Inspection on 07/09/06 for Bury Metro - Killelea

This inspection was carried out on 7th September 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

Bury Metro - Killelea 03/01/06

Bury Metro - Killelea 04/07/05

Bury Metro - Killelea 14/03/05

Bury Metro - Killelea 27/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Bury Metro - Killelea Killelea Residential Care Home Brandlesholme Road Bury Lancs BL8 1JJ Lead Inspector Grace Tarney Unannounced Inspection 7th September 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bury Metro - Killelea DS0000008465.V298009.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. Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bury Metro - Killelea Address Killelea Residential Care Home Brandlesholme Road Bury Lancs BL8 1JJ 0161 253 6550 0161 764 3075 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) Bury M.B.C. Mrs Marie Josephine Glynn Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (35), Physical disability (1) of places Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 36 service users, to include: up to 35 service users in the category of OP (Older People) up to 1 named service user in the category of PD (Physical Disabilities under 65 years of age) may be accommodated within the overall number of registered places. The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. The service must at all times employ suitably qualified and experienced staff to meet the assessed needs of service users. Within the maximum of 36 places registered, there is provision for up to 18 places for intermediate care. 3rd January 2006 2. 3. 4. Date of last inspection Brief Description of the Service: Killelea House is situated one mile from the centre of Bury and is on a main bus route. The home has undergone major refurbishment to create a purpose built facility. There is plenty of parking to the front of the home for the use of staff and visitors. The front door of the home allows a level access for wheelchair users and people who have problems climbing steps. The first floor is reached either by stairs or a passenger lift. Accommodation throughout the home is provided in single bedrooms that have an en-suite facility of toilet and shower. The toilets and bathrooms have aids to assist any resident with a disability or mobility problem. There is a therapy room on the ground floor plus a hairdressing salon, medical and chiropodist room. Details of the services at Killelea are described in a Statement of Purpose which is available on request. Killelea House provides a range of services to older people in the Bury area. These include Intermediate Care, the aim of which is to promote recovery, independence and daily living skills for people who may then be able to return to live at home following an illness or accident. The remaining places provide Short Stay Care, Interim Care, and a limited number of permanent residential care places. Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was not told that this inspection was to take place although the home was aware that an inspection was due. This was because several weeks before the inspection questionnaires were sent out to the residents, their relatives and to the home itself. These questionnaires asked what people thought of the quality of the service and the facilities provided. 11 questionnaires were returned. 6 were from residents, 4 from relatives and 1 from a GP. A total of 11 hours was spent at the home. During this time the Inspector looked at care and medicine records to ensure that the health and care needs of the residents were being met. The Inspector then looked around the building at the bedrooms, bathrooms toilets and sitting areas on each unit to check if they were clean and well decorated. She then visited residents in their own bedrooms and lounge areas. This was to check out the care that was being provided for them. The Inspector also looked at what the residents had for their lunch and evening meal. The Inspector also looked at how many staff were provided on each shift to make sure the residents needs were being met, and also looked at how management recruit and train their staff. To make sure that the home and the equipment in it were safe some of the maintenance and service records were looked at. In order to get further information about the home the Inspector also spent time speaking to 4 residents, 3 care assistants and the manager. A copy of the last inspection report is kept in the reception area. The provider informed the inspector that the fees within the home were £341.00 per week. This information was received on the 24/08/2006 What the service does well: All the staff who look after the residents needing short-term care, were very good at making sure that they could meet their needs. They made sure that before their rehabilitation treatment started, they looked at what a resident was able to do as well as that what they were less able or not able to do. They then made sure that the correct people were involved in the residents’ care People visiting the home are made welcome and can visit at any time. The residents live in a clean and very pleasant environment. The home has a commitment to ongoing staff training and learning and has provided the care team with the knowledge and skills they need to protect and meet the needs of the residents. Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 6 Comments were received such as “They are very kind, the people who work here. You couldn’t ask for anything more”, “Everything and I mean everything, is very good and I couldn’t be in, or find a better place to live”. 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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 7 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 Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 8 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): 3 & 6. Quality in this outcome area is good. The system for ensuring that all prospective residents had a detailed assessment undertaken before their admission gave an assurance both to residents, relatives and staff that a resident was only admitted if the home could meet their needs and assist in their rehabilitation. The facilities and the specialist professional services provided ensured that the residents admitted for intermediate care received the correct sort of help to enable them to return home. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The assessment documents of 2 of the residents who had recently been admitted under the Intermediate Care program were inspected. Both these assessments had been undertaken by the hospital social workers. They were kept within the residents’ care plans, were detailed and gave a clear indication of the residents’ needs and capabilities. Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 9 On the day of inspection the home was providing intermediate care for 14 residents. There is a specialist team of workers available for this service including physiotherapists, occupational therapists and nursing staff. Specialised equipment, facilities and dedicated space was available within the home for the provision of rehabilitative techniques, the promotion of daily living activities and mobility. One of the intermediate care residents told the Inspector that she was getting better slowly and it was so much better than being in hospital. She felt that it was “A really good system”. Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 10 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 7 & 10. Quality in this outcome area is poor. The care plans did not give enough information about the residents’ needs and how they were to be cared for. The system for handling medicines was not as safe as it should have been. This could put the residents at risk of not receiving their medicines correctly and safely This judgment has been made using available evidence including a visit to this service. EVIDENCE: The care plans of 4 residents were inspected. 2 of the care plans were of residents receiving long-term care and 2 were of residents receiving intermediate care (IMC). The care plans for the residents receiving IMC were kept in their bedrooms. This is good practice. There was also a daily records file kept separately that contained a lot of important information about their condition and progress. The personal details on both the IMC care plans were not filled in completely. There was no information written down about how they would like to be called and nothing about whether their family were to be called in an emergency or during the night. The care plan for 1 of these residents had information about her dietary needs and how she was able to mobilise. There were no other care plans in place. Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 11 This resident had a deteriorating medical condition and did have other problems but no care plan was in place to address them. The care plan of the other resident showed a plan for eating and drinking washing and dressing and how she was to mobilise. This resident had diabetes and there was not enough information about what her diet should consist of. This resident was being cared for on a pressure- relieving mattress and was receiving care from the district nurses for wounds to her legs and pressure sores. There was nothing in the homes’ care plan about the involvement of the district nurses, nothing about how to prevent further pressure sores and nothing to show that special pressure relieving equipment was in place. There was also no risk assessment to show if she was at risk of developing pressure sores. The district nurses notes were in the room but did not contain a plan for prevention of pressure sores. Whilst the district nurses have responsibility to care for any nursing needs, the staff at the home also have a responsibility to document what care is being provided and to ensure that the care is being delivered. The care plans of the 2 long-term residents showed the following: The care plans were kept in a locked cupboard in the staff room. 1 resident had a care plan that identified her staying in bed and her incontinence. These were handwritten. There were also some care plans that had been typewritten and were dated from as far back as 2003. These care plans were all bundled together in one plastic folder and were not easy to access. The Inspector spoke to a care assistant who said that the staff did not refer to those, only to the handwritten ones that were relevant. The care plans of the other resident were printed and bundled together. This resident had diabetes but there was nothing about her diabetes and how to care for the condition. This residents’ care plan had not been reviewed since April 2006. Care plans were evaluated on a review cover sheet and at times on the care plan sheet. The evaluations were no more than a date of review and very occasionally scanty information in the event of any change. Evaluations need to be meaningful. The inspector found the documentation in relation to care plans and the evaluations of care plans difficult to read. It was not easy, at times, to find the required information. It is the Inspectors view that the care plan documentation in place is not easy to access and leaves the question as to whether the care plans are actually working documents. The staff did not look to see if the residents receiving IMC were at risk due to problems with their diet and fluid intake. Also whilst the long-term residents were assessed, 1 of these risk assessments had not been looked at to see if there had been any change, since April 2006. . The residents were weighed at least on a monthly basis and the weight recorded on a chart kept in their care plan. Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 12 Equipment necessary for the prevention and treatment of pressure sores was available within the home or could be accessed via the community nurses. Entitlement to other NHS facilities was upheld. This was evidenced from the information available in the care plans. A district nurse told the Inspector “The staff are good and follow instructions and directions” The medications were inspected for both the IMC and the long-term residents. Only suitably trained and designated care staff administer the medications. The medication and controlled drug keys were kept with other keys and left in the open key cupboard on the wall. To ensure the security of the medicines the medicine keys must be kept on the person who is in charge of the medications. The medication administration sheets (MAR) were handwritten. The prescriptions were not signed, checked or countersigned. This should be done to prevent medication errors. Management should consider asking the supplying pharmacist to provide computer printouts. The times of medicine rounds were not clearly identified. The MAR sheets stated Breakfast Lunch Tea etc. The times when medicines are given out should be more specific. In the absence of computer printouts, management should consider devising a code to explain when the times are e.g. breakfast 8am etc. First Floor The medicine trolley on the IMC unit was not kept in a locked room. It was kept at the station and was not secured to the wall. The medications for 2 residents were prescribed 4 times a day but they were given only when required. If a medicine is not required as often as it is prescribed staff must contact the residents’ GP for a new prescription. The medication of another resident was prescribed as 3 tablets of 25mcg per day but the resident was being given only 1 tablet. The container that the medicine was dispensed in stated 1 in the morning. This raises the question as to whether staff are reading the prescription or the container. An antibiotic suspension was not being stored in the drugs fridge as directed. There were some sachets of medication that had no name on. Ground floor 1 resident on Warfarin (an anticoagulant) had his prescription written on a piece of paper. If a prescription for Warfarin has changed or is to stay the same then written confirmation is needed. This could be in the form of a facsimile. 1 resident was prescribed eye ointment 4 times a day but it was only being given 3 times a day. Inspection of the stock cupboard showed the following: There was a medicine pot containing various loose tablets and capsules. The Inspector was told that these were medicines that had been refused or dropped on the floor. Medicines no longer required must be documented in the returns book and then returned to Pharmacy. Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 13 There was a basket that contained 7 boxes of Paracetamol. The Inspector was told that they were for the staff. 6 were unlabelled and 1 was partially labelled with a residents’ name. These were tablets that were previously prescribed for residents and were no longer needed. They must be returned to pharmacy. Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 7 15. Quality in this outcome area is good. The home enabled residents to exercise as much personal freedom and choice as possible. The meals at the home were good, offering choice and variety, and catering for individual dietary needs This judgment has been made using available evidence including a visit to this service EVIDENCE: The residents spoken to said they were satisfied with the way they were allowed to spend their day, more or less as they pleased. Staff and residents told the Inspector that they are encouraged to go to the dining room for their meals but can stay in their room if they wish. An activities co-ordinator has just been employed by the home on a part-time basis of 16 and a half hours per week. As she was very new to the post the residents were not aware of what activities were on offer. Once the activities organiser becomes established and is able to undertake a range of activities then the amount of enjoyment and fulfilment that the residents could achieve should be increased. Residents are encouraged to bring personal possessions into the home. Many of their bedrooms were highly personalised with pictures, photographs and ornaments etc. Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 15 Residents told the Inspector that they are able to have visitors at any reasonable time and they can see their visitors in private. The visiting policy is written in the Service User Guide. The inspector did not dine with the residents but observed lunch being served. The dining room is large and is used by the majority of the residents. The tables were nicely set with tablecloths, napkins & cruets. The meal served was of ample proportion and looked appetising. One of the residents commented on the questionnaire that the food was “very nice and we can choose our meal the day before”. Another commented, “ I like my breakfast and if I don’t like it they would get me something else”. Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. The complaint system in place enabled residents to feel that their views were listened to and acted upon. Staff had a good knowledge and understanding of what abuse was, thereby reducing the possible risk of harm or abuse to residents. This judgment has been made using available evidence including a visit to this service EVIDENCE: A detailed complaints procedure was in place and was displayed in the reception area. Social services also have a complaints procedure that is contained within the welcome pack that is in each residents bedroom. The details of how to contact the CSCI were in place but the telephone number was not the main contact one for the CSCI. A discussion with residents indicated that there was a general awareness of how to make a complaint. Replies from the questionnaires showed that the residents knew how to make a complaint if they had to. One resident commented “ I know how to complain but I don’t need to complain as everyone is so kind”. Staff also knew what to do if someone complained. No complaints have been made to the CSCI in the last 12 months. Information from the pre inspection questionnaire showed that there have been 5 complaints made to the home, 4 were substantiated and 1 partially substantiated. A record is kept of all complaints made and includes details of investigation and any action taken. Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 17 A policy and procedure was in place in relation to the detection of abuse and neglect (including whistle-blowing) and how to respond to suspected abuse. The home had a copy of the Local Authorities procedure for protection of vulnerable adults. A discussion with the manager and several care staff showed that they were very aware of the different forms of abuse and the procedure to follow in the event of any allegation of abuse. Staff continue to receive training in abuse awareness. Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 24 25 & 26. Quality in this outcome area is good. The residents were living in a clean, safe and very pleasant environment This judgment has been made using available evidence including a visit to the service EVIDENCE: There is level access to the front of the home to allow access for wheelchair users and people who have problems climbing steps. There is plenty of parking to the front of the home. There is a therapy room on the ground floor plus a hairdressing salon, medical and chiropodist room. The accommodation is on two floors, with 18 single rooms on each floor. All bedrooms have an en-suite facility of shower and toilet. The first floor bedrooms are for intermediate care residents and the ground floor is for long term residents or residents requiring respite (short term) care. The Inspector walked around most of the building and looked at several bedrooms, the lounges, the dining room, bathrooms and toilets. . Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 19 Assisted bathing and toilet facilities were on either floor. The bedrooms on all the units were clean, suitably furnished and most were very personalised. The rooms were individually and naturally ventilated, they were all centrally heated and radiators were covered. The bedroom doors were fitted with over-riding safety door locks and each bedroom had a lockable space for the residents’ use. Each bedroom had an en-suite shower with toilet. The laundry was clean, adequately equipped and looked very well organised. Staff hand washing facilities were in place in bedrooms bathrooms and toilets and the home was very clean and free from any unpleasant smells. One resident commented “The home is always fresh and clean”. Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 20 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 & 30. Quality in this outcome area is adequate. The residents’ needs were being met although the staffing levels provided were the absolute minimum. The residents were cared for by staff who were suitably experienced and trained, and in the main, had the knowledge and skills to meet the residents’ needs. This judgment has been made using available evidence including a visit to the service. EVIDENCE: Examination of the duty rotas, a discussion with staff and residents showed that the home was working on absolute minimum staffing levels. On the day of inspection there was a total of 27 residents living in the home. The home usually works on 5 care staff throughout the day and 2 care staff at night. Staff spoken to said that they feel as though they work hard but can only meet basic care needs as they do not have enough time to spend with the residents. Throughout the inspection day the manager was involved with reviews and meetings, mainly in relation to the residents who were receiving IMC. The Inspector is of the view that 5 day staff and 2 staff at night is not adequate to meet the needs of the 27 residents. 16 of the residents were receiving IMC. Most of these residents had been discharged from hospital and whilst being medically fit were recovering from an acute condition. At least 2 of the residents seen, needed a lot of care and attention. As the numbers and needs of the residents can change continually the staffing must be kept under review. Management are reminded of their responsibility Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 21 to ensure that staffing is provided in accordance with residents’ needs and not the number of residents. The duty rota for nights did not document the actual times that staff worked or the designation of the staff. To ensure that an accurate duty roster is in place these details must be added. The Standard for recruitment was not inspected during this visit. All recruitment takes place centrally by the Bury Social Services Human Resources Department. The CSCI carries out an annual check of the recruitment procedures during which staff files are sampled. Staff are safely and correctly recruited. Of the 25 care staff employed 14 have obtained their NVQ level 2 or above in care. This is a percentage of 56 and therefore the home has met the Standard. Training records were in place. These showed training has been or is programmed to be, undertaken in the following areas: Moving and Handling. Fire Safety. First Aid. Food Hygiene. Infection Control. Health & Safety Protection of Vulnerable Adults Dementia Care Mapping The Ageing Process Medication Management Handling Violence and Aggression Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 22 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 35 & 38. Quality in this outcome area is good The experience and qualifications of the manager should ensure that there is effective leadership and guidance to the staff thereby ensuring that the residents receive consistent quality care. The home was safe and very well maintained thereby promoting and safeguarding the health, safety and welfare of the people using the service. This judgment has been made using available evidence including a visit to the service EVIDENCE: The Manager has 24 years of experience in residential care settings. She has worked at Killelea since 2003 and has obtained the Registered Managers Award and also holds a social work qualification. The Inspector was told that Bury Social Services are in the process of streamlining a system for seeking the views of people who use their services. Comment cards are sent out to people who use the Intermediate care services. Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 23 Management need to ensure that the results of the responses are collated and published in the Service User Guide. The home has a detailed Health & Safety Policy. The pre inspection questionnaire informed that equipment and services within the home were serviced on a regular basis in accordance with the individual requirements. The Inspector randomly checked the servicing of the Thermostatic Control Valves for the baths showers and sinks. Servicing had been undertaken on the 1/4/06 therefore ensuring their safety. Regular weekly checking and testing of fire detection system, fire exits and emergency lights was undertaken and documented. Any accidents that happen are properly recorded and monitored. Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 24 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 x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 x x 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x x x x 3 Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 25 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 15 Requirement Timescale for action 30/09/06 2. OP7 15 Care plans and documentation must be current and give a clear picture of the residents’ condition at any one time. Care plans must be reviewed and 30/09/06 updated as and when required but at least on the required monthly intervals. The evaluations must be meaningful. When a resident is at risk of or has developed pressure sores, a pressure sore prevention plan must be in place. The Registered Person must ensure that residents risk asessments are reviewed and updated regularly The medicine trolley must be securely stored. The medicine keys must be kept on the person responsible for the administering of medicines. They must be kept separate from other keys Medicines must be given in accordance with the prescription. Medications must be kept in the container they were dispensed in DS0000008465.V298009.R01.S.doc 3 OP7 15 07/09/06 4 OP7 13 30/09/06 5 6 OP9 OP9 13 13 11/09/06 07/09/06 7 8 OP9 OP9 13 13 07/09/06 07/09/06 Bury Metro - Killelea Version 5.2 Page 26 9 10 OP9 OP9 13 13 11 OP9 13 Medicines must be stored in accordance with the storage instructions. Medicines no longer required must be recorded in the returns book and returned to the disposing agency. If a prescription for Warfarin has changed or is to stay the same then written confirmation must be in place. 07/09/06 07/09/06 07/09/06 12 OP27 18 The staffing levels must be kept 07/09/06 under constant review. Staffing must be provided according to the needs and dependency of the residents, not in accordance with the numbers The duty rotas must contain the 30/09/06 full name and designation of the staff members and the actual hors of work. The registered person must 31/12/06 produce an quality improvement action plan based on the views of service users and other stakeholders. (Previous requirement of 31/03/06 not complied with) 13 OP27 17 & Schedule 7. 24 14 OP33 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 OP9 OP9 Good Practice Recommendations To ensure the accuracy of a transcription, handwritten transcriptions should be checked with another member of staff, signed and countersigned. Management should consider asking the supplying pharmacist to provide computer printouts In the absence of computer printouts, management should DS0000008465.V298009.R01.S.doc Version 5.2 Page 27 Bury Metro - Killelea consider devising a code to explain when the times are e.g. breakfast 8am etc. Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Bury Metro - Killelea DS0000008465.V298009.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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