Inspecting for better lives Key inspection report
Care homes for older people
Name: Address: Brincliffe Towers Brincliffe Edge Road Sheffield South Yorkshire S11 9BZ The quality rating for this care home is:
one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Sue Turner
Date: 0 1 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area.
Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection.
This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 32 Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home
Name of care home: Address: Brincliffe Towers Brincliffe Edge Road Sheffield South Yorkshire S11 9BZ 01142552821 01142552821 walker-jean@btconnect.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Ash House (Yorkshire) Limited Type of registration: Number of places registered: care home 35 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: All 24 DE(E) beds are registered `or MD(E)` and are sited in a separate wing. Service users may also be aged 60-65 years. Date of last inspection Brief description of the care home Brincliffe Towers is a care home providing personal care and accommodation for 35 older people, including care for twenty-four people with dementia. The home is privately owned, and is located in a residential area of Sheffield with nearby access to public transport. The home is a large old detached house with a modern annexe attached and has very pleasant well established gardens, which overlook Chelsea Park. There is a small car park to the front of the house. All of the bedrooms are single Care Homes for Older People
Page 4 of 32 Over 65 24 24 11 0 0 0 Brief description of the care home although two are registered, as doubles should there be a request to share. Seven rooms have an ensuite facility. There is a passenger lift. A copy of the previous inspection report was on display and available for anyone visiting or using the home. Information about how to raise any issues of concern or make a complaint was on display in the entrance hall. Care Homes for Older People Page 5 of 32 Summary
This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. This was an unannounced key inspection carried out by Sue Turner regulation inspector. This inspection took place over one day, between the hours of 8.15 am and 4.15 pm. The manager is June Michelle Howe, who was present during the inspection. The manager and two of the homes owners, Mr Zahur and Mr Sall were given feedback Care Homes for Older People
Page 6 of 32 during and at the end of the inspection. Prior to the visit the manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. Questionnaires, regarding the quality of the care and support provided, were sent to people living in the home, their relatives and any professionals involved in peoples care. We only received one from a person living in the home and one from a member of staff. Comments and feedback from these have been included in this report. On the day of the site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home and check the homes policies and procedures. Time was spent observing and interacting with staff and people. Six staff, four relatives, one professional and five people living in the home were spoken to. We checked all key standards and the standards relating to the requirements outstanding from the homes last key inspection in May 2008. The progress made has been reported on under the relevant standard in this report. The manager confirmed that the range of fees from April 2008 were 327 to 368 per week. Additional charges included newspapers, hairdressing and private chiropody. The inspector wishes to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. What the care home does well: People living in the home said that the care they were receiving was good. They made comments such as Its very good here, in fact its excellent The staff are very caring and I like it because the homes clean and tidy. This is a nice quiet place to live. The staff are good and will do anything you ask them to. Things are so much better since the new manager started, shes made so many changes for the better. I have no grumbles on any part. Comments received from questionnaires and from talking to relatives were positive and included: I have expressed concerns in the past regarding Brincliffe Towers and I am happy to say that under the new management the home has changed dramatically. These changes many immediate, others longer term have changed the atmosphere among the staff, residents and relatives. I now look forward to visiting and any anxieties I have regarding my sisters care have dissipated. Staff are first rate. Everything is so much better, its like a different place. Health professionals said I have recently seen noticeable changes that are for the better. Staff look more professional in their new uniforms and they seem to be doing a much better job. We observed that people were well dressed in clean clothes and had received a good standard of personal care. Peoples health care was monitored and access to health specialists was available. People and relatives said that staff were always respectful towards them. People said that they had a choice of food and that the quality of food served was good and plentiful. There was a complaints procedure and adult protection procedure in place, to promote Care Homes for Older People Page 8 of 32 peoples safety. People said they had confidence in the homes manager and staff, who would listen to any concerns and take them seriously. People said that they felt safe living at the home. What has improved since the last inspection? At the previous inspection 22 requirements were issued. At this inspection all of the requirements had been actioned. The provider, manager and staff at the home should be commended for this. The manager had been in post for two months. During this time she had worked extremely hard to make many improvements. The managers and deputy managers enthusiasm was commendable and it was very evident that the staff team had responded positively to their style of management. The Statement of Purpose (SOP) and Service User Guide (SUG) were up to date and accurate. We suggested to the manager that more information about the services on offer should be included in the SOP and SUG. Information within the care plans had been reviewed, updated and transferred onto a revised and improved format. Relatives said they had been asked to be involved in the care planning and reviewing process. Risk assessments were in place and were being regularly monitored and reviewed. Medication Administration Record (MAR) sheets were signed by staff at the time of administration. The managers were closely monitoring this. We saw that peoples privacy and dignity was considered. Staff were able to give us examples of how they maintained peoples privacy and dignity. We believe that further training for staff about privacy and dignity would be beneficial. An activities worker had been employed. People said they enjoyed the activities available at the home. The activities coordinator was keen to include as many people as possible in different types of activities. We were pleased to hear that the activity coordinator spent some individual time with people that chose not to join in with the group activities. Staff said that training opportunities available to them had improved. All staff had either received, or were booked in for training in adult protection and moving and handling. There was a training matrix that clearly scheduled the needs of all staff and prompted the manager when staff were due to undertake any mandatory training, which included fire drills and practises. This helped to ensure that people were safeguarded. Staff rotas confirmed that the staffing levels at the home were adequate. Relatives said there was a noticeable difference in the number of staff around. Care Homes for Older People Page 9 of 32 Staff files contained all of the required information. Two written references and a Criminal Record Bureau (CRB) check or Protection of Vulnerable Adults (POVA) first checks were seen in staff files. Action had been taken to eliminate the cause of any unpleasant odour in the home. Further action was needed so that odour was fully eradicated. The home had undertaken some refurbishment, carpets had been replaced and bedrooms had been redecorated. Further refurbishment and redecoration work should continue to enhance the appearance of the environment. The provider was carrying out a monthly monitoring visit and writing their findings in a report. Any actionsor improvements identified were then addressed. People were seen using wheelchairs with footplates fitted. The managers said they were making regular observations to ensure that this continued. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 10 of 32 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 32 Choice of home
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provided sufficient updated and relevant information to inform people about their rights and choices. Trial visits were encouraged to enable people to look around the home, meet other people living there and give them the information needed to make informed choices. Evidence: The homes Statement of Purpose (SOP) and Service User Guide (SUG) were available, both in the entrance hall, for anyone visiting the home and a copy was also in each persons room. These included useful information about the home and the services offered. Both the Statement of Purpose and Service User Guide had been updated recently. We believe that there should be further information provided in the SOP and SUG that would assist people to make a decision about living in the home. When someone showed an interest in the home social services carried out a full needs
Care Homes for Older People Page 12 of 32 Evidence: assessment. The manager also carried out a pre assessment by visiting people in their own home or hospital. This meant that everyone could be assured that the home could meet the persons needs. People were invited to visit the home, try out the meals and spend time meeting the staff and seeing the services available. Any information collated from the needs assessment would then form the basis for the care plan. This home does not provide intermediate care services. Care Homes for Older People Page 13 of 32 Health and personal care
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care needs of people were met. A range of health care professionals visited the home. Medication procedures did not fully protect peoples health and welfare. Staff should give more consideration to peoples privacy and dignity. Evidence: Three care plans were checked. The standard of the care plans had improved significantly since the last inspection. The staff had clearly made an effort to meet the requirements made at the last inspection. Further work was necessary to ensure that each person had a care plan that reflected their individual needs and preferences. Care plans seen contained details of all health care contacts, appointments and treatments, and the home supported access to these to ensure health was maintained. Access to dentists, chiropodists and opticians was available. A visiting chiropodist was spoken to during the site visit. They said that they were able to treat people in private and that any specialist advice they gave was incorporated into the care plan. One person said The staff assist me to get bathed once a week, this is my preference, I could have
Care Homes for Older People Page 14 of 32 Evidence: more if I wanted. One relative said The staff are helpful, friendly and nice and provide a good of standard of care. Four relatives were asked if they had been involved in completing and reviewing a care plan. Two said yes and two said no. The manager said that she was in the process of speaking to all relatives about them becoming involved if they wished. Staff completed daily records. These were done at the end of each shift. There was very little information in the daily records. Those seen were short, brief comments that were repetitive. Records didn’t detail how people had spent their day, what meals they had taken, if any visitors were seen, any personal care tasks undertaken and any activities they had joined in. Daily records did not link with the information recorded in peoples care plans. The manager agreed with us that staff would benefit from training in report writing. She said that training would be sought and provided. The homes medication system had been changed. Staff said this was a much safer system. The pharmacist, who supplied the medication carried out checks to ensure that medications were being administered, stored and disposed of correctly. There was evidence that the manager and deputy manager were auditing medication administration procedures. Trained staff administered medications in the home. Medicines were securely stored around the home in locked trolleys within treatment rooms. Medicine Administration Records (MAR) checked were completed with staffs signatures. One person had recently returned from hospital and brought with them medication. We checked this persons medication and found that some staff were using the ones sent by the hospital and others were using those still in the trolley from before their hospital admission. The medication was of the same type and strength so the person had not received the wrong medication, however when checking the number of tablets in the trolley there was a shortfall. One staff had made an error when recording the medication in from the hospital and two staff had continued to administer when they had become aware of an error. This was of concern and the manager was asked to take action to make sure people were being kept safe. The manager made a decision to stop the three members of staff administering medication until they had received further training. During the site visit we observed that people were cared for in a friendly way. Some staff were very skillful in ensuring that people maintained their privacy and dignity, others were not as mindful. We talked to the manager about staff being trained in privacy and dignity issues and she agreed that this was necessary. Care Homes for Older People Page 15 of 32 Care Homes for Older People Page 16 of 32 Daily life and social activities
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People had a choice of lifestyle within the home and were able to maintain contact with family and friends ensuring that they continued to be involved in community life. A range of activities was on offer, which promoted choice and maintained interests. Meals served at the home were of a good quality. Evidence: People said they were able to get up and go to bed when they chose, and were seen to walk freely around the home, if able. Relatives spoken to said they were able to visit at any time and were made to feel very welcome. Staff took time to make sure friends and family were made to feel comfortable whilst visiting their loved one. Some people said they preferred to stay in their room at certain times of the day and that the staff respected their decision. Since the last inspection the home had employed an activities worker who works 20 hours per week. We saw notices advertising decoration making, cooking, games, quizzes and music and movement. Special events were planned for Halloween and Bonfire week, Christmas and 1930s and 1940s celebrations. People said that they enjoyed taking part in social activities within the home. People were also looking
Care Homes for Older People Page 17 of 32 Evidence: forward to trips outside that were planned. We observed breakfast and lunch being served in two dining rooms. Choices were available and staff were aware of peoples meal preferences. Some people chose to eat breakfast in their room. People had a choice of cereals or porridge followed by bread or toast with preserves. People could also request a cooked breakfast. At lunchtime the dining room tables were set nicely with tablecloths, cutlery and matching crockery. The dining rooms were quite small and had a pleasant relaxed ambiance. People said If I dont like it I tell them. Theres always a choice, we had a nice meal yesterday. The food isnt bad, a lot of it is quite enjoyable. Relatives said Staff now give out fresh fruit between meals. Theres always plenty of drinks available, both hot and cold. One person was receiving a special diet. We looked at the records kept about what this person had eaten. These were not in sufficient detail to determine if the person was receiving the diet that professionals had recommended. Care Homes for Older People Page 18 of 32 Complaints and protection
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures were in place to enable people and relatives to feel confident that any concerns they voice would be listened to. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure people were protected from abuse. Evidence: People and their families had been provided with a copy of the homes complaints procedure, which was also on display in the entrance hall and bedrooms. This contained details of who to speak to at the home and who to contact outside of the home to make a complaint should they wish to do so. Relatives spoken to said that they felt very comfortable in going to the manager or deputy manager, knowing that any concerns they may have would be addressed without delay. The manager said that there were no outstanding complaints and since the last inspection we had not received any complaints about the service. Staff spoken to were clear how to respond and record any complaints received. Since the last inspection the majority of staff (20) had undertaken training in adult safeguarding. The remaining staff (8) were booked to undertake this training within the next few weeks. In conversation with staff, we noted that they had a good understanding of safeguarding adults and whistle blowing policies, procedures and
Care Homes for Older People Page 19 of 32 Evidence: practices. The manager said she didnt have a copy of the newly revised South Yorkshire protocol for dealing with adult safeguarding. Advice was given on how to obtain a copy. Since the last inspection we had received one safeguarding referral. This had been investigated by the safeguarding team and the manager. The manager had then taken appropriate action to ensure that peoples health, safety and welfare were not put at risk. People said they felt safe living at the home. Care Homes for Older People Page 20 of 32 Environment
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Controls of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. Staff said they had not undertaken training in infection control. Evidence: The home had outdoor space, which was accessible to all people including those with mobility problems. From the Elderly Mentally Infirm (EMI) wing people could walk outside into an enclosed patio area. Tables, chairs and shrubs made the area look pleasing. The home was clean and tidy. Lounge and dining areas were domestically furnished. Since the last inspection refurbishment of the home had continued. Some carpets and furniture had been replaced and some bedrooms had been redecorated. However there still remained many areas of the home in need of refurbishment and modernisation. The manager had made some attempts at making the communal areas look more homely. Bedrooms checked were clean but many were very basic. Some bedrooms would benefit from being made more homely and cosy. One person said they would have liked a television and fridge in their room. They said they liked to spend time in their
Care Homes for Older People Page 21 of 32 Evidence: room and these things would make it more like home. The administrator arranged for funds from the persons own account to be made available so that these items could be purchased. On arrival at the home early morning there was an odour, during the day this lifted but still lingered. The manager said they had completed work in the building to eradicate unpleasant odours. We believe that further work needs to be undertaken so that odours are thoroughly eliminated. Relatives said The smell is much better but still here. Things had got so bad it seems to be taking a lot to get rid of the smells. Controls of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. Staff said they had not undertaken training in infection control. Care Homes for Older People Page 22 of 32 Staffing
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff were provided to meet the needs of people. The recruitment information obtained for staff was sufficient to adequately protect the welfare of people. Staff had completed training that ensured they had the competences to meet peoples individual needs. Evidence: Staff interviewed said that they enjoyed working at the home and got a lot of job satisfaction. On the day of the site visit staffing numbers were at an acceptable level. Staff said that the new manager had ensured that staffing levels were kept at an acceptable level. They said that when people were sick or on holiday, other staff were called in. They also said that rotas were arranged so that the needs of people living in the home could be met. Relatives said that they had noticed that more staff were around and where necessary people were being more closely observed. The manager had undertaken a review of staff training and had identified the shortfalls. Mandatory training had been booked and further training in specialised topics for example diabetes, preventing falls and dementia was being delivered by the Sheffield Partnerships for Older Peoples Projects (POPPs) team. Staff interviewed said that when they started work they received induction training in
Care Homes for Older People Page 23 of 32 Evidence: the first three months of their employment. Three staff files checked identified that the member of staff had received induction training when they commenced work. Staff were able to talk about the various training courses that they had attended, which included mandatory training, for example, Moving and Handling, Food Hygiene, First Aid and Fire. Staff said they were encouraged to attend training on various care topics and the frequency of training had increased in recent months. A number of care staff had completed the NVQ Level 2 in care and others had commenced the training. However the number of staff trained did not meet the required minimum of 50 per cent of the staff team trained to NVQ Level 2 in Care. Three records of employment were checked. These included all of the required information including interview assessment, verification of identity, references, certificates of training, health checks and evidence of Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) check. Application forms fully recorded previous employment. Care Homes for Older People Page 24 of 32 Management and administration
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The managers approach benefited people and staff. The quality assurance systems needed further development to ensure that the home was run in the best interests of everyone. Peoples monies were safely handled, which ensured that finances were accurate and safeguarded. In the main peoples health and safety had been promoted and protected. Evidence: The manager at the home was in the process of registering with us. She had completed the Registered Managers Award (RMA) and had many years experience of working with older people. Since the last inspection the manager, with the support of the provider, had worked hard to action the requirements made and this was evidenced by the many developments made within the service. Care Homes for Older People Page 25 of 32 Evidence: The manager was hard working, competent and carried out her role to a very high standard. She was clearly very committed to ensuring that people living in the home were consistently well cared for, safe and happy. Everyone spoken to and information from questionnaires confirmed that people, staff and relatives were all happy to approach the manager at any time for advice, guidance or to look at any issues. They all said that they were confident that she would respond to them appropriately and swiftly. Recorded quality assurance visits by the registered provider had been carried out each month, as required by the regulations. Reports were seen in the home for visits that were undertaken. Mr Sall is the responsible individual (RI). He visited the home several times a month and spent time speaking to people, staff and relatives. Each month he completed a report about the quality of the service provided. These reports were seen. Regular resident, staff and relative meetings were arranged. Minutes from these were seen. The minutes didnt record who was present at the meetings or if any actions were to be taken in response to people raising issues or making a suggestion. The manager was aware that she needed a quality assurance system in place, based on seeking the views of people and other interested parties. The home handles money on behalf of some people. This was checked for three people. Account sheets were kept, receipts were seen for all transactions and monies kept balanced with what was recorded on the account sheet. Fire records evidenced that fire alarm checks took place each week. Staff said that they had received fire training and fire drills. Fire drills were being held at different times of the day so that all staff could participate in a drill. The fire service had carried out an inspection of the home and made a recommendation that some door closures were replaced. The manager said that this was being actioned. Following this the manager had not updated the fire risk assessment. As the home cares for people with dementia the fire risk assessment should have highlighted what particular precautions were in place to keep people with dementia safe. Environmental Health had awarded the home a good three star rating following their last inspection visit. In the main equipment at the home was serviced and maintained. However the home did not have a periodic inspection certificate to certify that the electrical fixed wiring
Care Homes for Older People Page 26 of 32 Evidence: had been checked. This is recommended to be carried out within a maximum of five years. Care Homes for Older People Page 27 of 32 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards
No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 28 of 32 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action 1 9 13 Staff who have made errors during medication administration must not administer medications until they have received further training. So that peoples health and welfare are protected. 20/10/2008 2 18 18 The staff that have not yet undertaken training in adult safeguarding procedures, must do so. To ensure the protection of people. 01/11/2008 3 26 23 All staff must be trained in infection control. To ensure safe working practices. 01/03/2009 4 38 13 The fire risk assessment 01/11/2008 must highlight any particular precautions that need to be in place for people that have dementia. Care Homes for Older People Page 29 of 32 So that people are kept safe. 5 38 16 The fire risk assessment 20/10/2008 must be kept up to date and accurate. To ensure the protection of people. Recommendations
These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 The Statement of Purpose and Service User Guide should contain more information about the services available at the home. Staff would benefit from receiving training in report writing and person centred care planning. Staff should undertake training in maintaining peoples privacy and dignity. So that professionals that have recommended a special diet can identify if a person is receiving adequate nutrition, detailed records should be kept of what the person has eaten. There should be, at the home a copy of the local South Yorkshire protocols for dealing with safeguarding. A planned programme of maintenance and refurbishment should continue. Satisfactory standards of hygiene have to be maintained. Therefore the cause of any unpleasant odour should be investigated and then appropriate action taken to eliminate this. There should be 50 of the care staff trained to NVQ Level 2 or equivalent. Minutes taken at resident, relative and staff meetings should record who was present. There should also be information about what action has been taken following any issues or suggestions raised at these meetings. The home should have a periodic inspection certificate to certify that the electrical fixed wiring had been checked. This is recommended to be carried out within a maximum
Page 30 of 32 2 3 4 7 10 15 5 6 7 18 19 26 8 9 28 33 10 38 Care Homes for Older People of five years. Care Homes for Older People Page 31 of 32 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 32 of 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
