Inspection on 14/06/06 for Britannia House

This inspection was carried out on 14th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Britannia House 13/09/07

Britannia House 08/11/05

Britannia House 07/06/05

Britannia House 08/12/04

Britannia House 28/06/04

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

CARE HOMES FOR OLDER PEOPLE Britannia House 7-11 Jameson Road Bexhill-on-sea East Sussex TN40 1EG Lead Inspector Caroline Johnson Key unannounced Inspection 14th June 2006 10:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Britannia House Address 7-11 Jameson Road Bexhill-on-sea East Sussex TN40 1EG 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) 01424 217419 Britannia Care Homes Limited Vacant Care Home 21 Category(ies) of Dementia (21) registration, with number of places Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. That the maximum number of service users to be accommodated will not exceed twenty-one (21). That service users accommodated will be older people aged sixty-five (65) years or over on admission. That only service users with a dementia type illness will be accommodated. One named service user aged under sixty-five (65) years on admission to be accommodated. 18th November 2005 Date of last inspection Brief Description of the Service: Britannia House registered to accommodate 21 older people with a dementia type illness. The property is an adapted building situated a short level walk from Bexhill town centre with its shops and access to bus and rail routes. Accommodation is provided on three floors with a shaft lift and a stair lift fitted to assist those who may have problems managing stairs. Bedroom accommodation consists of 3 double and 15 single rooms. The registered providers are Britannia Care Homes Ltd who also own another two homes in the area. The home makes CSCI reports available to prospective residents and/or their relatives/representatives upon request. The fee charged as of April 2006 is £360 to £400 per week. Additional charges are made for chiropody and hairdressing. Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the inspection process an unannounced site visit was carried out on 14 June 2006 and lasted from 10.15am until 6.20pm. A further visit was carried out on 15 June and lasted from 09.30am until 1.45pm. Over the course of the two days there was an opportunity to meet with most of the residents, with the owner, acting manager and three care staff. In addition there was time spent with one visiting professional and with the relatives of two residents. A wide range of records were examined including the preadmission assessment carried out in relation to one resident recently admitted to the home. In addition four care plans were seen, along with records for medication, complaints, menus, daily records, health and safety documentation and staff recruitment. Time was spent observing the lunch meal and talking with residents and time was also spent observing part of the motivation and exercise activity. A full tour of the building was also undertaken. As part of the inspection process a pre inspection questionnaire was sent to the home with survey cards for the residents to complete. Unfortunately the home did not receive the documents. However, as stated above there was an opportunity to meet with the relatives of two residents and they spoke very positively about the care provided. Comments form one relative was that the food is `good’ and that the `care staff do their best’. Another stated that they are `very happy’ with the way the home is managing their relative’s needs. They also stated that they are kept informed of any problems that occur. Since the last inspection the registered manager has left her position in the home. For a short period one of the deputy managers took on the role of acting manager with regular support also provided from the owner. A new manager has since been appointed but as she has yet to be registered with the Commission she will be referred to in this report as the acting manager. It should be noted that the acting manager had only been in post for three days at the time of this inspection. What the service does well: Relatives spoken with stated that the care provided in the home is very good. Staff spoken with stated that they are well supported. Those observed in the course of their duties were caring and courteous and there was a good atmosphere in the home. Pre admission documentation seen in respect of one recently admitted resident was good and there was a detailed account of the residents needs along with advice for staff on how needs were to be met. The home is well maintained and is decorated to a good standard. Residents, or their relatives on their behalf, are encouraged to bring in small items of Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 6 personal possessions so most of the rooms look homely with ornaments, photos and small items of furniture. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5,6 Quality in this outcome area is good. The statement of purpose with the exception of the areas referred to below provides good information about the care provided within the home. In relation to the preadmission documentation seen, the home was thorough in assessing the needs of the resident and ensuring that the home could meet them. EVIDENCE: The statement of purpose and service user guide has been revised since the last inspection of the home. The documents contain most of the information required by the Regulations. However, there is very little reference to the fact that the home is part of a company and no information about the owner, manager and staff structure. There is also very limited information about the activities provided in the home. Pre admission documentation was examined in relation to one newly admitted resident. The home had carried out a detailed assessment of the individual resident’s needs and abilities. This included assessing the residents hobbies and interests and any emotional support required. The resident was supported Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 10 by his social worker to visit the home for lunch prior to moving into the home. A report was also obtained form the resident’s psychiatrist prior to making a decision about providing accommodation. The home does not cater for intermediate care. Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. Risk assessments need to be reviewed as and when the needs of the residents change to try to minimise the risk of accidents/incidents occurring. The home should continue with the progress made in relation to record keeping in daily notes. This will assist staff when they are evaluating the care they provide. Medication must be signed for immediately after administration to residents to safeguard against errors occurring such as another member of staff administering the same medication because they think it has not been given. EVIDENCE: Four care plans were seen during the inspection. There was evidence that the home has been reviewing all the care plans in the past few weeks. Where there was still work to be carried out there were reminder notes in the plans to identify the areas still requiring further work. In relation to one of the plans seen it was noted that the resident had not been in the home very long and required support from two care staff for all personal care and one member of staff at meal times. The resident liked to wander and had been assessed as high risk in terms of falls. The resident had been admitted on a trial period. At the time of inspection staff reported that the Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 12 resident’s needs had increased since admission to the home in that they displayed behaviour that was having an impact on other residents and meant that the level of support provided had to be increased to minimise the risk of incidents occurring in the home. This behaviour was observed at the time of inspection. The home’s risk assessment was examined and it was recommended that a more detailed risk assessment be put in place to ensure that the resident received one-to-one support. An appointment was imminent for the resident to see a psychiatrist with a view to having their medication reviewed. The format for recording daily records has changed in recent weeks. Rather that having a daybook, records are now individualised and reference is made to progress made with individual care plans. It was noted that record keeping is now more detailed and the home hopes to build upon this even more. Throughout the inspection staff were observed to treat residents with respect and dignity. Residents have access to a wide range of healthcare appointments as necessary to meet their individual needs. During the inspection there was an opportunity to meet with a visiting professional that was in the home to see one of the residents. She advised that she had spoken with all the staff on duty that day in regard to feeding and positioning for one of the residents. She also stated that in the time she has been involved with the home the `care staff have been good at following the recommendations’ she has made. Records showed that residents receive regular chiropody treatment. The home is also in receipt of support from the district nursing service for two of the residents. Records show that both of the residents who spend the majority of their time in bed are turned regularly and their fluid and food intake is monitored daily. Medication records were examined and with the exception of one resident’s medication were in order. In relation to this one individual it was noted that not all the resident’s prescribed medication had been signed as having been administered over a period of three days. Staff spoken with were confident that the medication had been administered but just not signed. In addition it was noted that the home are not using the back of the MAR (medication administration record) chart to explain their coding system. For example a note was put on the signing section `unable to give’ rather that using the code system and providing the explanation at the back of the chart. A staff member advised that a record is kept of all medication returned to the home’s pharmacy but it was not known where the returns list/book is kept. There is a format in place to be used when residents are admitted to hospital. However it was noted on the second site visit that a resident was taken to hospital and whilst information was recorded on a piece of paper the format was not used. Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. There are some very good activities provided in the home but the programme of activities should be reviewed and a designated member of staff should take responsibility for ensuring that the activities happen when they are supposed to. Staff report that they spend time with residents that are unable to join in the home’s activities but they need to find a way of documenting how they meet these residents’ social and emotional needs. Unless specifically requested by residents the television in the dining room should not be on during mealtimes. EVIDENCE: On the afternoon of the first site visit an external entertainer was in the home providing a music and motivation session. Nine residents participated in this activity and they all appeared to enjoy the session. On the second site visit the home had also arranged to have an external entertainer playing the keyboard. Other activities in the home include board games such as scrabble, puzzles and reminiscence. Staff advised that the local vicar visits the home weekly and provides a service. A hairdresser also visits the home on a regular basis. Two of the residents spoken with stated that they love spending time in the garden and one stated that they love gardening. One of the staff spoken with stated Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 14 that the activities cupboard needs replenishing. Staff also said that although there is a programme for daily activities, this is not always followed. At the time of inspection there were two residents that were not physically able to join in the activities. Although staff advised that they spend a lot of time with both residents apart from when they are providing personal care, this was not clearly recorded in their daily notes. There was an opportunity to meet in private with one of the residents and her relative during the course of the inspection. All comments received were very positive. They stated that the food is `good’ and that the `care staff do their best’. The resident stated that she liked her room and liked spending time in her room. When her relative visits they enjoy listening to classical music. There was also another opportunity to speak with the relatives of another resident that has very complex needs. They stated that they felt their relative was settling well into the home and they were very happy with the way the home were managing their relative’s needs. They also stated that they are kept informed of any problems that occur. Menus showed that residents receive varied and well balanced diets. Breakfast menus are recorded in the daily records. The meal served at the time of inspection was appetising and well presented. Time was spent in both dining rooms and residents had plenty of time to eat their meal. Staff moved between each dining room and attended to residents as and when they needed support. When a resident said that she did not like her dessert an alternative dessert was provided. As staff were not monitoring individual residents it was not clear if they would have been able to say which residents ate all their meal, who had an alternative to the dessert or been able to monitor individual fluid intake. One of the residents stated that the food is `faultless’. It was noted that the small television in the smaller dining room was left on throughout the meal. Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. The home is good at responding quickly to complainants. The new system to be introduced for recording complaints should resolve the shortfalls mentioned below. In addition to the new complaints records, the home should keep a chronological list of all complaints made to the home so that they can keep track more easily. All records should be stored securely. EVIDENCE: The company is in the process of reviewing their procedure for recording complaints. However it was noted that the home does not have a complaints book but instead a folder is used to store any written complaints made to the home and the home’s response. The folder contained two complaints. In both cases the home had responded to the complainant, in one case on the same day, and in the other case the following day. In order to investigate both complaints it would have been necessary to interview staff on duty, however there was no record of the investigation process. In relation to the first complaint there was one complaint raised that was not referred to in the response from the home. The staff member on duty the day the second complaint was made, advised the action that would be taken by the home in response to the complaint. However the home’s written response to the complainant detailing the action to be taken was slightly different. However, the complainant was invited to get in touch again if needed. Since the last inspection of the home there were no complaints raised with the Commission about the home. Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 16 There is a detailed policy in place on adult protection and prevention of abuse. The home will also be adding to this a flow chart detailing the steps to be taken if abuse is suspected. Since the last inspection some of the staff have received training on the protection of vulnerable adults and further training dates have been arranged. Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. The home is well maintained and decorated to a good standard. Bedrooms have been personalised and are homely. EVIDENCE: A full tour of the building was carried out. There are two lounges and two dining rooms. Bedrooms are well decorated. Residents, or their relatives on their behalf, are encouraged to bring in items of personal possessions to make rooms more homely. Most of the rooms contain photos, ornaments and small items of furniture belonging to the individual. Some of the residents have televisions. In one of the bedrooms there was an area against an outside wall where the paint on the wall appeared to be flaking away from the wall. The acting manager agreed to discuss this with the owner and to make arrangements to have the area redecorated. There was an odour in one bedroom. The acting manger advised that the carpets are shampooed regularly and the bed linen is also changed regularly. Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 18 There is a shaft lift and a stair lift to enable easy access to all floors. Two of the bathrooms have assisted baths and there are also two hoists available. Raised toilet seats and additional grab rails are positioned where necessary. A small number of residents have cot sides on their beds and where this is the case risk assessments have been carried out. On the day of the first site visit a new washing machine was installed in the home. The home has two washing machines. The laundry area was not very clean particularly the floor. This may have been a result of the moving around of the old machine and installing the new machine. All other areas of the home were clean and with the exception of the area mentioned above were free from odours. Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. The management of the home is a full time role so if the acting manager is to spend some time on shift then designated time needs to be allocated to the deputy managers for management tasks. Staffing records need to be in the home so that the manager can refer to them as and when needed. Emphasis is to be placed on staff training in the coming months and this will obviously be of benefit to the residents. The staff training matrix needs to be up to date so that it is easy to identify individual staff’s training needs. The home’s staff induction procedure needs to be reviewed in relation to the content and time given to complete. EVIDENCE: There are three staff on duty on each shift through the day. This generally includes the manager’s shifts but there are some days when management time is protected. This needs to be more clearly detailed on the rota. In addition to the care staff there is a cook and a cleaner on duty in the mornings throughout the week. Care staff attend to laundry duties. There are two care staff on duty at night, one a waking night carer and one a sleep-in carer. Staff have job descriptions detailing their individual responsibilities in the home. However, on discussion with the deputy managers it was apparent that the tasks are very generalised and there are few areas of specific responsibility. This was discussed with the owner and the acting manager and it was agreed that the job descriptions for the management level of the home should be reviewed with specific roles and responsibilities clarified. Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 20 There is a staff training matrix in place detailing the courses attended by staff in recent years. The acting manager was not sure if the matrix was up to date. She has asked the owner to have all staff files stored on the premises so that she can go through them to update the matrix. The owner confirmed that courses have been arranged for staff throughout the company on dementia, protection of vulnerable adults, pressure care, first aid, infection control and food hygiene. Arrangements have yet to be made for medication training and fire safety. The acting manager is a qualified trainer in manual handling but needs to do a refresher course to update this. Once this has happened she will provide training for the staff team. It was not clear how many staff have completed NVQ level two or above. At least two of the staff on duty at the time of inspection had an NVQ one at level two, and one was studying for level three. Recruitment records were seen in relation to three staff recruited to work in the home. The application form does not allow for a detailed employment history to be recorded. In one of the files seen the dates of employment were not recorded. However, in another case the applicant had included all previous employment on an additional page. Identification was included along with two references and details of previous qualifications. Records show that staff induction consists of a checklist of topics that must be covered with the manager. The induction package takes two weeks to complete and checklist is then signed at the end completion date by the manager and by the staff member. In one of the staff files seen the staff member’s starting date in the home was recorded but the induction date was recorded as having been done six days prior to the start date. In the third file although the carer had started in post in early April they had not started their induction. The acting manager had looked at the home’s induction package and was aware that further work was required to bring the home’s package in line with Skills for Care guidance. Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 Quality in this outcome area is adequate. The manager had only been in post for three days and she was clear that new systems need to be introduced to ensure that the home runs more smoothly. Key to this is the delegation of areas of responsibilities. Once staff are clear about what is expected of them the introduction of a quality assurance system to monitor performance and quality will assist in building upon the quality of the care provided in the home. EVIDENCE: Since the last inspection the registered manager has left her position in the home. A new acting manager has been appointed and at the time of inspection she had just worked three shifts in the home. She advised that she would submit her application for registration as manager in the near future. She had already assessed many of the home’s strengths and areas where improvements were needed. She has completed NVQ level three and is hoping to commence studying for NVQ level four in September. Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 22 Staff spoken with over the course of the inspection stated that they are well supported. They stated that they would be able to speak with the acting manager or the owner if they had a problem. They all stated that they had had supervision in the past month but it was thought that the records were stored in the staff files at the head office. The home has an annual development plan in place. The plan is not very detailed and it was agreed with the owner that future plans would be drawn up with input from the registered manager. Since the last inspection, the home has distributed a quality assurance questionnaire to the relatives of the residents. The acting manager was not sure when it was distributed but was aware that there was at least one response from a relative. She agreed to follow this up. The subject of quality assurance was discussed in detail and ideas were given of how to encourage relatives to take part in the system and of how to introduce difference types of audits to assist with judging and building upon the quality of the care provided in the home. The acting manager advised that the home has no involvement in the management of residents’ finances. Chiropody and hairdressing are paid for via the head office and representatives of residents are then invoiced for the cost. There is a policy and procedure manual in place. Four staff have recently signed the manual as having read and understood it. Hot water temperatures were tested at two outlets during the inspection and both were within agreed safety limits. Records showed that there were three sessions on in-house training in fire safety training in May 2006. Fire drills are not held in the home. The fire risk assessment could not be located. The home is in the process of introducing a new procedure for recording accidents. At the time of inspection it was noted that some accidents were recorded in an accident book, some had been filed in an accident folder and some had been stored in individual’s files. In relation to one resident it was noted that they had had six falls since admission to the home. With the exception of one fall the rest were of a minor nature but on speaking with staff they were not sure if all accidents had been recorded on the accident record sheets and that it may be necessary to refer to the daily records. On examination of one resident’s care plan it was noted that there had been an incident that affected the well being of a resident. This incident had been investigated and the findings had been copied to Environmental Health and to the District Nursing Service. However, the Commission had not been informed. Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 3 2 2 Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13(1a,c) Requirement The risk assessment in place in respect of one resident must include more specific advice on the action to be taken by staff to minimise the risk of accidents/incidents as a result of behaviour or falls. Risk assessments must be kept continually under review. In relation to medication procedures the home must ensure that: (a) Records are signed immediately following administration of medication, (b) Where there is a need to use the code on the MAR chart or to explain why medication cannot be given this must be recorded on the back of the MAR chart. (c) A returns book must be kept detailing all medication returned to the home’s pharmacy. The home must review their activities programme to ensure that it meets the needs of the residents. A review must also be held in relation to meeting the social/emotional needs of two of the most dependent residents. DS0000021401.V291341.R01.S.doc Timescale for action 30/06/06 2 OP9 13(2) 15/07/06 3 OP12 16(2m,n) 31/07/06 Britannia House Version 5.2 Page 25 4 OP16 17(2) Sch 4 para 11 5 OP19 23(2b) 6 7. OP26 OP28 16(2j) 18(1a) 8. OP29 19 Sch 2 para 1-9 18(1a,c,i) 10. OP30 11. OP30 13(2),(5) 23(4d) 12. OP31 18(1a) 13. OP31 18(1a) 14. 15. OP31 OP33 9(1,2) 24(1) In relation to record keeping in respect of complaints, the home must record all action taken to investigate complaints and ensure all areas of complaints are addressed. The home must investigate and address the problem in one of the bedrooms where the paintwork is peeling. The laundry area must be kept clean at all times. That 50 of staff are trained to NVQ level 2 by the end of 2005. (This was a requirement of the last inspection, timescale given 31/12/05) It was not possible to check if this had been achieved so this will be assessed at the next inspection. Staff files including details of staff supervisions must be kept secure in the home and available for inspection. The staff training matrix must be kept up to date so that it is clear which members of staff have received training and where there are any shortfalls. Arrangements must be made for staff to receive training in medication, moving and handling and fire safety. That all management hours whether worked by the manager or deputies are clearly recorded on the rota. Job descriptions for the senior management of the home must be reviewed with clearly define areas of designated responsibilities. The acting manager must apply for registration as manager of the home. That quality assurance questionnaires are distributed and the results collated and DS0000021401.V291341.R01.S.doc 31/07/06 15/08/06 30/06/06 31/12/06 15/07/06 31/07/06 31/08/06 30/06/06 30/07/06 31/07/06 31/08/06 Britannia House Version 5.2 Page 26 16. OP38 23(4e) acted on. (This requirement was also made at the last two inspections. Last timescale given 8/2/06.) Since the last inspection some progress has been made but further work must be undertaken to address it fully. This includes expanding upon the home’s annual development plan. Fire drills must be held regularly 31/07/06 to ensure that all staff are aware of know the procedure to be followed in case of fire. Records must be kept of the outcome and must include, the date, time and length of drill, a list of the staff in attendance and a detailed evaluation of the drill. The home’s fire risk assessment must be available for inspection. CSCI must be informed of 30/06/06 significant occurrences that affect the wellbeing of service users. (This was a requirement of the last inspection, timescale given 8/12/05) 15/06/06 The home must review the procedure in place for recording accidents and ensure that everyone is following the same procedure. All accidents must be recorded and if accidents are not stored in a central location then a chronological list of all accidents that occur in the home must be kept along with the time of the accident and details of where to obtain the appropriate record. 17. OP38 37(1e,2) 18. OP38 17(1a) Sch 3 para (3j). Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The statement of purpose should include information about the company, the owner, manager and staff structure. It should also include more information about the activities provided in the home. The hospital transfer form should be completed in respect of all residents and only the medication section left blank. All staff must be informed of the whereabouts of the form and advised to complete the medication section prior to any resident being admitted to hospital. At meal times staff should be delegated responsibility for monitoring a particular group of residents in relation to their dietary intake. Unless specifically requested by residents, the television in the dining room should be turned off during mealtimes. When a member of care staff is in receipt of a complaint from a relative, the immediate action taken as a result is documented. However, if the manager is not in agreement with the action agreed by a staff member this must be clarified with the complainant. All complaint records should be stored securely. In relation to staff recruitment, the home must ensure that all gaps in prospective staffs’ employment history be explored. If necessary the home must encourage applicants to use a continuation sheet so that this can be achieved. The staff training matrix must be kept up to date so that it is clear which members of staff have received training and where there are nay shortfalls. The home must refer to Skills for Care in relation to induction and foundation training. Training must be spread out over a longer period. Details must be kept of the training provided to staff and the date the training was provided. The manager should commence training to NVQ level 4 in management and care. The policy and procedure manual is a very detailed and comprehensive manual. Rather than expecting all staff to read through the whole manual and sign, staff should be encouraged to read through key polices and then read the DS0000021401.V291341.R01.S.doc Version 5.2 Page 28 2. OP8 3. OP15 4. OP16 5. OP29 6. 7. OP30 OP30 8. 9. OP31 OP37 Britannia House remainder as they are reviewed and sign each individual policy. Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Britannia House DS0000021401.V291341.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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