Inspection on 08/10/07 for Bridlington House

This inspection was carried out on 8th October 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bridlington House 06/10/09

Bridlington House 28/07/09

Bridlington House 08/04/09

Bridlington House 07/04/08

Bridlington House 17/04/07

Bridlington House 20/06/06

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Bridlington House 4 Bridlington Avenue Hull East Yorkshire HU2 0DU Lead Inspector Angela Sizer Key Unannounced Inspection 8th October 2007 10:30 DS0000064654.V352530.R01.S.doc Version 5.2 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 DS0000064654.V352530.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. DS0000064654.V352530.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bridlington House Address 4 Bridlington Avenue Hull East Yorkshire HU2 0DU 01482 217551 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) Mr Akintola Oladapo Dasaolu Mrs Lynne Hunter Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (22) of places DS0000064654.V352530.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Bridlington House to provide personal care for one named service user and one additional service user who have reached 65 years of age. Refer to Application Number V33154. 17th April 2007 Date of last inspection Brief Description of the Service: Bridlington House is a care home providing accommodation and personal care for 22 persons who have enduring mental health problems. The category for older people is to make sure that individuals can continue to have Bridlington House as their permanent home as they approach and pass the age of 65. An individual privately owns the care home. The building is a detached property and it is situated within walking distance of the City Centre, shops, and local community centres, churches other places of interest are also nearby. The home has 6 single and 8 double rooms; four of the single rooms and two double rooms have en-suite facilities. The home has four bathrooms, one assisted and 12 communal toilets. There are two lounges and a dining room. There is a garden to the rear and a small parking area to the front of the property. The weekly fees are currently £273.00 - information supplied by the manager during the inspection visit on 08.10.07. The registered manager stated that all residents are given a service user guide and this contains the last inspection report. The registered manager also stated that prospective residents are offered a copy of the home’s statement of purpose and service user guide. DS0000064654.V352530.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place over one day and took a total of 7.5 hours. A regulation inspector and a pharmacist inspector visited the home as part of the process. Prior to the visit surveys were posted out to people living in the home, their representatives and social and healthcare professionals; 10 residents surveys were returned, one of the relative surveys was returned, 1 staff member and 2 of the health and social care professionals surveys were returned. The Annual Quality Assurance Assessment was completed and returned to the CSCI (Commission for Social Care Inspection). The CSCI commenced enforcement action following a random inspection visit being undertaken on 23.7.07. This meant that the Registered Provider had a timescale to improve the standards in certain areas including the recruitment of staff and the medication procedure. During this visit sufficient improvement had been made for the enforcement action to be suspended, however this will be closely monitored and the Registered Provider and Registered Manager will have to demonstrate their continued compliance and commitment to raise the quality of the standards within the home to avoid further enforcement action being taken. The previous requirements were discussed with the manager and it was identified that a large proportion have been met, although some requirements in relation to the medication procedure remain unmet. A discussion occurred regarding how the residents are supported to follow their religion of choice and practise their faith and how the home meets diverse needs of individuals. The majority of the residents were spoken to throughout the day regarding the care they receive and what it is like to live in the home, some of their comments have been included in this report. Three residents’ care records were tracked during the site visit and 2 staff personnel files were looked at. Two of the staff were spoken to find out what it was like working in the home and what training, management and support was offered to them. A tour of the premises was undertaken and a number of records were looked at to ensure that the correct maintenance has been undertaken. The manager was given feedback during and at the end of the visit. The inspectors would like to thank the residents, manager and staff for welcoming them into the home and contributing to the content of this report. DS0000064654.V352530.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Since the last inspection visit the paperwork in relation to the care planning and risk management have been improved and the care plan fully describes the needs of the people living in the home and what support is required. The risk management system ensures that the people who live in the home are safe and risks are either eliminated or reduced to a minimum. All of the new paperwork has now been successfully implemented and the activities of daily living or service user plan is being used by staff on a daily basis. DS0000064654.V352530.R01.S.doc Version 5.2 Page 7 People who use the service are protected from possible harm or abuse, as the home only employs staff when the appropriate vetting has taken place prior to them starting work. Since the previous inspection the home has increased it’s domestic hours by 30 per week and there has been a marked improvement in the standard of cleanliness. People live in a clean and hygienic environment, although some areas of the building require refurbishment and renewal to ensure that people live in a safe and well-maintained home that meets all of their needs. An action plan for refurbishment and redecoration has been implemented. The staffing levels appear sufficient in order to ensure that the basic needs of the people using the service are met. Equality and diversity is promoted to some extent within the home. The residents have a range of diverse needs relating to mental health and substance. Several of the staff group are also from ethnic minorities giving breadth and experience to the staff group as a whole. The staff group have not received any training in relation to equality and diversity and this would promote empowerment for the residents. Since the last inspection evidence was received that the water system had been tested for Legionella and the bath hoist had been serviced. Some staff have undertaken infection control training, as stated previously some staff have limited knowledge in areas such as cross infection or contamination. What they could do better: People who live in the home take part in activities, but further development would take into account the social/recreational needs of all residents, as this would ensure inclusion for those with more diverse needs. People who live in the home are not fully protected by the medication procedure and several requirements remain unmet from previous inspection visits. The CSCI has made a decision that enforcement action in relation to this area be suspended at this point, although there hasn’t been 100 compliance there has been sufficient improvement and the level of risk to the people living in the home has been reduced and managed in a way that maintains their safety. However, prosecution may be considered at a later date if there is any deterioration in the level of compliance and improvement. Not all staff have undertaken the safeguarding vulnerable adults training so therefore may not be aware of their responsibilities if a safeguarding incident occurred. DS0000064654.V352530.R01.S.doc Version 5.2 Page 8 The lack of infection control training for staff place people who live in the home at risk of infection or cross contamination. People are supported by staff who do not receive appropriate training in relation to maintaining health and safety, this means that their safety may be compromised. Staff receive supervision, however this is not always on a regular basis. This means that people using the service receive care from staff who are not properly supervised and monitored. The quality assurance system requires implementing, so therefore currently the views of the people who live in the home, their relatives, staff and other professionals are not sought or recorded and the system does not reflect the views of the service users or their representatives. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000064654.V352530.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000064654.V352530.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 & 5 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use this service have their needs fully assessed before they are admitted into the home. Prospective residents are able to visit the home and ‘test drive’ it before they decide to move in. People who live in the home receive a contract/statement of terms and conditions that fully describes what services, facilities and support they will receive whilst residing there. EVIDENCE: Three residents files were looked at during the inspection visit, this was to make sure that the home finds out what residents’ needs are and to ensure that the home can meet their needs. The registered manager stated that the home usually receives a community care assessment of need from the placing Authority, in addition the home also undertakes their own assessment and evidence of this was seen on the files looked at. The assessment includes the DS0000064654.V352530.R01.S.doc Version 5.2 Page 11 likes/dislikes of the person, medication, past history and current difficulties, communication, mobility and mental health. From speaking to several people who live in the home and from the surveys received before the inspection it was confirmed that they were able to visit and test drive the home before making a decision to move in. Some comments included; “I had a choice of three homes”, “my wife came to look at the home to make sure I would be comfortable and she was quite happy and satisfied”, “I was able to come and have a meal with the other residents and see my room before I decided to come and live here”. The home ensures that prospective residents or their representative are able to visit the home, have a meal, meet the other residents, see their room before making the decision as to whether they would like to move in. The manager stated that all residents receive a contract that details what a person living in the home can expect to receive in relation to care and services. Three of the residents’ files looked at contained a contract or statement of terms and conditions. Several of the residents stated that they had received a contract and that they had a signed copy. It is evident that people who live in this home receive information about what support, facilities and services they can expect to receive whilst they are residing there. DS0000064654.V352530.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 & 9 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service have a care plan that fully describes their needs and what support is required. People living in the home are enabled to make choices about everyday life in the home. The risk management system ensures that the people who live in the home are safe and risks are either eliminated or reduced to a minimum. EVIDENCE: During a random inspection undertaken on the 23.7.07 two of the residents’ case files were looked at and it was confirmed that the care plans had been updated and a new system was being implemented. There are now two files in place, a working care plan file and a general file that held other documentation DS0000064654.V352530.R01.S.doc Version 5.2 Page 13 such as the community care assessment and medical records. The system has improved and it was much easier to locate information. The working care plan file contained useful information including likes, dislikes, preferences for getting up and going to bed, room to be occupied. The manager has recently developed a healthcare-monitoring sheet that covered optical, hearing, dental, chiropody and general medical appointments. As these were in the implementation stage there was little information recorded on the sheets and it will be fully assessed at the next key inspection visit. Although it should be noted that the staff and manager have worked hard to update the current files, these are more organised and give clear information about the people living in the home. During this key unannounced visit on 8.10.07 three of the residents’ files were looked at and overall were found to be of a good standard. The recording was up to date, clear and gave clear instruction to staff about what they should do and when. All of the new paperwork has now been successfully implemented and the activities of daily living or service user plan is being used by staff on a daily basis. From speaking to two staff members it was evident that the improvements to the system has made a positive change to the way the home records information. Some comments included; “I feel that the care plans and risk assessments have really improved, they give lots of information about what the person needs or likes”, “it has made our job easier and I feel more confident”. Both staff members could describe what the needs of individual residents were and were clear about what support they required. Some staff have undertaken training in relation to managing challenging behaviour and mental health awareness, this was confirmed by speaking to the manager and looking at written evidence. From observation and from speaking to the people who live in the home it was apparent that overall choice and independence are promoted and the residents are enabled to make their own decisions about everyday life within the home. Everyone who lives in the home are free to come and go and the majority lead a fairly independent lifestyle. One resident said, “I am very pleased that I am able to decide what to do”, “everybody is very supportive”, “I have freedom, I come and go as I please, but I usually let the staff know when I am going out”. Other residents who are less able and have communication problems do require more support from staff, but during the visit staff were observed to interact and include those individuals in everyday life and activities within the home. The manager spoke about the long-term plan for staff to attend specific training for equality and diversity to ensure that the staff group are knowledgeable and skilled to deal with all of the needs of the residents. The risk management system has been improved and there were various risk assessments on the individual files of people who live in the home. These covered all sorts of issues including medication, communication difficulties, memory impairment, self-harming, sexualised behaviour. The risk DS0000064654.V352530.R01.S.doc Version 5.2 Page 14 management plan clearly describes what the risk is and how this is to be minimised, also what staff need to do and at what point would other agencies need to be contacted. Two surveys were received from healthcare professionals confirming that the home’s staff are co-operative and helpful and comments included; “the staff of Bridlington House often contact myself or the team if they have concerns relating to the service users”, “Bridlington House appears to provide a level of service that facilitates the individual to live as they choose, respecting as far as is reasonably practicable their privacy and wishes”. DS0000064654.V352530.R01.S.doc Version 5.2 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who live in the home take part in activities, but further development would take into account the social/recreational needs of all residents, as this would ensure inclusion for those with more diverse needs. People who live in the home have their rights respected. People receive a varied and healthy diet. EVIDENCE: Prior to this inspection visit taking place the Annual Quality Assurance Assessment was returned to the CSCI and this stated that all service users are encouraged to take part in appropriate activities. Some attend religious groups, clubs or meetings at the MIND centre. Activities accessed are detailed DS0000064654.V352530.R01.S.doc Version 5.2 Page 16 in individual care plans and risk assessment documentation is in place to ensure that risk is minimised. Visitors are welcome at any time, a menu board will display options available and the cook will ask service users each morning what they would like for their lunch and again in the afternoon for their tea as often people change their minds. Questionnaires that had been sent out to all of the people who live in the home stated that some activities and outings take place. During the inspection some of the residents were spoken to about the range of activities and outings, it was confirmed that since the last inspection visit the activities have continued to occur, but not as regular as they would like them to be. A discussion was held with the manager and she stated, “we rely upon volunteers to come in and undertake activities, sometimes this is not as regular as I would like it to be”. The majority of the residents were satisfied with the amount of activities currently offered. During the inspection visit on 8.10.07 residents were spoken to about the level of activities and some comments included; “we have a game of bingo a couple to times and I really enjoyed this”, “I go out once a week to an arthritis club”, “we go out for meals too”. It was also observed that some of the more able residents go out independently on a regular basis. One resident commented, “I like to go out everyday just for a walk or to the shops”. Other residents who either have physical problems or their mental health prevents them from going out alone, tend to remain in the home during the day. Other residents informed the inspector that they go to local community centres and day centres that run groups that enable the residents to partake in events occurring in the community. During the visit staff were observed interacting with residents and this was carried out in a caring and sensitive way. From speaking to several people who live in the home it was clear that staff treated them with respect and called them by the name they prefer. Staff spoken to could describe clearly the principles of good care and how they should treat the residents. Visitors are welcomed into the home and there are several quiet areas that residents can meet with their visitors in private. Some comments from residents and other professionals included; “the staff are always friendly and polite, they are also approachable”, “I think the staff treat me ok and I respect them”, “I think the home is run very well, the manager is very good”. There was evidence to suggest that day trips or outings are also offered to the residents, again this is for the more able or independent residents and often people with more severe or diverse needs are not included. One person said, “we went to Bridlington a couple of months ago, that was good”. It was confirmed by speaking to the residents that they have a key to their own room and that staff refer to them by the name they prefer. There was DS0000064654.V352530.R01.S.doc Version 5.2 Page 17 written evidence in place identifying if there was a particular risk to a resident holding his or her own key. The home continues to offer a varied menu and this is now displayed on a wipe board in the dining room. From speaking to several of the people who live in the home it was evident that the cook or staff consult them on a daily basis in order to discuss the options for lunch and tea. Some comments made by people included; “the food is nice”, “it’s always nice and hot”, “we get a good amount”, “on Sundays we always have a roast dinner”. There were no negative comments on the visit to the home. Lunch was observed and consisted of meat pie or Cornish pasty with mashed potato and vegetables, followed by fruit and ice cream. The main meal of the day is served at lunchtime with a lighter option for tea. From speaking to the residents it was confirmed that if there is something that they do not like on the menu then they can have an alternative, “the cooks talk to us everyday about what we are having”, evidence of this was recorded in the residents meetings. Breakfast and supper are also offered, there are set times for drinks (hot), staff explained that cold drinks are available throughout the day. Residents confirmed that they find it acceptable to have drinks at set times. DS0000064654.V352530.R01.S.doc Version 5.2 Page 18 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 People who use the service experience poor outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service receive a good level of personal and healthcare support that ensures their needs are met. People who live in the home are not fully protected by the medication procedure. EVIDENCE: Included in this section are extracts from a random inspection that was undertaken on 23.7.07, this is to show that there have been improvements made to the medication procedure. People who live in the home are not fully protected by the medication procedure and several requirements remain unmet from previous inspection visits. The CSCI has made a decision that enforcement action in relation to this area be suspended at this point, although there hasn’t been 100 compliance there has been sufficient DS0000064654.V352530.R01.S.doc Version 5.2 Page 19 improvement and the level of risk to the people living in the home has been reduced and managed in a way that maintains their safety. However, prosecution may be considered at a later date if there is any deterioration in the level of compliance and improvement. Random Inspection – 23.07.07 A random inspection was undertaken and a CSCI Pharmacist Inspector looked the medication procedure. The medication policy is currently being updated. Record Keeping The current Medication Administration Record (MAR) charts were looked at. There is a list of staff authorised to administer medicines and examples of their signatures. This means it is possible to identify who was involved in administration if a query or problem occurred. The recording of medicine administration is poor; there were a number of gaps on the MAR charts. To demonstrate that people are getting the medication as prescribed the MAR chart should record each administration. There is inconsistency in the recording of the quantity of medication supplied and the date received. The quantity of medication from one monthly cycle to another is not recorded on the new MAR. This means it is difficult to have a complete record of medication within the home and to check if medication is being administered correctly. There was inconsistency in handwritten entries and changes made to medication. For example the dose of one medicine had increased from one to two daily. A new MAR entry had been made but the old one had not been cancelled. Records of administration had been made against both entries. This means that the person is at risk of receiving an overdose of medication. To make sure there is an accurate record the quantity supplied, the date of entry, the signature of the person making the entry and a witness signature where possible should be included. Similar requirements are needed for a change of dose or cancelled medicines. Details of the person authorising the change should also be included. This makes sure that there is an accurate record of any changes or new medicines. The code ‘O’ was used on a number of occasions to record no administration. However there was no definition on the chart to explain why the person had not received their medication. It is important that a clear reason is given so there is accurate information on how a person is taking their medication. The prescriber, who may wish to review the medication, may also use this information. DS0000064654.V352530.R01.S.doc Version 5.2 Page 20 A number of MAR charts had medication not given because there was no stock available. It is important to make sure that the quantity of medication is regularly checked so that a prescription can be ordered in plenty of time to prevent a person being without. For example one person had not received any medication since 16 July 2007. The MAR chart in the folder was from the previous month’s cycle. Only one record of administration had been continued on this cycle. The daily record notes recorded that there were problems getting a prescription from the GP surgery and delays in the person seeing a member of the healthcare team. There must be a robust system in place to prevent people being without their medication. Administration An audit of current stock and records showed that some medication had been signed for but not given whilst others had been given but not recorded. For example a course of 28 antibiotics had been prescribed for one person. There were 24 entries of administration on the MAR chart but 11 remained. On one MAR chart a handwritten entry stated that the medication had been stopped on the 13 July 07. However, records of administration had been made since then. This medication had continued to be supplied from the pharmacy. It is important to have a robust system in place to make sure medication that is stopped or changed is not given incorrectly. The pharmacy should be advised of any changes so that the medication supply can be updated. MAR charts for two people recorded regular refusal of medicines. These people are prescribed a number of medicines including ones to treat heart conditions. The inspector was unable to establish if a system has been put in place to contact the prescriber when people regularly refuse. Storage There is a standard lockable medication trolley stored in the dining room. This is chained to the wall. There is also a locked cupboard in the office for the storage of medication. The fridge is a small domestic fridge that is not suitable for storing medication. There is no facility for the checking of fridge temperatures. This means there is a risk that medication may not be stored correctly. There was medication in the cupboard that was no longer prescribed or on the MAR chart. Medication that has been stopped must be removed and disposed of to prevent incorrect administration. Medication with limited use once opened was not marked with a date of opening. This means that there is a risk that people may receive medication that was no longer safe to use. A number of medicines were found that were out of date. Any medicine that has gone out of date must be disposed of. This means that there is a reduced risk DS0000064654.V352530.R01.S.doc Version 5.2 Page 21 of people receiving medication that may be unsafe, not working properly or cause harmful effects. Other The ordering of prescriptions is the responsibility of one of the senior members of staff. However, the prescriptions are not sent to the home before the supply is made. The person in charge of ordering medication must have sight of the prescriptions before a supply is made. The prescription is the authority for the staff to administer medication. This also provides an opportunity to check if any new medicines or dose changes are included. Any problems with prescriptions can be addressed at this point rather than after the supply has been made. The checking of prescriptions is an important part of the management of medication. Key unannounced inspection – 8.10.07 During this key unannounced inspection staff were observed interacting and assisting some of the people who live in the home and this was carried out in a caring, sensitive and professional way. From speaking to the people who live in the home it was confirmed that they are treated with respect and that their dignity and privacy are promoted. Some comments included; “the staff always knock before they come in and they listen to me when I need to talk”, “the staff are king, helpful and very patient”, “I feel that I have been treated fairly at all times, I am also treated with respect”. A discussion was held with a visiting district nurse who confirmed that staff are approachable and welcoming. “the staff listen to myself and the advice given, staff are fairly supportive to the residents and encourage personal care”. Residents confirmed that they see healthcare professionals including their GP, Community Psychiatric Nurse, District Nurse and Psychiatrist on a regular basis; this was also confirmed from reading the case files. Residents spoken to stated, “if I need to the see the doctor then staff will come with me”, “my CPN comes to see my every two weeks and gives me my injection, but if I forget the staff remind me”. People who live in the home were observed to be individual in the way that they dressed and residents’ bedrooms were personal to them. From speaking to the residents it was evident that the home promotes their independence and encourages residents to go out for walks or to local day centres in order to integrate into the community. One person said, “I come and go as I please, but I do let the staff know when I am going out”. From discussion with the manager it was stated that individuals are given the choice of male or female worker were staffing levels permit. The manager said, “I always ask the person if they would have a preference with regard to the choice of worker and do try to offer this were possible”. DS0000064654.V352530.R01.S.doc Version 5.2 Page 22 Three of the files for people who live in the home were looked at confirming that their physical and emotional health needs are met. Annual health care checks are undertaken and written records were up to date to confirm this. One person who is a diabetic administers their own medication and staff observe this being carried out. The CSCI Pharmacist Inspector looked at the medication procedure and the outcome was as follows; The medication policy has been updated since the last inspection. It now contains information on procedures within the home that staff should be following. Record Keeping The current and previous month’s Medication Administration Record (MAR) charts were looked at. A number of people still do not have a current photograph attached to their MAR chart. This means there is a risk that a person may be wrongly identified and given incorrect medication. At the time of the visit the information relating to individuals medication and medical conditions was stored on top of the medicines trolley in the dining room. To make sure confidential information is securely stored these records must be locked up. The recording of medicine administration has improved. There were very few gaps on the MAR charts. This means that there is a record of a person receiving their medication as prescribed. A good record was made for the administration of prednisolone prescribed for one person. The dose was a reducing dose over a 15-day period. The MAR chart was handwritten and provided clear and detailed information on how much medication to give and for how long. This is an example of good practice as it helps to make sure medication is given correctly. There is inconsistency in the recording of the quantity of medication supplied and the date received. The quantity of medication from one monthly cycle to another is not recorded on the new MAR. For example one person had medication supplied from the hospital in addition to regular monthly supplies from the pharmacy. However the quantity on the MAR chart did not include all the stock being stored. This means it is difficult to have a complete record of medication within the home and to check if medication is being administered correctly. There was inconsistency in handwritten entries and changes made to medication. To make sure there is an accurate record the quantity supplied, DS0000064654.V352530.R01.S.doc Version 5.2 Page 23 the date of entry, the signature of the person making the entry and a witness signature where possible should be included. Similar requirements are needed for a change of dose or cancelled medicines. Details of the person authorising the change should also be included. This makes sure that there is an accurate record of any changes or new medicines. The code ‘O’ was still being used on a number of occasions to record no administration. However there was no definition on the chart to explain why the person had not received their medication. It is important that a clear reason is given so there is accurate information on how a person is taking their medication. The prescriber, who may wish to review the medication, may also use this information. A number of MAR charts had medication not given because there was no stock available. It is important to make sure that the quantity of medication is regularly checked so that a prescription can be ordered in plenty of time to prevent a person being without. For example one person had not received any medication on the 10, 12,13 and 14 September although a record of 28 supplied on the 10 September had been made on the MAR. This is an outstanding requirement from the previous inspection. A number of medicines were found that were not listed on the MAR chart. The medication had started in the previous cycle, but was not listed on the new MAR. This had not been identified when the supply was made. It is important that all medication to be administered is listed on the MAR to make sure an accurate record can be made. A number of MAR charts had medication listed that was no longer in use. The pharmacy should be advised of medication not in use and asked to provide up to date charts. This makes sure people are only getting medication that is currently prescribed. There was inconsistency in the writing on the MAR chart for medication that is administered by a member of the healthcare team. For accurate records any administration activity that is performed by someone other than the care home staff must be indicated on the chart. A record of refusal is made for each time medication is not given. This is recorded on a separate form to the MAR chart and is kept at the front of the MAR folder. The inspector advised that the forms should be for each person and kept with the each MAR folder so that the information can be crosschecked. The MAR charts have a section on the back that allows for more information to be added about administration, it may be better to use the back of the charts rather than a separate form to make sure information is not lost. A good record of returns is kept which means that medication leaving the home is accounted for. DS0000064654.V352530.R01.S.doc Version 5.2 Page 24 Administration An audit of current stock and records showed that some medication had been signed for but not given whilst others had been given, but not recorded. For example one person has Tiotropium 18mcg capsules prescribed as one daily for asthma. The box originally contained a quantity of 30 and 26 records of administration were recorded. However, there were 17 left in the box. One person spends time away from the home. The current practice is for staff to take medication from the pharmacy supply, put it into another container for the person to take with them. This system should be stopped, as there is a risk that incorrect medication may be supplied. The GP and pharmacist should be approached to help with the provision of medication to cover episodes of leave. Storage There are two standard lockable medication trolleys stored in the dining room, both are chained to the wall. There is also a locked cupboard in the office for the storage of medication. The fridge is a standard clinical fridge that is suitable for storing medication. The recording of fridge temperatures is not consistently done. This means there is a risk that medication may not be stored correctly. There was medication in the cupboard that was no longer prescribed or on the MAR chart. Medication that has been stopped must be removed and disposed of to prevent incorrect administration. For example a number of boxes of nicotine patches for one person where in the cupboard and trolley. This person no longer requires the patches but more had been ordered. A system must be in place to advise the pharmacy of changes to medication and to make sure medication is not ordered that is no longer required. Medication with limited use once opened was not marked with a date of opening. For example a bottle of Risperdal liquid for one person has a limit of three months use once opened, this medication is prescribed as when required and may therefore be in use after 3 months. Without a system to record opening dates there is a risk that people may receive medication that was no longer safe to use. Other The ordering of prescriptions has improved since the last inspection. The prescriptions are sent to the home before the supply is made which means the person in charge of ordering medication has sight of the prescriptions before sending to the pharmacy. This provides an opportunity to check if any new medicines or dose changes are included. Any problems with prescriptions can be addressed at this point rather than after the supply has been made. The DS0000064654.V352530.R01.S.doc Version 5.2 Page 25 checking of prescriptions is an important part of the management of medication. A risk assessment has been done on one person who self-administers their insulin. There is nothing within the care plan to record who checks the blood glucose and how it is recorded. Staff observe this person administering their medication, but this is not always recorded. It is important to record any activity that staff are involved in when someone self-administers their medication. This helps when a review of the risk assessment is done. For example if someone regularly needs prompting then the review may decide that it is better for the staff to administer the medication. DS0000064654.V352530.R01.S.doc Version 5.2 Page 26 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service are informed about the complaints procedure and are able to express their concerns in an open culture. Overall people who use the service are protected from possible harm or abuse, as the home only employs staff when the appropriate vetting has taken place prior to them starting work. However, not all staff have undertaken the safeguarding vulnerable adults training so therefore may not be aware of their responsibilities if a safeguarding incident occurred. EVIDENCE: The home has a complaints procedure in place and people who live in the home are given a copy of the service user guide, which details how to make a complaint and who to, the Commission for Social Care Inspection address and telephone number are also included. From speaking to several residents it was clear that they understood what to do if they did have a complaint or concern. One person stated, “I could tell any of the staff, but I would probably go straight to the manager”, “yes I know who to complain to”, “when I have had a problem in the past I have spoken to the manager and she has sorted it out”. There have been three complaints since the last key inspection visit on 18.4.07, written evidence was looked at confirming that these have been dealt with appropriately. DS0000064654.V352530.R01.S.doc Version 5.2 Page 27 From speaking to the manager it was stated that the majority of the staff group have now undertaken safeguarding vulnerable adults training and the remainder will undertake this when a space becomes available at the Social Services Training Department. Written documentation was seen to confirm that some staff members had undertaken the training. Also from speaking to two staff members during the visit it was clear that they had a good understanding of the procedure and where aware of what their responsibilities were. Since the last inspection there has been two safeguarding referrals made to the local care management team, the outcome of these resulted in no further action being taken. The manager responded in accordance to the procedure and sought advice about what action she would need to take, therefore the people who live in the home are protected from abuse, neglect and self-harm. During the inspection visit an incident occurred involving a resident who became extremely agitated, raising their voice to another resident, staff member and the inspector. The staff member dealt with this situation in a calm and professional manner and resolved the situation quickly by diverting the person concerned to another room. It was evident during the incident that the staff member had experience in dealing with difficult situations, but it would appear that from speaking to other staff members and looking at records that not all staff members have either the experience or training to deal with such incidents. Written evidence was seen confirming that some of the staff has undertaken training in relation to challenging behaviour and mental health awareness, this was a recommendation from a previous report and will remain outstanding until all staff has completed it. This will ensure that people who live in the home will receive support from a well-trained and experienced staff group who will understand more challenging behaviour, addressing this in an appropriate and professional way. The home maintains records for the personal finances of residents. Residents have their own individual bank accounts and several of the residents’ families take care of their finances. DS0000064654.V352530.R01.S.doc Version 5.2 Page 28 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27 & 30 People who use the service adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People live in a clean and hygienic environment, although some areas of the building require refurbishment and renewal to ensure that people live in a safe and well-maintained home that meets all of their needs. The lack of infection control training for staff place people who live in the home at risk of infection or cross contamination. EVIDENCE: Random inspection – 23.07.07 During a random inspection on 23.7.07 a tour of the building was undertaken and all of the requirements in relation to this section remained unmet. Some improvement had been made and the small games room has been redecorated and has a pool table for residents to use. Room 9 had been redecorated and a DS0000064654.V352530.R01.S.doc Version 5.2 Page 29 new carpet ordered. The manager has developed a maintenance plan for 2007 and this does detail what requires redecoration or refurbishment. The manager stated, “I have undertaken an audit of the building and prioritised what needs doing first. Someone is coming tomorrow to measure the carpets in the main hallway, stairs and landing and hopefully these will be replaced in the near future”. Several of the residents were spoken to about the environment and some comments included; “I am happy with my room, it’s nice, the bedding is changed once a week and the sinks are cleaned everyday”, “the home provides us with our own towels and flannels”, “I share a double room and get on well with the person, we talk a lot so I wouldn’t want a curtain or divide in there”. Two residents did comment that they would like a key to their room as this would make them feel “safer”. This issue was discussed with the manager and she said that this would be discussed with all of the residents about having a key to their room. The two bathrooms on the first floor did not have soap in them and although there were paper hand towel dispensers in place, one was broken and requires replacement and did not contain any towels. The manager confirmed that all of the staff are scheduled onto the next available Infection Control training offered by the Social Services Department, this is to held in August 2007. No offensive odours were detected during this inspection and the manager explained that a domestic has been appointed and works 5 days per week; she said, “the cleanliness has improved and it was allowed the carers to spend more time doing activities”. Key unannounced inspection – 8.10.07 During this visit a tour of the building was undertaken and there was a marked improvement to the cleanliness of individual service users rooms and communal living areas. From speaking to some people who live in the home it was confirmed that the cleanliness of the home has improved. Some comments included; “the cleaning staff are very good”, “the staff are frequently busy cleaning all parts of the building”, “there have been improvements over the past few months, the carpets and decoration too”. An action plan for refurbishment and redecoration has been implemented and the home now employs 2 cleaners and has recently increased the domestic hours by 30 hours a week. There is a cleaning rota in place and seniors are monitoring the cleanliness of the home. From speaking to the manager, staff and looking at written records it was confirmed that some staff have undertaken Infection control training has been applied for and dates are awaited for training. A visiting district nurse was spoken to during the visit and confirmed that the general environment had improved, “the environment has improved over the past few months, which is nice for the people who live here”. DS0000064654.V352530.R01.S.doc Version 5.2 Page 30 The main entrance and hallway has been redecorated and has a new carpet fitted. The stairs leading to the annex has had a new carpet fitted and has also been redecorated. There are several areas that still require attention and these include the communal toilets and bathrooms, particularly the two bathrooms on the first floor as these are in very poor condition, the baths themselves are badly marked with cigarette burns. One person who lives in the home said, “the baths are not nice that’s why I don’t have one”. There were hand washing and drying facilities in all of the bathrooms and toilets and one person said, “usually there are hand paper towels and soap, put people pinch the soap and then we don’t have any”. Most of the individual bedrooms were found to be clean, warm and personalised and from speaking to several people who live in the home it was confirmed that they are happy with their room. Some comments were, “I have a single room now and I like it, I have my own privacy now”, “I like this home”, “there have been improvements over the past few months and I am happy living here”. One person did show the inspector their mattress and pillows as they felt that these required replacing. The mattress and pillows were badly stained and worn and a discussion was held with the manager about this and she confirmed that these items would be ordered immediately. DS0000064654.V352530.R01.S.doc Version 5.2 Page 31 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34,35 & 36 People who use the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The staffing levels appear sufficient in order to ensure that the basic needs of the people using the service are met. People receive support from staff who have been properly vetted and therefore the protection and safety of the residents is promoted. People are supported by staff who do not receive appropriate training in relation to maintaining health and safety, this means that their safety may be compromised. Staff receive supervision, however this is not always on a regular basis. This means that people using the service receive care from staff who are not properly supervised and monitored. DS0000064654.V352530.R01.S.doc Version 5.2 Page 32 EVIDENCE: Random inspection – 23.7.07 During a random inspection visit on 23.7.07 the staffing levels in relation to care hours have remained the same as at the previous inspection visit on 18.4.07, although the manager did state that she had authorisation from the Registered Provider to recruit for an additional 30 care hours per week. This would be fully assessed at the next key inspection. Two staff files were looked at confirming that a POVA 1st check and two references had been sought prior to employment commencing. A discussion was held with the manager and she was again instructed that all new staff members must have a full Criminal Records Bureau check in place prior to commencing work and that a POVA 1st check must only be sought in exceptional circumstances that would be agreed with the CSCI due to the current rating level of the home being poor. Key Inspection – 8.10.07 During this inspection visit two staff files were looked at, both files contained personal details including identification of the person, two references and an up to date Criminal Records Bureau check. During a previous inspection a staff member who had a different nationality did not have any paperwork in relation to working in this country. An official letter was issued during that inspection visit detailing regulations have been breached and stating that the registered provider must respond immediately. During this inspection visit the manager said, “the staff member has left after a period of sickness”. No evidence was gained confirming whether that person was able to legally work in this country. The manager did state, “I have learned from the last inspection and will not be employing anyone without the appropriate checks in place first, I have recently interviewed a person and have sent off and received back their Criminal Records Bureau check and two references. I am going to arrange for the person to come in for an induction day and then discuss a start date”. Evidence was seen to confirm that the home is following the recruitment procedure and gaining the appropriate checks and references prior to employing a person. This ensures that people living in the home receive support from staff who have been properly vetted. The home has a small staffing team of eight care workers; in addition there are three senior care staff and the manager. From discussion with the manager it was confirmed that since the last inspection the care hours have been increased from 334 to 364 per week and also the domestic hours have been increased by 30 hours per week. From speaking to staff and residents it was apparent that the staffing numbers were sufficient to meet the basic needs of the residents. Some comments included; “the staffing levels have DS0000064654.V352530.R01.S.doc Version 5.2 Page 33 increased and the cleaning hours”, “at the moment we have 3 carers and the manager and I feel this is enough”, “some days we do not have enough staff to do activities with people”. The home has two care staff on duty at all times, the manager is in addition to this. Again as stated in the previous report it was clear from speaking to several people living in the home that they do not feel sufficient activities are offered either within or outside of the home. Staff confirmed, “it would be nice to have more time to spend doing activities”. Staff meetings occur and written evidence was seen confirming this, but these meetings are not held on a regular or consistent basis. The manager said, “we hold a lot of informal meetings and discussions, but we do not always record these”. The home has training plan for 2007, but from looking at individual staff member’s files it was difficult to ascertain whether this had been implemented. When the manager was spoken to about this she said, “I have been undertaking an audit of the training and will have developed the plan fully over the next few months”. From looking at the two files and speaking to the staff members it was clear that the training continues to be sporadic and the written evidence confirmed that not all of the mandatory training courses are being kept up to date. A staff member said, “I started working here on a paid basis in January and did a one day in house induction, I have also done the POVA, dealing with aggression, medication and values and attitudes training”, “I am waiting to go on the social services induction training”. The manager confirmed that all new staff receive the induction and foundation training through the local authority’s training section, but because of the recent flooding of the building the majority of the courses have been cancelled and no new dates have been received”. During the last inspection it was identified that there were still some areas requiring development in particular specific training for challenging behaviour or difficult to hep residents, epilepsy, alcohol related illnesses. Staff confirmed that the training had improved, but confirmed that not all of them had undertaken training in relation to more specialist areas. Supervision records were looked at and staff were spoken to, it was confirmed that supervision is not occurring on a regular basis. Some comments included, “I have had one supervision in the last year”, “I think I have had two supervision meetings”. Staff did confirm that they could go to the manager for advice on an informal basis. Staff were observed interacting with the residents throughout the visit, this was done in a sensitive and caring way, speaking to residents with respect and courtesy. From speaking to the people who live in the home it was clear that they had developed good relationships with the staff and manager and some comments included; “I just wanted to tell you about the nice things about the home, I have been here for three years and have only ever found DS0000064654.V352530.R01.S.doc Version 5.2 Page 34 the staff to be kind, helpful and patient. The staff are subject to a lot of abuse, but they do not respond in anyway”, “the staff are alright, they help me and listen tome”, “I think the staff treat me ok and I respect them”, “the staff are very good, they come and make sure that I am ok”, “they are friendly and I get on well with them”, “the staff are exceptionally cheerful, helpful and courteous and I have no complaints to make”. Comments received from other professionals in the surveys returned included; “the staff at Bridlington House often contact myself or the team if they have concerns relating to the service users”, “they are very good at liaising with the community mental health team when concerns are identified”, “appears to provide a good level of support”. DS0000064654.V352530.R01.S.doc Version 5.2 Page 35 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 People who use the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The quality assurance system requires implementing, so therefore currently the views of the people who live in the home, their relatives, staff and other professionals are not sought or recorded and the system does not reflect the views of the service users or their representatives. People using the service receive support from staff who have either not undertaken or updated essential health and safety training including; fire safety, first aid, safeguarding adults, moving and assisting, infection control and food hygiene and therefore their health and safety may be compromised. DS0000064654.V352530.R01.S.doc Version 5.2 Page 36 EVIDENCE: An application for the Registered Manager has been submitted and approved by the CSCI Registration Team. The manager explained that the company who was assessing the Registered Manager’s Award has gone into liquidation and therefore has not completed this as yet. She stated, “I have obtained funding for the course and will be commencing it again as soon as possible”. The manager also confirmed that she had attended training in relation to infection control. The manager stated that the Registered Provider visits on a regular basis and undertakes Regulation 26 visits, written records confirming this were seen. She stated, “the owner comes up 2-3 times a month and is always available on the phone”. The Annual Quality Assurance Assessment received on 21.8.07 stated that many of the policies have been updated and this is an ongoing process. The quality assurance system has been restructured and the questionnaires have been changed to reflect a wider opinion. Equality and diversity is promoted by staff, respect and promote individual dietary requests or needs. Key workers support service users to attend religious meetings of their choice. Staff to attend equality and diversity training in 07/08. From speaking to the manager and staff it was evident that although the quality assurance system is being updated, currently the people who live in the home do not partake in this procedure. From speaking to several people who live in the home it was clear that they are consulted, but currently this is on an informal basis. Some comments included; “the cook asks us what we want to eat everyday and there is always a choice”, “we have meetings and discuss what’s going on in the home”. There was written evidence to confirm that residents meetings are held, but these are not on a regular basis. The system requires further development to ensure that all stakeholders are contacted for their views and an annual report produced explaining what the shortfalls are and what if any corrective action is needed. The home has safe working practices in place and during a discussion with the manager she confirmed that one area that requires attention is the training plan. She said, “I am currently reviewing the training plan and individual staff members to ensure that all of the mandatory training is undertaken”. From looking at written records it was clear that this is an area that requires major input and it was evident that key training in relation to maintain the health and safety of the residents have not been undertaken or updated as required. The fire risk assessment has been updated since the last inspection and this has been approved by the Fire Department. The manager said that all staff receive fire safety training on a regular basis and the home is adhering to the DS0000064654.V352530.R01.S.doc Version 5.2 Page 37 new smoking regulations. However, during the inspection visit two staff files and a training plan were looked at confirming that fire safety training has not been offered to staff in over 12 months. The designated smoking area in the main lounge, this is sign posted, but during the visit was observed to be left open on several occasions and smoke drifted into the main entrance hallway. Equality and diversity is promoted to some extent within the home. The residents have a range of diverse needs including mental health issues, depression, schizophrenia, anxiety disorders, alcohol and drug related issues. Several of the staff group are also from ethnic minorities giving breadth and experience to the staff group as a whole. The staff group have not received any training in relation to equality and diversity and this would promote empowerment for the residents. Since the last inspection evidence was received that the water system had been tested for Legionella and the bath hoist had been serviced. Some staff have undertaken infection control training, as stated previously some staff have limited knowledge in areas such as cross infection or contamination. All other maintenance certificates were in order and up to date. The registered provider stated that all new staff will undertake induction and foundation training that meets Skills for Care specification and that this will be undertaken through the local authority’s training section. DS0000064654.V352530.R01.S.doc Version 5.2 Page 38 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 2 34 3 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 2 X 1 X X 2 X DS0000064654.V352530.R01.S.doc Version 5.2 Page 39 Yes Are there any outstanding requirements from the last inspection? 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 YA20 Regulation 13 Requirement There must be a system in place to check for expiry dates and medicines with a limited number of days of use after opening. This helps to reduce the risk of medication being administered that may no longer be safe to use. (Previous timescale 18.9.07 –not met) There must be a system in place to make sure that there is enough stock of medication to administer to a person. This makes sure that people do not go without their medication, which may affect how their medical condition improves. (Previous timescale 18.9.07 – not met) Bathing and washing facilities must be in good order and of a good quality to ensure that people who live in the home have access to clean and wellmaintained facilities. Staff must undertake the appropriate induction and foundation training that meets the Skills for Care standard and DS0000064654.V352530.R01.S.doc Timescale for action 08/01/08 2 YA20 13 08/01/08 3 YA24 23 08/04/08 4 YA35 17,18 08/01/08 Version 5.2 Page 40 5 YA35 18 6 YA36 17,18 7 YA37 9 8 YA39 17, 24, 26 written evidence of this must be kept. This will ensure that a properly trained and skilled staff group supports people who use the service. (Previous timescale 17.07.07 - not met) Staff training and development programme includes specialist subjects around mental health problems, challenging behaviour or difficult to help residents and all other mandatory training including infection control must be undertaken to ensure that people using the service are supported by a well-trained staff group who can ensure their health and safety. (Previous timescale 1.6.06, 21.11.06 & 18.04.07 - not met) Staff must be appropriately supported and receive regular supervision as this would ensure that people using the service receive care from staff who are properly supervised and monitored. (Previous timescale 17.07.07 - not met) The manager must obtain NVQ Level 4 in Management to ensure that a person who is adequately qualified runs the home. (Previous timescale 17.07.07 & 23.04.07 - not met) The quality assurance and quality monitoring system must seek the views of all stakeholders including people who use the service, staff, relatives and other professionals as this will measure success in achieving DS0000064654.V352530.R01.S.doc 08/01/08 08/01/08 08/04/08 08/01/08 Version 5.2 Page 41 the aims, objectives and statement of purpose of the home and highlight areas requiring improvement. (Previous timescale 1.06.06, 21.11.06 & 17.07.07 - not met) 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. Refer to Standard YA14 YA23 Good Practice Recommendations Activities should be held on a regular basis both inside and outside of the home, as this would involve everyone living in the home especially those with more complex needs. People who use the service should be supported by a welltrained staff group, staff should the have the opportunity to attend training around challenging behaviour and breakaway techniques as this would enhance their skills in dealing with difficult situations. A current photograph of each person should be attached to their MAR chart. This helps to reduce the risk of medication being given to the wrong person. A system should be in place to record all medication received in to the home and medication carried over from the previous month. This helps to confirm that medication is being given as prescribed and when checking stock levels. The pharmacy should be contacted to provide up to date MAR charts. This makes sure that there is an accurate record of medication administration in accordance with the prescriber’s directions. Handwritten entries and changes to MAR charts must be accurately recorded and detailed. This makes sure that the correct information and dose is recorded so a person receives their medication as prescribed. 3. 4. YA20 YA20 5. YA20 6. YA20 DS0000064654.V352530.R01.S.doc Version 5.2 Page 42 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000064654.V352530.R01.S.doc Version 5.2 Page 43 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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