Inspection on 16/03/04 for Butler Green House

Care Home For Older PeopleButler Green HouseWallis Street Chadderton Oldham OL9 8NGUnannounced Inspection16th March 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) Mrs Brenda Buckley 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 22nd December 2003 NO YES 5/02/04 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 316th March 2004 09:30 am Lisa Quirk N/A N/A N/AID Code149941Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at the time of inspectionN/A N/A Mrs B BuckleyButler Green HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection FindingsInspection Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/Good Practice Recommendations from this Inspection Part B: Inspection FindingsNational 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: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration (if applicable) Lay Assessors Summary (where 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 National Care Standards Commission (NCSC), 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 NCSC 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 NCSC 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 Report of the Lay Assessor (where relevant) Providers response and proposed action plan to address findingsThis 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.) Choice of Home (Standards 1-6) None of the two assessed standards were met at the previous inspection. Timescales set for compliance with requirements relating to standards 1 and 2 from the previous inspection have not yet lapsed. Health and Personal Care (Standards 7-11) None of the two assessed standards were met. Care plans were in good order and there was evidence of service user consultation and involvement in care planning. Dating of review records was not always evident and some risk assessments required updating. Policies and procedures should be reviewed in relation to the care of the dying. Daily Life and Social Activities (Standards 12-15) All of the four assessed standards were met. Service users expressed satisfaction with the daily routine and conduct of care staff within the home. Relatives and visitors were observed around the home throughout the inspection. Interactions between staff and service users were observed to be positive. Complaints and Protection (Standards 16-18) The one assessed standard was not met. One relative/visitor returned a comment card; they noted that they had not been made aware of the homes complaints procedure. One senior district nurse spoken to during the inspection commended the home for the quality of and approach to care. Environment (Standards 19-26) None of the four assessed standards were met. The accommodation is purpose built and attractively furnished. The home was clean and free from offensive odours. Timescales set for compliance relating to standards 21, 24 and 26 from previous inspection have not yet lapsed. Water tested in some communal toilets and bathrooms was too hot.Butler Green HousePage 6 Access to the sink in the laundry area was blocked. Staffing (Standards 27-30) The one assessed standard was not met. All other standards in this section were met at the previous inspection. Induction and training is taking place at the home covering the mandatory courses as laid out by the National Training Organisation. Management and Administration (Standards 31-38) None of the five assessed standards were met. The manager has recognised management qualifications and many years experience of care home management. She reported that she is in the process of finding out about enrolment onto the registered managers award. Timescales set for compliance with standards 33 and 34 have not yet lapsed. Storage of refrigerated and frozen foods can be improved.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. No. Regulation Standard Required actions Timescale for action 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 that documentation is consistently signed and dated. The Registered Person must ensure a designated toilet facility for the kitchen staff, is provided, in accordance with the conditions set down at the time of registration. The Registered Person must ensure that furniture and fittings in service users bedrooms are provided in line with the National Minimum Standards, subject to a risk assessment, or unless the service user requests that individual items are not required. The Registered Person must ensure that the arrangements for transporting laundry within the home meet with the Environmental Health Officers approval. Timescale not lapsed 1.04.0414OP125OP2Timescale not lapsed 1.04.04315OP7Immediate413, 16, 23OP21Timescale not lapsed 1.06.04513, 16, 23OP24Timescale not lapsed 1.04.04613, 16OP26Timescale not lapsed 1.04.03Butler Green HousePage 8 STATUTORY 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. No. Regulation Standard Required actions Timescale for action 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. 8 17 Schedules 3&4 16 OP37 The Registered Person must ensure records required by legislation are maintained and made available for inspection at all times. The Registered Person must ensure that food is always effectively resealed after opening. The Registered Person must ensure that accident records include details of the injuries to service users or the actions taken to minimise the risk to other service users.724, 10, 12OP33Timescale not lapsed 1.04.03Immediate9OP38Immediate1017, 37OP38ImmediateAction is being taken by the National Care Standards Commission 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 Standard 1 2 OP28 OP31 The Registered Person should ensure that at least 50 of the care staff holds an NVQ by 2005. The registered manager should obtain a qualification at NVQ Level 4 (Registered Managers Award) by 2005.Butler Green HousePage 9 CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). The registered person must ensure a designated toilet facility for kitchen staff is provided by 1.06.04 The registered person must ensure all staff receive first aid training by 31.05.04Met (Yes / No) timescale not lapsed timescale not lapsedButler Green HousePage 10 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 and recommendations are to be addressed with the timescale 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. No. Regulation Standard * Requirement Timescale for action 1 13(2) OP9 The registered person must ensure that all medication retained within the home is stored at the appropriate temperature. The registered person must ensure that medication administration records are signed contemporaneously and accurately. The registered person must ensure that the receipt, administration and disposal of controlled drugs are recorded accurately and contemporaneously in a controlled drugs register. The registered person must ensure that the temperature of the medicines refrigerator is recorded daily on a maximum/minimum thermometer and that staff members understand the action to take if the temperature recorded is outside the normal range. The registered person must ensure that the dosages of any medication which is administered differently to the labelled directions, should be confirmed with the service users GP and the prescriptions altered accordingly. 30/03/04217(1)(a)OP915/05/04317(1)(a)OP915/05/04413(2)OP931/05/04513(2)OP931/05/04Butler Green HousePage 11 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. No. Regulation Standard * Requirement Timescale for action The registered person must ensure that medication is only administered to service users from containers which have been dispensed by a pharmacist or dispensing doctor.613(2)OP930/06/04713(2)OP9The registered person must ensure that the medication policy is updated to reflect the individual requirements and procedures of the home and expanded to include the ordering 30/06/04 and receipt of medication, the administration of controlled drugs and the action to take if a medication administration error is identified. The registered person must ensure that the self-administration policy and risk assessment framework are expanded and developed in 30/06/04 order to protect the health and safety of service users who wish to administer their own medication. The registered person must ensure that an accurate individual record is made of the administration of each medication. The registered person must ensure that hot water is not delivered above a temperature of 43°C. The registered person must ensure that staff handling laundry have unrestricted access to hand washing facilities in the laundry area. The registered person must ensure that frozen and refrigerated food is labelled and dated. The registered person must ensure that the homes cats do not have access to the main food preparation areas. Immediate 30/06/04813(4)(c)OP9917(1)(a)OP91013(4)OP251113(3)OP261213(4)(c)OP38Immediate1313(3)OP38ImmediateButler Green HousePage 12 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) No. Refer to Good Practice Recommendations Standard * 1 OP9 The registered person should take action on the pharmacists good practice recommendations. The registered person should review the homes procedure in relation to the use of emergency medical services in conjunction with local GPs and the Coroner.2OP11* Note: You may refer to the relevant standard in the remainder of the report by omitting the twoletter prefix, e.g., OP10 refers to Standard 10.Butler Green HousePage 13 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 NO YES NO YES YES YES NO YES 7 2 0 NA NA YES YES X 0 16/03/04 09:30 5Butler Green HousePage 14 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards for Care homes for older persons 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 15 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 (£) X To (£) XAny charges for extras If yes, please state what the extras are: Key findings/EvidenceYES Standard met? 2The manager reported that details of the range of fees were held at head office. Amendments are still required to the statement of purpose and service user guide to fully comply with the Regulations and Standards. The registered person must ensure that the statement of purpose and service user guide are provided in accordance with the Regulations and National Minimum Standards.Butler Green HousePage 16 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 recently been provided for new service users. They were not however consistently provided on the day of admission and signed by all relevant people involved. 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. 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection.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. 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection.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. 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection.Butler Green HousePage 17 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. 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection.Butler Green HousePage 18 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 files that were selected contained detailed care plans. These had recently been reviewed and signed by service users and staff. Dates of reviews were not consistently recorded on forms. One care plan viewed held records of detailed assessments from a speech therapist but did not contain an updated risk assessment relating to an increased risk to the service user identified in the report. The registered person must ensure that care planning documentation is consistently signed and dated. The registered person must ensure that risk assessments are developed for service users when new areas of risk are identified.Butler Green HousePage 19 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. Number of incidents where service users have been taken to Accident and Emergency during last 12 months Number of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence This standard was not fully assessed at this inspection.X 1 0Standard met?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. 1 Key findings/Evidence Standard Met? A pharmacist inspector assessed this standard on 25th March 2004. A letter detailing good practice recommendations has been sent to the home. Butler Green House possesses a medication policy which has been produced by the Local Authority. The medication policy refers to the practice of secondary dispensing by staff. Medication should never be secondary dispensed for someone else to administer to the service user at a later time or date. The medication policy does not cover the administration of controlled drugs or the action to be taken if a medication administration error is identified. Intermediate care service users are encouraged to manage their own medication wherever possible. Service users are assessed as to their ability to do so before medication is provided to them. However, the self-administration policy and risk assessment framework are minimal and requires development in order to protect the health and safety of service users. On the day of inspection the Inspector found four items of medication which required storage at room temperature stored in the medication refrigerator and one item of medication which required storage in the refrigerator stored at room temperature. Medication requiring refrigeration is stored in a dedicated secure refrigerator. The temperature of this refrigerator is not currently recorded.Butler Green HousePage 20 If a service user is unable to organise a monitored dosage system before admission to the continuing care section, a manager at the home currently dispenses the service users medication into a weekly compliance aid for carers to administer. The Inspector was informed that this practice will cease on 7th April 2004, when the new pharmacist filled Venalink system, which has recently commenced on the intermediate care section, will be extended across the home. Guidelines produced by the Royal Pharmaceutical Society state that medication should never be removed from the original container in which a pharmacist or dispensing doctor supplied it until the time of administration. On examination of the medication administration record charts for intermediate care service users for the period 22nd to 24th March 2004 inclusive, the Inspector discovered nine occasions where medication had not been signed as being administered. The medication administration charts used for intermediate care service users currently do not provide an accurate record of the time that medication is administered and they are not signed to show the administration of individual medication. The Inspector was informed that the new medication system due to commence on 7th April 2004 will ensure that an accurate record of the time of each medication administered is maintained. On examination of the medication administration records, the Inspector found that the Salbutamol inhaler for a service user was not being administered as indicated in the printed directions. On examination of the controlled drug register, the Inspector found a previous discrepancy between the actual stock level of an item and the balance recorded in the register. This discrepancy indicates that staff members are not checking the balance of medication at each administration. Nine requirements have been made in respect of this standard. 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 inspectedButler Green HousePage 21 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. 2 Key findings/Evidence Standard met? A comment card was received from a local GP practice that expressed concerns about the procedures at the home when a service user dies. The homes policy relating to care of the dying was reviewed and it is unclear about the steps that should be taken if a GP is unable to visit to certify an expected death but does not issue further instruction to the home. The registered person should review the homes procedure in relation to the use of emergency medical services in conjunction with local GPs and the Coroner.Butler Green HousePage 22 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? Information gathered during discussions with service users indicated that this standard is being met.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, they confirmed that their relatives and friends were able to visit when they wished and that they were made welcome. During the inspection visitors were observed throughout the home. 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. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Butler Green HousePage 23 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? Seven service users reported favourable comments about the food. Service users were observed having breakfast at varying times during the morning. A variety of hot and cold drinks are on offer throughout the day.Butler Green HousePage 24 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 timescales 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 NCSC Percentage of complaints responded to within 28 days Key findings/Evidence 0 0 0 0 0 0 X 3Standard met?A senior district nurse spoken to during the visit commended the home for the care provision and atmosphere at the home. One relative/visitor comment card received reported satisfaction with the overall level of care but commented that he/she had not been made aware of the homes complaints procedure.Butler Green HousePage 25 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 at this inspection.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 Key findings/Evidence This standard not fully assessed at this inspection. Standard met? YES 0 0Butler Green HousePage 26 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 inspected at this inspection.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. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Butler Green HousePage 27 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 timescale set for requirements to meet this standard have not yet lapsed. The registered person must ensure a designated toilet facility for the kitchen staff is provided in accordance with the condition set down at the time of registration. 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. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Butler Green HousePage 28 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 met at the previous inspection. YES NO NO 0 39 0 0 Standard met? 0 39 00 0 0 0Butler Green HousePage 29 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. 2 Key findings/Evidence Standard met? The registered person must ensure that furniture and fittings in service users bedrooms are provided in line with the National Minimum Standards, unless the service user requests that individual items are not required. The timescale set to meet this requirement has not yet lapsed. 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. 1 Key findings/Evidence Standard met? Water temperatures tested around the home highlighted some problems with the water supply in communal toilets and bathrooms. The registered person must ensure that hot water is not delivered above a temperature of 43°C. 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. 2 Key findings/Evidence Standard met? During the inspection, access to the sink in the laundry area was blocked by boxes and racks of freshly laundered clothes. Care staff who worked in the laundry could not get to the sink tow ash their hands without moving the boxes or the clothes. To prevent the risk of cross-infection, the registered person must ensure that staff handling laundry have unrestricted access to hand washing facilities in the laundry area. At the time of inspection the home was clean and free from offensive odours. The timescale to meet further requirements for this standard has not yet lapsed.Butler Green HousePage 30 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 This standard was not inspected. 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? 0Butler Green HousePage 31 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 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 Key findings/Evidence 3 8 Standard met? 2The 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. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.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. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.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. 2 Key findings/Evidence Standard met? The manager has a certificate in social services and a certificate in management studies, in addition to many years experience at senior level. The manager is a qualified NVQ assessor and holds D32/D33 and A1 awards for this purpose. The registered person should obtain the Registered Managers Award by 2005. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed during the inspection.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? There was no quality assurance or quality monitoring system in place, but the manager reported that work was in progress at Head Office to develop a system to meet this standard. The registered person must ensure that there is a system of quality assurance or quality monitoring in place. Feedback must be sought from service users, their representatives and other stakeholders from the local community. Such views must be published and made available to current and prospective service users, their representatives and the NCSC. The registered manager must ensure all policies and procedures are reviewed. Timescales to meet requirements relating to this standard have not yet lapsed. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? The manager is a budget holder and detailed records of accounts are kept at the home. These were in order.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 This standard was not inspected. Standard met? 0 X X XStandard 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 inspected.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? Records required by regulation do not meet fully with this standard. In particular, those in schedule 2, which are not retained at the home and numbers 8, 1 and 2 of schedule 4. The registered person must ensure records required by legislation are maintained and made available for inspection at all times.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? During the inspection of the main kitchen and food storage areas it was noted that one of the homes cats was in the kitchen. Food in fridges and freezers was labelled but many items were not dated. Dry stores were located in sealed containers and the general area appeared clean and free from spillages. The registered person must ensure that frozen and refrigerated food is labelled and dated. The registered person must ensure that the homes cats do not have access to the main food preparation areas.Butler Green HousePage 36 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateL Quirk J Robson K LoweSignature Signature SignatureButler Green HousePage 37 PART D(where applicable) Not applicable.LAY ASSESSORS SUMMARYLay Assessor Date Public reportsN/A N/ASignatureN/AIt should be noted that all NCSC inspection reports are public documents.Butler Green HousePage 38 PART EE.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 16th March 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleButler Green HousePage 39 Action taken by the NCSC in response to provider comments: Amendments to the report were necessary NOComments 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 accurateNONote: 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 19th May 2004, 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. E.2 Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction 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 planYESOther: enter details here Butler Green HousePage 40 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.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 E.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 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!