Inspection on 05/02/04 for Butler Green House

Care Home For Older PeopleButler Green HouseWallis Street Chadderton Oldham OL9 8NGAnnounced Inspection5th February 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 NA 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 35th February 2004 09:15 am Carol Makin N/A N/A N/AID Code074703Name 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 Brenda 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 areas 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 announced inspection took place on 5th February 2004. It is the first inspection since the home was registered on 22nd December 2003. It was found that the majority of the assessed standards had been met or partially met, and that the overall quality of care provided was good. Service users who chose to speak with the Inspector expressed satisfaction with the care they were receiving. Choice of Home (Standards 1-6) Four of the six assessed standards were met. The manager did not have information regarding the range of fees, which she reported was held at head office. A statement of purpose and a service users guide were available for inspection, but required further work to meet fully with the standard. A statement of terms and conditions is required for all service users. Assessments of service users individual needs were in place. Training in specialist needs and ethnic difference is available to staff. Health and Personal Care (Standards 7-11) Three of the four assessed standards were met. Care plans and risk assessments were in place, and regular reviews of care needs were carried out. There was documentary evidence to show that service users or their representative had been involved in completing the care plan. The health care needs of service users are well documented and service users have access to the full range of health service professionals. Daily Life and Social Activities (Standards 12-15) All four of the assessed standards were met. Service users confirmed that their relatives and friends were able to visit when they wished, and that they were made welcome by the staff. They also expressed their satisfaction with the food provided, and said that their rights to privacy and dignity were respected by the staff at Butler Green House. Complaints and Protection (Standards 16-18) All three of the assessed standards were met. A complaints procedure was in place. All service users are entered onto the electoral register on admission and voting can take place either in person or by postal vote.Butler Green HousePage 6 Training in the procedures and protocols, concerning the protection of vulnerable adults has been undertaken by the staff. Environment (Standards 19-26) Five of the eight assessed standards were met. The accommodation is purpose built. The communal areas presented as being attractively furnished and decorated. There are several small lounge areas and a large open plan sitting area to the front of the building. All bedrooms are single occupancy and the furniture and lighting was domestic in style. The grounds are fully accessible to the service users. There are no en-suite facilities. New laundry equipment had recently been provided to meet with current standards. The manager reported that arrangements were in hand to provide separate toilet facilities for kitchen staff, to meet the required standards. Staffing (Standards 27-30) One of the three assessed standards was fully met. Information provided for inspection indicated that the staffing levels at the time of the inspection met with the standards. 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. There was evidence that the appropriate Criminal Records Bureau checks are made before potential staff are offered a post at the home. A staff training programme is in place to meet with NTO Work Force Training targets. Management and Administration (Standards 31-38) Three of the eight assessed standards were met. The manager has a certificate in Social Services and a Certificate in Management Studies in addition to many years experience at a senior level. Staff meetings are held at regular intervals, in addition to monthly service users meetings. There was no quality assurance or quality monitoring scheme in place at the time of the inspection. On the day of the inspection the manager was unable to evidence any business and financial planning. Where service users monies are held for safekeeping, appropriate records are retained. Records required by regulation do not fully meet the standard. The Local Authority provides training in health and safety matters. A programme was in place to provide first aid training for 35 members of staff by the end of April 2004.Butler Green HousePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNASTATUTORY 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 actionAction 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 StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). The registered person must ensure a designated toilet facility for the kitchen staff, is provided by 1/6/04. The registered person must ensure all staff receive first aid training by 31/5/04.Met (Yes / No) timescale not lapsed timescale not lapsedButler Green HousePage 8 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 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.14OP11.4.0425OP21.4.04315OP7Immediate413, 16, 23OP21The Registered Person must ensure a designated toilet facility for the kitchen staff, is 1.6.04 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 1.4.04 assessment, or unless the service user requests that individual items are not required.513, 16, 23OP24Butler Green HousePage 9 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 6 13, 16 OP26 The Registered Person must ensure that the arrangements for transporting laundry within the home meet with the Environmental Health Officers approval. 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 25 17 Schedules 3&4 16 OP34 The Registered Person must ensure that a financial plan and a business plan are available for inspection. 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. 1.4.041.4.04724, 10, 12OP331.4.041.4.049OP37Immediate10OP38Immediate1117, 37OP38ImmediateButler Green HousePage 10 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 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.* 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 11 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 YES YES YES NO NO NA YES YES YES NO YES YES YES YES YES YES YES YES 8 2 0 NA NA YES YES X 0 05/02/04 9.15 10Butler Green HousePage 12 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 13 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. The statement of purpose and the service user guide were available for inspection. Further amendments were required for these documents to fully comply with the Regulations and the standards. 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 14 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. 3 Key findings/Evidence Standard met? Full assessments of needs were available in individual care files. Assessments are carried out initially by social workers in addition to senior staff prior to admission. Care plans are devised based on the assessments.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. 3 Key findings/Evidence Standard met? It was reported that all the staff have training and development assessments. Training in specialist needs, sensory impairment, dementia awareness and ethnic difference is available to the staff. The manager stated that the home accommodated older people and older people with physical disability and/or sensory impairment. They did not offer care to older people with mental health problems. The intermediate care unit accommodates older people who have previously been coping at home and have recently experienced an acute episode which is potentially reversible. The provision of intermediate care is a jointly funded scheme with care provided by staff in the home. Information gathered from records, and interviews with management and staff during the inspection indicated that the collective skills and experience of the staff were appropriate to deliver the care and services which the home offers to provide.Butler Green HousePage 15 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? All prospective service users are visited by the senior staff at their current situation and are invited back to the home before making a decision to enter the home. Any emergency admissions are through the Social Services Department. The associated paperwork is made available to the service user within the timescale. 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 fully meet with the standards.Butler Green HousePage 16 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 which were selected for inspection contained a comprehensive care plan and risk assessment setting out the action that needs to be taken by care staff to ensure assessed needs are being met. There was evidence that care plans are drawn up in conjunction with service users and/or their representative, but dates were not consistently recorded. The specific date of reviews needs to be recorded rather than the month of when the review was carried out, and there was inconsistency regarding the signing and dating of some other documentation by staff, (e.g., risk assessment, care plan). The Registered Person must ensure that care planning documentation is consistently signed and dated.Butler Green HousePage 17 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/Evidence3 1 3Standard met?The service users health care needs were well 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. Service users have access to hearing and sight tests and chiropody is available via the NHS. In discussions with community nurses during the inspection, and in questionnaires returned to the National Care Standards Commission by other health care professionals, the response was very positive regarding the service provided at Butler Green. 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. 0 Key findings/Evidence Standard Met? This standard was not fully assessed on this occasion.Butler Green HousePage 18 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. 3 Key findings/Evidence Standard met? All staff are instructed in their induction period on how to treat service users and maintain their dignity. Medical treatments are carried out in service users own rooms. There are no shared rooms at Butler Green House. In discussions with service users during the inspection, they confirmed that their rights to privacy and dignity were respected by the staff. 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. 3 Key findings/Evidence Standard met? It was reported that service users could remain at Butler Green House, whilst their needs were able to be met in conjunction with the district nursing service. Policies and procedures concerning the management of death and dying are in place.Butler Green HousePage 19 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 was 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 by the staff.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? It was reported that the service users manage their affairs with the assistance of their family or solicitor. There is a policy and procedure concerning the management of service users personal allowances. Where monies are retained on behalf of the service users by the management, records and receipts of all expenditure are retained. The manager stated that Age Concern continues to provide an advocacy service.Butler Green HousePage 20 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 food and drinks which are provided at the home.Butler Green HousePage 21 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?The complaints procedure has been amended and is made available to service users. A log is kept, but none had been made in the last 12 months. There was evidence of numerous compliments made regarding the service provided at the home.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. 3 Key findings/Evidence Standard met? All service users are entered onto the electoral register on admission. They are enabled to exercise their right to vote either in person or by post.Butler Green HousePage 22 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 Standard met? YES 0 3The manager reported that all staff had now received training in the procedures and protocols concerning the protection of vulnerable adults, as provided by the Local Authority. She further stated that regular two day courses are provided which enable new staff to receive this training. Written procedures are in place and the manager was aware of the requirements concerning the protection of vulnerable adults.Butler Green HousePage 23 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. 3 Key findings/Evidence Standard met? The layout and location of the home appeared suitable for the stated purpose. It was reported that the building complied with the Fire Service and the Environmental Health Department. Minor works and repairs are contracted out by the Local Authoritys Building Works Department. The grounds are also maintained by the Local Authority. The manager reported that officers from the council had carried out an assessment of the maintenance and renewal of the fabric and redecoration which was required in the home and a programme of refurbishment had subsequently been carried out. The accommodation provided for service users looked bright and comfortable and was attractively furnished and decorated.Butler Green HousePage 24 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. 3 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. All bedrooms are single occupancy and are above the minimum standard size. The lighting and furniture were domestic in style. The grounds are fully accessible to the service users and appropriate garden furniture is available. 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? There are no en-suite facilities at Butler Green House. 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 which was a particular issue for those with a walking aid or wheelchair. The manager reported that arrangements were in hand for the installation of a separate toilet for the use of kitchen staff, by 1st June 2004, in accordance with the conditions of registration. 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. 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. 3 Key findings/Evidence Standard met? An occupational therapist is employed on the intermediate care unit and is available to offer advise elsewhere in the home. There are also aids and adaptations to meet the assessed needs of the service users.Butler Green HousePage 25 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 YES NO NO 0 39 0 0 Standard met? 3 39 00 0 0 0It was reported that all the bedrooms are 13 square metres and, as such, fully meet the standard.Butler Green HousePage 26 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 service users are encouraged to personalise their rooms and this was evident on the day of the inspection. Within each room there is a lockable facility with the key left in-situ for use by the service user. The bedrooms did not all have all the furniture required by the National Minimum Standards. It was recommended that each service user should be asked if they wanted all the furnishings identified in the National Minimum Standards, and, if not, a record should be kept of their choice. 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. 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? All bedrooms have central heating radiators that are controllable by the service users. The radiators have guaranteed low temperature surfaces and there is no exposed pipe-work. Water storage is monitored for Legionella and checked by the Local Authoritys Building Services. It was noted that emergency lighting was in place in communal areas and corridors but not in individual bedrooms.Butler Green HousePage 27 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? It was reported that only personal clothing is laundered in-situ, with bed linen, towels, etc., sent to an external contracted laundry. There is no dedicated laundry worker. Access to the laundry is via areas where service users are eating or relaxing. The manager reported that to address the health and safety issues which this poses, she has obtained `wheelie bins for transporting laundry through these areas. She was requested to contact the local authority environmental health officer to seek confirmation that the matter has been satisfactorily addressed. The senior staff have completed training in infection control. New laundry equipment has been obtained which complies with accordance with Water Supply (Water Fittings) Regulations 1999. The registered person must ensure that the arrangements for transporting laundry within the home meet with the Environmental Health Officers approval.Butler Green HousePage 28 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 00 0 00 X X Standard met? 3Statistics for the above table were not collected on this occasion. On this inspection staffing levels were measured against the standards of the previous regulating authority. Information provided for inspection indicated that the staffing levels at the time of the inspection met with those standards.Butler Green HousePage 29 Adequate catering staff are employed but there are no dedicated staff for the laundry. It is the duty of the care staff to ensure the laundry is completed each day. At the time of the inspection the home was found clean and free from offensive odours, which indicated that the number of domestic hours provided 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 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 trained members of staff to NVQ level 2 standard 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. 3 Key findings/Evidence Standard met? Personnel files for staff are 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 manager reported that the local authoritys policy regarding recruitment and selection was in accordance with this standard. There was evidence that the manager is informed when satisfactory Criminal Records Bureau checks have been received. She reported that agency staff are employed until the Criminal Records Bureau checks have been obtained for staff awaiting appointment. A code of conduct and practice set by the General Social Care Council was available.Butler Green HousePage 30 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? All staff receive training to NTO standards with an induction programme within six weeks of appointment. All staff receive a minimum of three paid days training per year.Butler Green HousePage 31 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 a senior level. The manager is required to undertake additional training to obtain NVQ level 4 (Registered Managers Award). The registered manager should obtain a qualification at NVQ Level 4 (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. 3 Key findings/Evidence Standard met? The manager arranges full staff meetings and smaller team meetings at regular intervals. Staff reported that they found the meetings to be beneficial and provided a forum for airing their views and putting forward ideas, which were also acted upon by management. Leadership by the managers was reported to be good, as was the team-work amongst the staff. Service users and their representatives are able to meet together at monthly intervals with a member of staff chairing the meeting.Butler Green HousePage 32 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 manager stated that work was in progress 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 that 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 office. A business and financial plan were not available in the home for inspection. The registered person must ensure that a financial plan and a business plan are available for inspection.Butler Green HousePage 33 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? 3 5 0 0Where service users monies are retained for safekeeping, the appropriate records with receipts of all expenditure are maintained. Secure facilities and records are available for valuables held on behalf of the service users.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. 3 Key findings/Evidence Standard met? There is a supervision policy and all staff have recorded formal supervision at least six times a year.Butler Green HousePage 34 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 establishment 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. There is a published policy concerning service users right to access information held in them. Reports of visits to the home made by the Registered Person in accordance with Regulation 26, are sent to the National Care Standards Commission and are available in the home. 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 Local Authority provides mandatory training on safe working practices to staff in care homes. The programme includes moving and handling techniques, fire safety, infection control, health and safety procedures and food hygiene. The manager reported that arrangements were in hand for training in first aid to be provided for staff by the end of April 2004, in accordance with a requirement of registration. A written programme was provided for inspection to confirm that 35 members of staff are listed for first aid during the period 5th February to 27th April 2004. There are contracts with two relevant departments within the local authority to maintain equipment and services in the approved manner. During an inspection of the kitchen and food storage areas it was noted that food was not always effectively resealed after opening. The Registered Person must ensure that food is always effectively resealed after opening. New accident report forms, which are required to ensure confidentiality, were in use in the home. The management of the home felt that the format of the new forms was not entirely appropriate for use in residential care homes. Areas where improvements were required in recording, were discussed with the manager, and the following requirement was made: 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. Butler Green House Page 35 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateC Makin K LoweSignature Signature SignatureButler Green HousePage 36 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 37 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 5th February 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleButler Green HousePage 38 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. E.2 Please provide the Commission with a written Action Plan by 2nd April 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. 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 39 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 40 - 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. 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