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Inspection on 11/08/04 for Butler Green House

Also see our care home review for Butler Green House for more information

Care Home For Older PeopleButler Green HouseWallis Street Chadderton Oldham OL9 8NGUnannounced Inspection11th August 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Butler Green House Address Wallis Street, Chadderton, Oldham, OL9 8NG Email address socs.gwylfa.evans.@oldham.gov.uk Name of registered provider(s)/company (if applicable) Oldham M.B.C. Name of registered manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 39 Tel No: 0161 911 5086 Fax No:Category(ies) of registration, with (number of places) Dementia - over 65 years of age (10), Old age, not falling within any other category (28), Physical disability over 65 years of age (18) Registration number F040000346 Date first registered Date of latest registration certificate 22nd December 2003 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection 19th July 2004 NO YES 16/3/04 If Yes refer to Part CButler Green HousePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 311th August 2004 09:10 am Carol Makin Jennie RobsonID Code074703 142274Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionTeresa Lever - Acting ManagerButler Green HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementButler Green HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Butler Green House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Butler Green HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Butler Green House is a purpose built establishment, commissioned and managed by Oldham Metropolitan Borough Council. Designed around a central hub, the ground floor is home to 39 people who are elderly and have physical disabilities. There are three distinct units, each one having a kitchen, lounge, dining area and bedrooms. One unit is designated for service users who require intermediate care. All bedrooms are single occupancy and are above the minimum space standards. There are no en-suite facilities. All the bedrooms are lockable and there is a secure facility within each room. There are aids and adaptations to meet the assessed needs of the service users. The gardens are well maintained and provide seating for the service users in the better weather. The home is located in a residential area of Chadderton with access to local and community resources.Butler Green HousePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This unannounced inspection took place on 11th August 2004. It was found that many of the assessed standards had been met or partially met, and service users who chose to speak with the inspector expressed satisfaction with the care they were receiving. Choice of Home (Standards 1-6) 3 of the 6 assessed standards were met. Dedicated accommodation is provided for intermediate care with professional inputs from occupational therapists and physiotherapists. Further work was required to enable the statement of purpose and service users guide to meet fully with the standard. Health and Personal Care (Standards 7-11) 1 of the 3 assessed standards was met. The health care needs of service users were well documented and service users had access to the full range of health service professionals. Care plans and risk assessments were in place, and service users had signed their care plans. Improvements were required regarding reviews. A pharmacist inspector assessed the medication. Substantial improvements have been made since the last inspection A total of 3 requirements were issued regarding medication storage, self-administration and recording. Daily Life and Social Activities (Standards 12-15) All of the 4 assessed standards were met. Service users expressed their satisfaction with the food provided, and felt that they were able to make choices within the routines of daily living in the home. A visitor and service users who spoke with the inspector confirmed that relatives and friends were able to visit when they wished and were made welcome by the staff.Butler Green HousePage 6 Complaints and Protection (Standards 16-18) The standard which was assessed was met. Staff had received training regarding Abuse Awareness and the Protection of Vulnerable Adults procedures, and relevant policies and procedures were in place. Environment (Standards 19-26) 3 of the 6 assessed standards were met. At the time of the inspection the home was found to be clean and free from unpleasant odours. Service users confirmed that this was the normal standard of cleanliness within the home. Bedrooms which were viewed during the inspection, were personalised, clean and attractively furnished and decorated. A requirement was made regarding the need for storage facilities for aids and equipment. Staffing (Standards 27-30) 2 of the 4 assessed standards were met. Staffing rotas provided for inspection indicated that there were sufficient numbers of staff on duty at that time to meet the standards set by the former regulating authority. There was evidence that staff receive training to NTO standards, with an induction and foundation programme being completed within the first 6 months of their employment. A requirement has been made regarding staff records. Management and Administration (Standards 31-38) 2 of the 6 assessed standards was met. Where service users monies are held for safe keeping appropriate records are retained. At the time of the inspection the registered manager has left and the deputy manager has taken on the role of acting manager. Her qualifications include HNC in Social Care Management, and she is an NVQ Assessor. Some records required by regulation are not held within the home. Requirements have been made regarding some health and safety issues.Butler Green HousePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 4 OP1 The registered person must ensure that the statement of purpose and service user guide are provided in accordance with the Regulations and the National Minimum Standards The registered person must ensure that service users are provided with a statement of terms and conditions in accordance with the Regulations and the National Minimum Standards. The registered person must ensure there is a system of quality assurance and quality monitoring in place, in accordance with the standard and the Regulations. The registered person must ensure all policies and procedures are reviewed. The registered person must ensure records required by legislation are maintained and made available for inspection at all times. 1/4/0425OP21/4/04312,24OP331/4/044 524 17 schedule 4 19 schedule 2OP33 OP371/4/04 Immediate6 13(2) 7 17(1)a OP9 OP9The registered person must ensure that all medication retained within the home is stored at the appropriate temperature. The registered person must ensure that the receipt, administration and disposal of controlled drugs are recorded accurately and contemporaneously in a controlled drugs register.30/03/200406/04/2004Butler Green HousePage 8 8 13(4)c OP9The registered person must ensure that the self-administration policy and risk assessment framework are expanded and developed in 25/05/2004 order to protect the health and safety of service users who wish to administer their own medication.Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Provision of a toilet facility for kitchen staff.Met (Yes / No) YESButler Green HousePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The registered person must ensure that statement of purpose and service user guide are provided in accordance with the regulations and the national minimum standards. The registered person must ensure that service users are provided with a statement of terms and conditions in accordance with the regulations and the national minimum standards The registered person must ensure that care plans and risk assessments are provided and reviewed for all service users in accordance with the standards and the regulations. The registered person must ensure that the lounge carpet on Green Wing is replaced. The registered person must ensure that storage facilities are provided for aids and equipment. The registered person must ensure that records are maintained in accordance with Schedules 2 and 4 of the Care Home Regulations 2001 and are available in the home for inspection.14OP11/11/0425OP21/11/04315OP7Immediate423OP2015/12/04523OP2201/02/0567 and 17(2)OP27ImmediateButler Green HousePage 10 724OP33The registered person must ensure there is a system of quality assurance and quality monitoring in place, in accordance with the standard and the regulations. The registered person must ensure all policies and procedures are reviewed. The registered person must ensure that a financial plan and a business plan and records of transactions in relation to the running of the home are available for inspection. The registered person must ensure that the kitchen is properly ventilated at all times. The registered person must ensure that tests and checks in relation to fire precautions are carried out and recorded at the prescribed intervals. The registered person must ensure that service users who wish to manage their own medication are assessed as to their ability to do so, before medication is provided to them, ensure that the self-administration policy and risk assessment framework are expanded and developed in order to protect the health and safety of service users who wish to administer their own medication. The registered person must ensure that all medication retained within the home is stored at the appropriate temperature. The registered person must ensure that items of medication designated as controlled drugs are stored in a secure dedicated area, to which access is restricted, ensure that the receipt, administration and disposal of controlled drugs are recorded accurately and contemporaneously in a controlled drugs register.1/11/04824OP331/1/05917OP341/11/041016OP381/11/041123OP38immediate1213 (4) cOP918/11/20041313 (2)OP923/09/20041413 (2)OP921/10/2004Butler Green HousePage 11 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 2 3 OP21 OP28 OP38 The registered person should ensure that sluices are located separately from service users toilet and bathing facilities. The registered person should provide a minimum ratio of 50 of staff members with NVQ level 2 by 2005. The registered person should ensure that the food storage area, which is situated near to the kitchen toilet facility, is enclosed. The Registered Person should ensure that all tests and checks in relation to fire precautions are recorded in the same book, preferably the book which has been obtained from the local Fire Authority. The registered person should take action on the pharmacists good practice recommendations.4OP385OP9* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Butler Green HousePage 12 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES YES NO NO NA YES YES YES NO YES YES NO NO NO YES YES YES 6 1 0 NA NA YES YES X 0 11/8/04 9.10 8Butler Green HousePage 13 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Butler Green HousePage 14 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 327.00 To (£) 327.00Any charges for extrasYESIf yes, please state what the extras are: 2 Key findings/Evidence Standard met? It was reported that the statement of purpose and the service user guide had been redrafted, but further amendments were required to comply with the standard. The registered person must ensure that statement of purpose and service user guide are provided in accordance with the regulations and the national minimum standards.Butler Green HousePage 15 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 2 Key findings/Evidence Standard met? There was evidence that a statement of terms and conditions had been provided for new service users. They were not however consistently provided on the day of admission. The actual fees payable were not included in the statement, the information regarding fees referred to an assessment being carried out by the social worker. The registered person must ensure that service users are provided with a statement of terms and conditions in accordance with the regulations and the national minimum standards. Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? Assessments of needs were available in the care files which were selected for inspection. Assessments are carried out initially by social workers with input from other professionals where necessary. It was reported that service users who chose to visit the home prior to admission were assessed during the visit. Those who did not wish to visit the home, were assessed in their own home or hospital, by a member of the homes management team prior to admission. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 2 Key findings/Evidence Standard met? Without the completed statement of purpose, and improved care plans, and reviews of service users needs, it is difficult for the registered person to effectively demonstrate the homes capacity to meet the needs of the service users. (See standards 1& 7.)Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? As previously mentioned in standard 3, service users are invited to visit the home prior to admission to the home. It was reported that service users are admitted on a trial basis. A decision regarding permanency is made following the review of the placement, which takes place 6 weeks after admission.Butler Green HousePage 16 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 3 Key findings/Evidence Standard met? The intermediate care services meet with the standards.Butler Green HousePage 17 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? The care files which were selected for inspection, contained structured care plans and risk assessments, and service users had signed their care plans. The information in the care plans was not, however always easy to follow. There was evidence that some information had been updated, but all aspects of the care plan need to be reviewed at least once per month in accordance with the standard. The acting manager agreed that there were areas where improvements could be made to care plans and the review system, and she stated that she already had some ideas for improving the system. The registered person must ensure that care plans and risk assessments are provided and reviewed for all service users in accordance with the standards and the regulations.Butler Green HousePage 18 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 2 13 Key findings/Evidence Standard met? The service users health care needs were documented within the individual care plans. The district nursing service is involved in carrying out assessments of those service users who are at risk from developing pressure sores. The same service provides appropriate aids to prevent pressure sores. Detailed and updated records, and a risk assessment were available regarding the service user who was receiving treatment for a pressure sore at time of the inspection. Service users have access to hearing and sight tests, and chiropody is available via the NHS, and their weight is checked and recorded regularly by the carers in the home.Butler Green HousePage 19 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? nd A pharmacist inspector assessed this standard on the 22 September 2004. A letter detailing good practice recommendations has been sent to the home. The home has made substantial improvements since the last inspection in the areas of medication policy, storage, administration and records. The home possesses a comprehensive medication policy which complies with the national minimum standards and reflects current guidance issued by the Royal Pharmaceutical Society. Medication is administered by carers who have completed basic training in the handling and administration of medication. At the time of inspection the home was accommodating seven service users who were selfadministering their medication. Since the last inspection the home has improved the selfadministration risk assessment framework, however, the inspector found that risk assessments had not been completed for two service users, and that the completed risk assessments lacked detail. The registered person must ensure that service users who wish to manage their own medication are assessed as to their ability to do so, before medication is provided to them, ensure that the self-administration policy and risk assessment framework are expanded and developed in order to protect the health and safety of service users who wish to administer their own medication. On examination of medication storage areas, the inspector found an item of ophthalmic medication which requires refrigerated storage, stored at room temperature. Ophthalmic preparations must be stored at the appropriate temperature in order to reduce the risk of bacterial contamination and degradation. The registered person must ensure that all medication retained within the home is stored at the appropriate temperature. The home possesses a controlled drugs cabinet and hardbound controlled drug register, however at the time of inspection the inspector found that Temazepam, a schedule 3 controlled drug, was stored in the medicines trolley and was not entered into the controlled drug register. The registered person must ensure that items of medication designated as controlled drugs are stored in a secure dedicated area, to which access is restricted, ensure that the receipt, administration and disposal of controlled drugs are recorded accurately and contemporaneously in a controlled drugs register. The registered person ensures that service users medication is reviewed on a regular basis.Butler Green HousePage 20 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Butler Green HousePage 21 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? Service users commented positively about the provision of activities and entertainment, and they felt that routines in the homes were flexible. (See also standard 14).Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? During discussions with service users and a visitor, it was confirmed that relatives and friends were able to visit when they wished, and that they were made welcome by the staff. All bedrooms are single rooms, and service users are therefore able to meet with their visitors in the privacy of their own room if they wish to do so. Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? Service users were able to personalise their rooms to meet their needs, and examples were given of choices which they were able to make within the routines of daily living within the home e.g. times of rising and retiring, pursuing interests/hobbies, choices regarding food, meal times and venue.Butler Green HousePage 22 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? During discussions with service users they confirmed that they continued to be very satisfied with the meals which are provided at Butler Green.Butler Green HousePage 23 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence This standard was not assessed on this occasion. X X X X X X X 0Standard met?Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Butler Green HousePage 24 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 03 Key findings/Evidence Standard met? It was reported that during the 12 month prior to this inspection 8 members of staff, including managers and senior care assistants, had received training regarding Abuse Awareness and the Protection of Vulnerable Adults procedures. Abuse Awareness is also included in the TOPSS induction and foundation training for new staff. Relevant policies and procedures were in place, and the acting manager stated that she was aware of procedures in relation to the POVA list, which was implemented on 26/7/04.Butler Green HousePage 25 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? This standard was not fully assessed on this occasion.Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 2 Key findings/Evidence Standard met? The communal accommodation was spacious, with several small areas and one large open plan sitting area to the front of the establishment. There is a designated smoking area for the service users. The lighting and furniture were domestic in style. The grounds are fully accessible to the service users and appropriate garden furniture is available. It was noted that the lounge carpet in Green Wing was showing signs of wear and tear, and a potential tripping hazard had developed in one area. The registered person must ensure that the lounge carpet on Green Wing is replaced.Butler Green HousePage 26 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 2 Key findings/Evidence Standard met? The Home provides 14 toilets, 5 bathing facilities and 2 shower rooms. There are no en-suite facilities at Butler Green, but all bathrooms and toilets are accessible throughout the home and are situated close to lounge areas. It was noted that an assisted toilet on each wing also had a sluice within the area, thus reducing the available space for service users. The registered person should ensure that sluices are located separately from service users toilet and bathing facilities. Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 2 Key findings/Evidence Standard met? Appropriate professionals have undertaken an assessment of the building to meet the needs of service users in particular those receiving intermediate care. It was reported that Input from a physiotherapist was always available to ensure that assessments of the premises and facilities are up to date and continue to meet the needs of service users. It was noted that a hoist was stored on a corridor. The acting manager reported that storage space in the home was limited. The registered person must ensure that storage facilities are provided for aids and equipment.Butler Green HousePage 27 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence This standard was not assessed on this occasion. YES NO NO X X X X Standard met? 0 X XX X X XButler Green HousePage 28 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? Bedrooms which were viewed during the inspection, were personalised, clean and attractively furnished and decorated. Service users had signed their care plans to confirm that they had been consulted about the furniture provided in their rooms, and that they had been able to choose which items they wished to have. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? The acting manager reported that a requirement made at the last inspection, regarding the regulation of the water temperature in communal toilets and bathrooms, had been addressed, and the contractors invoice was provided for inspection to confirm that the work had been carried out. The lighting in service users private accommodation was domestic in style. Bedrooms have central heating radiators that are controllable by the service users, and the radiators have guaranteed low temperature surfaces.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? Since the last inspection a designated toilet facility for the kitchen staff had been provided in accordance with the condition set down at the time of registration. Other requirements previously made in relation to this standard had also been addressed. At the time of the inspection the home was found to be clean and free from unpleasant odours. Service users confirmed that this was the normal standard of cleanliness within the home.Butler Green HousePage 29 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X 0 needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X 0 0 00 X X Standard met? 3Butler Green HousePage 30 Statistics to complete the above table were not collected on this occasion Staffing rotas provided for inspection indicated that there were sufficient numbers of staff on duty at that time to meet the standards set by the former regulating authority. The acting manager confirmed that staff providing personal care are over the age of 18, and those left in charge of the home were always over the age of 21. Service users who chose to speak with the Inspector expressed their satisfaction with the provision of care within the home. At the time of the inspection the home was found clean and free from offensive odours, which indicated that the number of domestic staff employed was sufficient.Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 3 8 2 Key findings/Evidence Standard met? The registered person should provide a minimum ratio of 50 of staff members with NVQ level 2 by 2005.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? Personnel files for staff continue to be held at the head office of the Social Services Department. Basic information regarding staff was available in the home, together with their training/ development file. The registered person must ensure that records are maintained in accordance with Schedules 2 and 4 of the Care Home Regulations 2001 and are available in the home for inspection.Butler Green HousePage 31 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? There was evidence that staff receive training to NTO standards, with an induction and foundation programme being completed within the first 6 months of their employment. It was reported that all staff receive a minimum of three paid days training per year.Butler Green HousePage 32 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 0 Key findings/Evidence Standard met? Since the last inspection the registered manager has left the home and in the interim the deputy manager has taken on the role of acting manager. Her qualifications include HNC in Social Care Management, and she is an NVQ Assessor. The inspector is aware that a permanent replacement for the manger was being recruited. Therefore this standard was not fully assessed during this inspection.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? As stated previously, the home did not have a registered manager at the time of the inspection (See standard 31). It was reported that a system of regular meetings for staff, and for service users was in operation. Staff were able to express their views and put forward ideas at their meetings, which were listened to by management. Observations made during the inspection indicated that management and staff worked well together as a team.Butler Green HousePage 33 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 2 Key findings/Evidence Standard met? The registered person had devised a quality monitoring system, but it had not been implemented at the time of the inspection. The acting manager has devised and implemented a system of checking procedures regarding admissions and assessments of service users needs, to ensure that all the necessary information has been obtained. The registered person must ensure there is a system of quality assurance and quality monitoring in place, in accordance with the standard and the regulations. Evidence was available to confirm that work was continuing to review the Local Authoritys policies, procedures and practices in the light of changing legislation. The registered person must ensure all policies and procedures are reviewed. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 2 Key findings/Evidence Standard met? A current certificate of insurance cover was displayed in the home. The previous requirement in relation to this standard had not been addressed, and it therefore remains outstanding. The registered person must ensure that a financial plan and a business plan and records of transactions in relation to the running of the home are available for inspection.Butler Green HousePage 34 Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence Standard met? Statistics for the above table were not collected on this occasion. 3 X X XThe personal allowance records in relation to 3 service users were selected at random for inspection and were found to be in order.Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? Many of the records seen were found to be up to date and had been correctly completed. Those where improvements were required have been noted previously when reporting on compliance with other standards, e.g., staff records, care plans /reviews. Reports of visits to the home made by the registered person in accordance with Regulation 26, are sent to the Commission for Social Care Inspection.Butler Green HousePage 35 Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? The acting manager reported that 14 members of staff had completed first training during the period February ­ April 2004. It was noted that it was excessively hot in the kitchen at the time of the inspection, and extractor fans are required to ensure that the room is properly ventilated. The registered person must ensure that the kitchen is properly ventilated at all times. An examination of the fire precautions records identified the following shortfalls: Means of escape from fire need to be inspected and recorded each week. Fire extinguishers need to be checked by a nominated person in the home once per month to ensure that access to them is not obstructed and they are readily available for use. Weekly tests of the fire alarm must be recorded. Various recording systems for recording tests and checks in relation to fire precautions were in use at the time of the inspection. It was recommended that all tests and checks in relation to fire precautions should be recorded in one book, preferably a fire log book which has been obtained from the local Fire Authority. The registered person must ensure that tests and checks in relation to fire precautions are carried out and recorded at the prescribed intervals. The Registered Person should ensure that all tests and checks in relation to fire precautions are recorded in the same book, preferably the book which has been obtained from the local Fire Authority. The following recommendation was made regarding food storage: The registered person should ensure that the food storage area, which is situated near to the kitchen toilet facility is enclosed.Butler Green HousePage 36 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateCarol Makin Keith LoweSignature Signature SignatureButler Green HousePage 37 Public reports It should be noted that all CSCI inspection reports are public documents.Butler Green HousePage 38 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on enter date(s) of inspection here and any factual inaccuracies: Please limit your comments to one side of A4 if possibleButler Green HousePage 39 Action taken by the CSCI in response to provider comments: Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 28/10/04, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required D.2Action plan was received at the point of publicationAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: enter details here Butler Green HousePage 40 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Butler Green HousePage 41 Butler Green House / 11th August 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000035532.V142420.R01© This report may only be used in its entirety. 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