the last inspection. It appeared that all hot water outlets had thermostatic mixer valves fitted with the exception of the shower, which was running well in excess of 43 degrees. The inspectors were informed this had been taken out of use after the last inspection but it was till working and needed to be addressed as a matter of urgency. Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 20 There was also a small amount of hot piping in the ground floor toilet that needed to be boxed in and this remained outstanding from the last inspection. All bedrooms were naturally ventilated and window restrictors had been fitted where appropriate. All the internal extractor fans in the toilets and bathrooms that were tested were working; this had been an issue at the last inspection. The home was clean and odour free and several improvements had been made in the hygiene and infection control at the home. The kitchen was much cleaner that at the last inspection and a new dishwasher had been installed. There was liquid soap and disposable towels in all toilets, bathrooms, the kitchen and laundry, the rusting commodes had been replaced, a new storage bin had been purchased for the clinical waste and the laundry had had a new washing machines installed with a built in sluice cycle. There were numerous commodes being used in the home and the effective cleaning of the commode pots was difficult therefore the home should at their earliest opportunity install a mechanical commode pot washer/disinfector. It was also noted that several COSHH items were stored in the staff toilet, which was not locked, and the COSHH cupboard on the first floor of the home was also unlocked. Bretby House DS0000064275.V280489.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 Good staffing levels were being maintained at the home. Several staff had worked there for a considerable amount of time, which was good for the continuity of care of the residents. Staff employed at the home needed to undertake structured induction training to ensure they were equipped with all the necessary skills and knowledge to fulfil their roles. There were robust recruitment procedures but these needed to be applied consistently to ensure the protection of the residents. EVIDENCE: There had been little staff turnover at the home since the new proprietors had taken over and there was only one staff vacancy at the time of the inspection. Several of the staff had worked at the home for a considerable amount of time, which was good for the continuity of care of the residents. The home were complying with the condition of registration in relation to staffing numbers this being a minimum of three care assistants throughout the waking day in addition to the manager’s hours and two waking night staff. The home also employed, a cook, domestic assistants and laundry assistant. The inspectors were unable to track the majority of training for staff as there were no individual training records and little evidence on the staff files sampled of any certificates. There was evidence that three staff were qualified to NVQ level 2 and the inspectors were informed that a further two staff had almost completed the qualification. There was no evidence that any of the care staff recently employed had had any induction training. Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 22 The acting manager and responsible individual of the home needed to ensure that all new staff received induction training in line with the specifications laid down by Skills for Care and that this was completed within the first twelve weeks of employment. Staff needed to have individual training records and copies of certificates to evidence that they had undertaken all their mandatory training, for example, manual handling and food hygiene, and that this was up to date. The inspectors were informed that staff had undertaken fire and food hygiene training and that manual handling, adult protection and first aid were booked and were being facilitated by a local college. The recruitment files for four staff were sampled, three had all the required documentation in place the other did not. The file that was incomplete had no evidence of a POVA first check being undertaken, the application form was not fully completed and there was no evidence of any references being obtained. The acting manager and responsible individual needed to ensure that the recruitment procedures were followed consistently for all staff employed. It was also strongly recommended that records of the interview undertaken were kept. Bretby House DS0000064275.V280489.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 A new manager had been appointed to the home and she demonstrated a commitment to addressing the many issues raised during the course of the inspection to ensure the home was a safe place for the residents to live. EVIDENCE: A new manager had been appointed for the home and she had been in post for a month at the time of the inspection. She had several years experience of caring for older adults and was just getting to know the needs of the residents in the home. She had undertaken the Registered Manager’s Award and was undertaking her NVQ level 4 in care. As the acting manager had been in post for a relatively short space of time it was difficult to assess her abilities. Several issues were raised with the acting manager throughout the course of the inspection some that needed urgent attention and she demonstrated a commitment to addressing these. The responsible individual needed to ensure that an application for the registration of the manager was forwarded to the CSCI. Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 24 The acting manager needed to develop some methods for monitoring the quality of the service offered at the home based on seeking the views of the residents with a view to continuous improvement. The home was managing some finances for the residents for every day needs. The records for these were sampled and found to be much improved from the last inspection. Individual records were being kept and relatives were signing when they deposited money in the home, two staff were signing for any expenditure made on behalf of the residents and receipts were available. The responsible individual for the home was in the process of updating several of the policies and procedures for the home as those on site had been left by the former proprietors. Several issues were raised during the course of the inspection in relation to record keeping and ensuring policies and procedures were met. It was also noted that regulation 37 notifications were not being forwarded to the CSCI for all notifiable incidents and many did not include enough detail. During the course of the inspection it was discussed with the responsible individual the requirement for her to complete regulation 26 visit reports on a monthly basis on the conduct of the home and ensure these were available for inspection. Several issues were raised in relation to health and safety including the guarding of the radiators and the safe storage of COSHH items. It was also noted from the fire log book that the emergency lighting was not being checked every month as required, the alarms were not being tested on a weekly basis and that at the last alarm test one of the call points was not working and there was no evidence to suggest this had been addressed. Staff had undertaken updated fire training and a fire drill had been carried out. The majority of the equipment on site had been serviced and the water samples had been sent off to be checked for the prevention of legionella. The electrical wiring certificate on site was out of date and this was outstanding from the last inspection. Prior to the publication of this report evidence was forwarded to the CSCI that the electrical wiring in the home had been checked and that the fault on the fire alarm system had been addressed. The two requirements in relation to these points have been removed from this report. Bretby House DS0000064275.V280489.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 1 1 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 2 1 2 X 2 1 2 STAFFING Standard No Score 27 3 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X 2 2 Bretby House DS0000064275.V280489.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) 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. All residents must be issued with a contract/statement of terms and conditions of residence at the point of admission to the home. The registered person must ensure that a suitably qualified person assesses the needs of any prospective residents and a copy of the assessment has been obtained. For individuals who are selffunding the registered person must ensure the assessment undertaken includes all the areas detailed in standard 3 of the National Minimum Standards. Timescale for action 01/04/06 2. OP2 01/04/06 3. OP3 14(1) 01/04/06 Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 27 4. OP4 5. OP7 12(1)(a,b) The registered person must ensure that the home can meet the needs of the residents admitted and that they are within the registration category of the home. An application for variation must be forwarded to the CSCI for any prospective residents that have been assessed as outside the registration category of the home. 15(1) All residents must have care plans that detail all their current needs in respect of health and welfare and how these are to be met by care staff. There must be evidence that wherever possible the residents have been consulted about the care plans. Care plans must be reviewed monthly. (Previous time scale of 01/01/06 not met.) All residents must have personal risk assessments undertaken to minimise any identified risks. (Previous time scale of 01/12/05 not met.) There must be clear guidelines for staff to follow for the management of any challenging behaviours. All residents must have manual handling risk assessments. (Previous time scale of 01/12/05 not met.) The manager must ensure that all staff adhere to the Manual Handling Regulations. 01/04/06 01/04/06 6. OP7 13(4)(c) 01/03/06 7. OP7 13(5) 01/03/06 8. OP7 13(5) 01/03/06 Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 28 9. OP8 12(1)(a) 10. OP8 12(1)(a) 11. OP9 13(2) 12. OP9 13(2) 13. OP9 13(2) 14. OP9 13(2) 15 OP10 12(4)(a) All residents must have tissue viability and nutritional screenings and action must be taken to minimise any identified risks. (Previous time scale of 01/12/05 not met.) Records of any identified health care needs must detail how these have been followed up and monitored. The amounts of controlled medication remaining in the home must correspond with the amounts received into the home and those administered. Regular staff drug audits must take place to assess staff competence in medicine management. Appropriate action must be taken when discrepancies are found. (Previous time scale of 04/11/05 not met.) The purchase of a Controlled Drug cabinet that complies with the Misuse of Drugs (Safe Custody) Regulations 1973 is required. All CDs must be stored within it. (Previous time scale of 30/11/05 not met.) 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 scale of 04/11/05 not met.) The registered person must ensure that staff are respectful to the residents at all times. 01/03/06 01/03/06 11/02/06 01/03/06 01/05/06 01/03/06 01/03/06 Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 29 16 OP12 12(1)(a) 17 OP14 12(2) 18 OP16 22(7) 19 OP16 17(2) Sch 4(11) 20 OP18 13(6) 21 OP18 13(6) Staff must record how residents are spending their days to evidence their social needs are being met. Residents must be enabled to make choices and take control over their lives wherever possible. The complaints procedure must be amended to ensure complainants are aware they can refer a complaint to the CSCI at any point. Complaints records must include the outcomes of any investigations undertaken and details of when and how the complainant received feedback. The incidents discussed at the time of the inspection must be referred to the appropriate parties as adult protection. All staff must undertake training to enable them to recognise and report appropriately any suspicions or events of abuse. The adult protection procedure for the home must include the addresses and telephone numbers of the local social care and health office and the CSCI. Fire doors must not be wedged open. (Previous time scale of 25/10/05 not met.) The stair carpet must be made safe or replaced. The uneven garden path must be replaced or re-laid. (Previous time scale given had not expired.) Additional dry goods storage space must be provided. (Previous time scale had not expired.) 01/03/06 01/03/06 01/04/06 01/03/06 10/02/06 01/04/06 22 OP19 13(4)(c) 01/03/05 23 24 OP19 OP20 13(4)(c) 13(4)(c) 01/03/06 20/03/06 25. OP21 23(2)(l) 20/06/06 Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 30 26. OP21 27. OP21 28. OP22 29. OP22 30. OP24 31. OP25 32. OP25 33. OP25 The vinyl flooring in the bathrooms and toilets must be adequately sealed around the edges or the vinyl replaced. (Previous time scale of 01/12/05 not met.) 23(2)(j,n) Assisted bathing/showering facilities must be provided on the first and second floors of the home. (Previous time scale given had not expired.) 13(4)(c) Wheelchairs must not be used without footrests unless specifically detailed in a care plan. (Previous time scale of 26/10/05 not met.) 23(2)(n) An audit of the aids and adaptations available in the home must be undertaken and additional equipment fitted as necessary. (Previous time scale given had not expired.) 16(2)(c,p) The furnishings and fittings in the bedrooms must be audited against the National Minimum Standards and shortfalls rectified. (Previous time scale given had not expired.) 13(4)(c) The registered person must ensure the hot water temperature to the shower is not in excess of 43 degrees or take the shower out of use. (Previous time scale of 29/10/05 not met.) 13(4)(c) All radiators must be covered or guarded. (Partially met although previous time scale had not expired.) 13(4)(c) The hot pipe work in the ground toilet bathroom must be boxed in. (Previous time scale of 01/12/05 not met.) DS0000064275.V280489.R01.S.doc 23(2)(b) 01/05/06 20/09/06 10/02/06 01/03/06 01/05/06 10/02/06 20/03/06 01/03/06 Bretby House Version 5.1 Page 31 34. 35. OP26 OP26 13(3) 13(3) 36 37 OP28 OP29 18(1)(a) 19 Sch 2 38 OP30 18(1)(c) 39. OP30 18(1)(c) All COSHH items must be locked away when not in use. A commode pot washer/disinfector must be installed in the home. (Previous time scale had not expired.) 50 of care staff must be qualified to NVQ level 2 or the equivalent. The responsible individual for the home must ensure that all the documentation detailed under schedule 2 of the Care Homes Regulations 2001 is obtained for staff prior to their commencing their employment. 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 all staff have undertaken all the required mandatory training. 10/02/06 20/08/06 01/06/06 01/03/06 01/04/06 01/06/06 40. OP31 41. 42. OP31 OP33 All staff must have individual training records. 9(2) The responsible individual for the 01/04/06 home must ensure that an application for the registration of the manager is forwarded to the CSCI. 9(1)(b)(i) The manager must be qualified 30/06/06 to NVQ level 4 in care and management or the equivalent. 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. Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 32 43. OP37 37 All events detailed under regulation 37 of the Care Homes Regulations must be notified to the CSCI. Regulation 37 notifications must include all the relevant details. The responsible individual for the home must complete monthly visit reports on the conduct of the care home and ensure these are available for inspection. The emergency lighting must be checked on a monthly basis. The fire alarm must be tested on a weekly basis. 01/03/06 44. OP37 26 01/04/06 45. OP38 23(4)(c) (v) 10/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP18 OP18 OP29 Good Practice Recommendations It is recommended that a copy of the multi agency guidelines for adult protection is obtained. It is strongly recommended that the restraint policy be further developed to include examples of what could be deemed as restraint. It is strongly recommended that records be kept of employment interviews. Bretby House DS0000064275.V280489.R01.S.doc Version 5.1 Page 33 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.V280489.R01.S.doc Version 5.1 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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