Inspection on 12/05/08 for Byker Hall

This inspection was carried out on 12th May 2008.

CSCI found this care home to be providing an Poor service.

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

Other inspections for this house

Byker Hall 27/10/08

Byker Hall 26/06/07

Byker Hall 29/06/06

Byker Hall 05/12/05

Byker Hall 22/04/05

Byker Hall 09/12/04

Byker Hall 27/07/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Byker Hall Allendale Road Byker Newcastle Upon Tyne NE6 2SB Lead Inspector Suzanne McKean Key Unannounced Inspection 09:30 12th May, 27 May & 20th June 2008 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Byker Hall Address Allendale Road Byker Newcastle Upon Tyne NE6 2SB Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0191 224 0588 0191 276 3080 Byker.Hall@fshc.co.uk www.fshc.co.uk Tamaris Healthcare (England) Ltd Manager post vacant Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48), Physical disability (5) of places Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 5 service users can be admitted in the category PD aged 50 years plus. 26th June 2007 Date of last inspection Brief Description of the Service: Byker Hall Care Home is purpose built and is situated in a residential area of Byker. The site is shared with another home owned by the same company. The Home is within easy reach of shops, public transport and all other amenities. Byker Hall provides general nursing care for up to 49 older people in single en-suite rooms. The home has communal lounges, dining rooms and smoking rooms on each floor. The laundry and kitchen areas are on the lower ground floor, from resident areas. All areas of the home are accessible and a passenger lift services all floors. Externally there is a garden and patio area and there is ample car parking. The home charges fees of between £355 and £505 per week depending upon the needs and requirements of the individual residents. As the home provides nursing care the free nursing care element of the funding is provided in addition to the costs charged to the resident. The home provides information about the service through the service user guide. A copy of the last inspection report from The Commission for Social Care Inspection is available in the entrance to the home. Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. How the inspection was carried out:Before the visit: We looked at: • Information we have received since the last visit on 26 June 2007. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 12th May 2008 and further visits were made on 27th May and 20th June 2008. A visit was also carried out by a specialist pharmacy advisor on 16th June 2008. During the visit we: • • • • • • Talked with people who use the service, relatives, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building/parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the acting manager and regional manager what we found. What the service does well: The company have reacted well to address the issues that have been raised as part of the inspection process and from professionals involved in the home. Senior managers are working in the home to support the new manager in making the improvements necessary. Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 6 The residents were very positive about the staff said that they work hard to help them, particularly the improvements that have been made in the social activity opportunities. Residents said that the staff were “lovely” and that they felt that they “worked hard and were friendly”. There was a homely, pleasant atmosphere in the home by the final visit and staff were positive about he changes taking place. What has improved since the last inspection? What they could do better: The home must have an effective manager to improve the standards and to make sure that there is effective leadership in the day to day management of the home. This will also improve the standard of the care being given and support residents to have a good quality of life taking into account their views and choices. The staff must be supported so that they can feel confident that they will be able to meet the needs of the residents in a professional and effective way taking into account good practice principles. Specific improvements are necessary including: • Improving the quality of the care planning and keeping records in line with the Company’s policies and procedures. Including the information prior to admission. • Improving the care delivered and making sure that the health and welfare of the residents is centred on the person. • Review how the way medication is managed and improving the records kept. • Look at how complaints are handled and review the way they are recorded. Make sure that the outcome and action taken is clearly recorded. • For senior staff to follow adult protection procedures so that residents are protected. • Undertaking a programme of redecoration, re-carpeting and replacement of furniture in the bedrooms, communal areas and bathrooms, so that resident live in a pleasant and safe environment. • Review staffing levels and providing training and supervision for them so that staff working in the home have the skills to do their job. • Making sure that there are record of the health and safety monitoring taking place. Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6 (the home does not provide intermediate care) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents cannot be fully confident that they will have their needs met by the home, as the although the assessments carried out they are not always consistent and in sufficient detail. EVIDENCE: The company has very detailed assessment tools that are expected to be used prior to a placement being offered to a perspective resident. Care plans showed that although these assessments were starting to be used the actual assessments were not consistently of a good enough standard. Also where a need, in one case for particular pressure relieving mattress, had been identified. This had not been effectively communicated to the nursing team or the equipment sourced prior to, or soon after, the admission. This Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 10 resulted in a period of time when the resident did not have appropriate equipment in place. It is acknowledged that management and staffing changes had been made by the time of the last visit of the inspection and this had resulted in an improvement in this area of care. Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There have been some recent improvements to the way care is given. However prior to this there was poor communication and leadership which resulted in the care not being given effectively and the care planning being inconsistent and not showing the changing needs of the residents. EVIDENCE: All residents have a care plan which includes an assessment of their needs and a plan of how these should be met. Some were up to date and contained information necessary to care for the residents safely. However some of these were not completed in sufficient detail to show the changing and complex needs of the residents. Not all of the care plans were up to date. The Four Seasons documentation includes a variety of risk assessments for prevention of falls, wound care, and moving and assisting as well are Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 12 assessment tools for clinical areas such as continence promotion. These had been completed to a varying standard and did not always reflect the health or social care needs of the residents in sufficient detail. There is an also assessment and care plan to look at the way individual residents wounds are managed these were not fully up to date. Discussion with the NHS tissue viability specialist advisor confirmed that wound management was not always as she had advised. Communication between the nursing team was poor and this had resulted in them not being aware of the current advice when they were carrying out dressings. The care plans were not detailed enough to assist the nursing staff who had not been around at the time o the specialist advisor visit to find out what was required. During the first visit there was a peripatetic manager in place and she was clear that she felt that there were improvements necessary. She had begun a process of audit of the care plans and there was evidence that these had been started. She was no longer in the home by the last visit and had been replaced by another who showed a clear understanding of how the improvements must be made. He was being well supported by the regional manager for the company. The care plans are not fully person centred, however during the period of the inspection additional resources had been allocated to the home to make sure that all staff are training effectively in care plan development and maintenance. A member of the nursing team had carried out an audit of the care plans and had developed an improvement plan. Residents access NHS services and facilities as necessary. The care plans showed that specialist advisors are used for individual residents. The home liaises with the General Practitioners who provide care to the residents. The care was being given by staff who were pleasant and courteous and number of residents were enjoying the staffs company. Generally, the staff were friendly toward the residents and were attempting to engage them in conversation. Residents said that they felt well supported by the staff an example in on of the surveys was “the staff have always been very warm, considerate and attentive”. The care plans show that the personal and health care needs of some of the residents are being met. However the care being delivered to some of the more poorly residents was not adequate, residents who were being cared for in their rooms were left for long periods without any stimulation or personal contact. By the time of the last visit to the home new management arrangements had been put into place and this showed some general improvement. The new manager, who is placed in the home temporary basis was aware of the Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 13 problems and had begun to make the necessary improvements. He was involving himself in the clinical needs of the residents and had ensured that there were nurses in the home who would be able to provide more consistent care. Additional resources had been put in place and a number of nurses had been brought from other homes to assist in making the necessary improvements. There was a limited set of medicines policies in the home (Four seasons dated March 06), and there was no record of who had read them. Ordering was controlled by the Home and photocopies of prescriptions were kept alongside MAR charts. Blister packed medicine is returned to pharmacy at end of month but other medication were not and no carried over figure was transferred onto new MAR chart making audit difficult. Good waste medicine records were available. The ground floor storage was appropriate. The fridge had min/max thermometer but only one temp recorded, there was no record of the room temp. The first floor treatment room is used to store all spare medication, liquid feeds, and controlled drugs. There were good records of room temperature. Min/max temperature had been recorded but the max temperature was recorded as 10c since 4/6/08 and no action had been taken. Therefore medication was being stored above the recommended 2-8 degree C. In both fridges inappropriate drugs were being stored in the. Cans of drink were stored in the fridge on the ground floor. The medicine trolley in use downstairs was very full. There was a large stock of nutritional supplements and liquid feeds and some were out of date. The controlled drugs cupboard was small for the amount of stock. Records were kept in a bound book. All stock balanced with the register on the day. Entries were difficult to read and in some cases did not match with entries on MAR charts. Medication was administered to people in the dining room and to some people in their own rooms. Medicine pots were available on the trolley for the medicine round a tablet crusher was also on the medicine trolley on each floor but these were not being used (both were unclean and unlabelled). One resident had been assessed for self- medication and this was reviewed on a monthly basis and records were kept in her Care Plan. She was waiting for appropriate storage to be provided. MAR charts in use started on 16/6/08. Pharmacy supply date was 12/6/08. Because the MAR charts in use were on the first day the MARs looked at were from the previous cycle with start date 19/5/08. Charts for both floors were looked at MAR folder dividers all had photographs and allergies recorded. The date of opening was on all liquid medication open in the trolley but there was no date of opening on some, which must be used within 6 weeks after Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 14 opening. There was a spray in downstairs trolley with no name or pharmacy label. There was a signature sheet for the person administering medication however one nurse signed A which looked very similar to the A (refused code on the MAR chart. There were good records for 3 residents on Warfarin and recent results and current dosage regime was available in yellow book along with MAR chart. The records for a diabetic resident also had BM recordings stored along with MAR chart. Handwritten entries were poor quality, none were countersigned, some were completely unsigned and very few had starting quantities of stock recorded. Stock was balanced against old MAR record and returns record made at the end of last medication cycle. When the boxed stock was checked on the ground floor trolley against current MAR charts only one dose given stock in many cases could not be balanced. Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are improved opportunities for the residents to take part in meaningful activities and keep control of everyday decisions. This supports people to lead full and active lives. EVIDENCE: The staff described how they try give residents ways of taking control of their daily routines, in simple but important ways for example the time they get up, what and when they eat and how they spend their time. Staff confirmed that they assist residents to make choices about how they spend their day, however the lack of leadership and reduced staffing numbers results in poor choices and the care being task led. The home employs an activities co-ordinator however due to staffing shortages in the recent past she has not always been able to carry out her duties in this role. She has been covering for domestic or care duties. She has started to develop the social activities programme of activities offering differing Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 16 opportunities. This is now more developed to offer individualised activities for the residents in line with their social assessment. However it has significantly improved and the residents were happy with the way this was progressing. The dependency level of some of the residents means the activities on offer need to be less active and provided on a more one to one basis. The records of the activities provided are not yet in sufficient detail, and need to be developed further to show the full extent of the things going on in the home. The staff involved is working towards achieving this. Residents have visitors at any time and are able to use their own rooms, the small lounges or the larger, busier lounges to receive them. Relatives are given information within the residents’ guide about visiting arrangements. Residents said they were satisfied with the arrangements for visitors and that staff welcome them. During the visit the main meal was reasonably well organised however there have been examples of residents becoming verbally aggressive toward each other and this has resulted in some it not always being a good experience for residents. The views of the residents were varied both from surveys and during the visits, some described the food as “very good” but some were not happy with the choices particularly at the “tea time” meal. One person said that she felt that her particular needs were not being met. This has been a problem in the past when people needed a specialist diet however there is evidence that this has since improved. Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints and safeguarding issues are generally well managed but individual staff have not always followed the homes guidance and may leave people at risk of harm. EVIDENCE: The company’s complaints procedure is available in the service users guide and a copy is available at the front entrance and is displayed in the home. The records of the complaints were examined. There is some evidence that concerns were being raised by relatives and staff, which were not considered through the complaints process. Although staff were trying to resolve them at a very local level they were not being recorded and therefore could not be used as part of the quality assurance level or trends identified by the management. Relatives who were visiting the home were aware of the complaints procedure and had raised concerns with the manager. One said that she felt that the manager (now no longer in the home) had been “defensive and unhelpful” when she was approached. Staff felt that they were not given opportunities to express their concerns with the manager, although this has improved since the new manager has started and also the regional manager has now taken steps to find out their views. Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 18 Staff are given protection of vulnerable adults training both as part of the inhouse training package and from outside organisations. The company has written guidance in place regarding the protection of vulnerable adults through detailed policies and procedures. These are included in the induction training and ongoing in-house training. There have been recent examples of safeguarding issues being raised, which have not been well managed by the team. Individual nurses do not all have a good understanding of how to make referrals. Care staff confirmed that they knew about the safeguarding guidance and could identify the action they would take if they were made aware of or had any concerns. It was noted that care staff had followed procedures and reported concerns to nursing staff; these were not acted upon meaning residents were at potential risk. Improvements have been recently made as the new manager has a good understanding of the safeguarding processes. There have been safeguarding adults investigations carried out involving the home. The new manager and the regional manager are working within the process and some remedial action has already been taken in response to some of the issues raised. And they will be looking again at the issues raised when completing the improvement plan for the home. Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The building requires further redecoration refurbishment and control of infection procedures are not always being followed. This fails to consistently create a safe or comfortable environment for people to live in. EVIDENCE: The home’s location and layout is suitable for the current needs of the residents. There is easy access to the garden area from the downstairs dining room and the main reception. All of the bedrooms have an en-suite facility and there are bathrooms, shower rooms and toilets close to all resident areas. The bedrooms are all for single occupancy. Residents have brought small items with them making their rooms Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 20 personalised and homely. Some of the bedroom furniture is showing signs of wear and some of the rooms have wheelchair damage to doors and walls. Also some carpets are worn or stained and need to be replaced. Some communal areas need to be redecorated and the carpet replaced. Also some furnishings including lounge chairs need replacement or repair as they are worn or damage and dirty. The sluices were locked and there are disinfectors on both floors. The laundry is on the lower ground floor. There are separate areas for clean and soiled linen. There the home was clean and tidy by the last visit, however individual issues found suggest that the control of infection practices are variable and some examples of poor practice. During this visit a soiled incontinence pad was found on the floor of a communal shower room. This was not bagged and disposed of appropriately. Not all areas requiring liquid soap, disposable hand towels and waste bins had them provided, making it difficult to ensure that staff are able to follow control of infection practices. Four bathrooms and one shower were out of use during the first of the visits. Work was planned or underway to address this by the final visit. However, the home did not have suitable numbers of assisted bathing facilities available for use. This is not an exhaustive list of the work that is needed but it is an overview of the type of issues that were found. The home has identified the work to be carried out as part of the “remedial action plan” which is part of the company’s quality assurance process. Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels and systems around recruitment, selection and training of staff are inadequate to meet the range of needs of the people using the service. The home has insufficient number of staff employed. EVIDENCE: Staff recruitment and selection records were complete including two references and a completed application form. The requirement to have a CRB and POVA check in place is applied to all of the staff in the home. There have been problems when staff who have been recruited have left their posts after a short time and there has generally been a high turnover of staff. This has included a significant change in the nursing and management team. The nurses have not always displayed a level of competency necessary to care for the residents needs. It is acknowledged that staff changes will occur, however this has also resulted in the use of a high number of agency staff. The company has put additional resources into the home so that the training programme will support the staff. This way the care can be planned and frequently reviewed. Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 22 The staffing rotas showed that there were periods when there was not enough staff scheduled to work. Staff sickness and holidays results in periods when there are insufficient numbers of staff on duty to meet the needs of the residents. Staff were working additional hours to those they were contracted for and were being asked to cover at short notice and when they had already worked a number of days. This is now being reviewed by the manager and steps are being taken to address this. Relatives said that they were concerned that there are not enough staff on duty and that there were times when the nurse call buzzers were not being answered within a reasonable time scale. The staff are not all fully up to date with statutory training although a large amount of additional resources have been allocated and significant improvements have been made. This has reduced the number of outstanding training and there is an action plan in place. Currently there are less than 50 of the staff with NVQ or equivalent. The staff are encouraged to undertake National Vocational Qualifications (NVQ 2) once they have had their induction training. Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although recent improvements have been made to the way the home is run, prior to this the management of the home lacked consistency and leadership. This has placed people at risk of harm. EVIDENCE: At the beginning of the inspection there was a peripatetic manager in the home, however by the last inspection visit there was another was manager in the home. He had begun to take the necessary action to improve the service and was working hard to liaise with other professionals to make this possible. Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 24 There was poor leadership in the home both in the way the care was being delivered to the residents and in the way the home was being organised. This included the organising of training, staffing and supervision and ensuring that the home was being maintained and equipped adequately. There was very poor leadership on a day to day basis this resulted in staff focusing on tasks rather than looking at the overall needs of the residents. The staff worked hard however they were not being well supported. Relatives were complementary about the staff but were concerned as they felt that there were not enough of them and that they were always too busy to spend time with the residents. A relative said that sometimes call their relatives were not being given the time they needed to give them good care. Discussion with the relatives suggested that they related better to the carers than the qualified staff. Although it is positive that they felt that they could talk to the carers it suggested poor communication with the senior staff and is at risk of compromising the way information is shared. The staff, residents and relatives were not confident that their views were listened to and valued by the previous manager. However this was not the case by the last visit when they were all more positive about the way the new manager is managing the home. There were insufficient records in place to show that the health and safety checks were being carried out. The company has a very detailed system for recording the checks that are carried out but these had not been completed fully. The quality assurance tool used by the company is very detailed and has been completed by the previous manager. This was carried out in great detail and identifies the areas that are not at the necessary standards. The remedial action plan was provided to the inspectors and showed that the managers are committed to making the necessary improvements. Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 1 X X 2 X 1 STAFFING Standard No Score 27 1 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X X X X 1 X 1 Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement All residents must be fully assessed prior to the admission and equipment procured to ensure that they can have their needs met at the time of admission. There must be adequate care plans in place, which are completed in sufficient detail and up to date reflecting the complex and changing needs of the residents. The residents must be provided with adequate care in line with best practice guidance. Storage of medication must comply with the guidance on the package information. The disposal of controlled medication must be recorded accurately. The home must manage complaints in the best interest of the residents in line with the company procedure. Staff must understand and comply with the safeguarding guidance and best practice. The home must be well maintained and decorated to DS0000000396.V366703.R01.S.doc Timescale for action 01/09/08 2. OP7 15 01/09/08 3. 4. OP8 OP9 12 13 01/08/08 01/09/08 5. OP16 22 01/08/08 6. 7. OP18 OP19 12 23 01/08/08 01/12/08 Byker Hall Version 5.2 Page 27 8. OP21 16 9. OP24 16 10. OP26 18 11. 12. 13. OP27 OP28 OP30 18 18 18 14. 15. 16. OP31 OP36 8 18 12 OP33 17. OP38 23 bring the home back to the required standard. Bathing facilities must be provided at adequate numbers for the resident numbers and their needs. Bedrooms must be maintained and furnished to satisfactory standards to meet the needs and comfort of the residents. The staff must trained in good control of infection practices and must comply with the company polices and procedures. The home must employ sufficient numbers of staff be permanent staff consistency. A minimum ratio of 50 of staff must achieve NVQ 2 or equivalent. Staff must be provided with appropriate training so that they can provide the care necessary for the safety and welfare of the residents. The home must be effectively managed. Staff working in the home must receive appropriate formal supervision. The home should be managed in the best interest of the residents and their views must be taken into account in the development of the service. The home must have records in place to show that safe working practices are being maintained at all times with regard to the maintenance of a safe environment. 01/09/08 01/10/08 01/09/08 01/09/08 01/12/08 01/12/08 01/10/08 01/10/08 01/10/08 01/09/08 Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Byker Hall DS0000000396.V366703.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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