Inspection on 06/04/05 for Camelot Rest Home

This inspection was carried out on 6th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Camelot Rest Home 16/05/07

Camelot Rest Home 12/07/06

Camelot Rest Home 06/12/05

Camelot Rest Home 24/01/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Camelot Rest Home 152 Stourbridge Road Dudley West Midlands DY1 2ER Lead Inspector Jean Edwards Unannounced 6/04/05 at 08:50 hours 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 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. Camelot Rest Home Version 1.10 Page 3 SERVICE INFORMATION Name of service Camelot Rest Home Address 152 Stourbridge Road Dudley West Midlands DY1 2ER 01384 214920 01384 214920 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr. & Mr. R. Odedra Ms Susan Laws Care Home 25 Category(ies) of Past or present alcohol dependence over 65 registration, with number years of age (1), Past or present drug of places dependence over 65 years of age (1), Mental Disorder, excluding learning disability or dementia - over 65 years of age (5), Old age, not falling within any other category (13), Physical disability (1), Physical disability over 65 years of age (4) Camelot Rest Home Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 24/01/05 Brief Description of the Service: Camelot is a private Care Home registered to provide residential care for up to 25 frail older people, with some provision for older people with a physical disability, mental disorder and dementia. The home has been owned by the current Registered Proprietors since October 2004. The home is located on the main bus route, close to the Merry Hill shopping centre and Dudley town centre. There is limited parking at the front of the Home and there are large gardens to the rear. The Home comprises a number of large traditional properties, which have been extended and adapted to provide 21 single and 2 double bedrooms, located on the ground and first floors. There is a passenger lift, and a chair lift providing access to the first floor. Communal accommodation is available in two large rooms at the rear of the property that have been extended out to meet in a large conservatory. The home offers a number of aids and adaptations, including adapted bathing facilities, floor level showers, portable lift equipment, emergency call system in every room and some adjustable beds. The Home has developed links with organisations that are able to offer some culturally appropriate diets for Afro-Caribbean elders. Camelot Rest Home Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit was undertaken by two inspectors from the Commission for Social Care Inspection using the following information: the action plan submitted by the home, notification of incidents and accidents, and records held at the home. The purpose of the inspection was to monitor progress in areas needing improvement, which include the provision of sufficient members of staff to meet the residents’ needs. The visit started at 8:50 am and lasted until 4.00pm. During the visit the inspectors spoke to the majority of the 20 residents who were at the home. One person was in hospital. Longer discussions took place with 4 residents whose care was looked at in depth. Two relatives and four members of staff were interviewed. The inspectors toured building, looking in particular at the kitchen, laundry, bathing facilities and a sample of residents’ bedrooms, with their permission. The Inspectors would like to thank staff and residents for their hospitality during this inspection visit. What the service does well: What has improved since the last inspection? Camelot Rest Home Version 1.10 Page 6 The décor of corridors has been considerably improved, with dark panelling now painted white. This gives a light and airy impression and comments from residents indicate that they were very pleased with the results. New comfortable chairs have been provided in the communal lounges. Improvements to the communal bathrooms and toilets are continuing, which now gives residents a choice of whether to have a bath or shower in pleasant surroundings. The number of staff on duty throughout the day has been increased as a result of immediate requirements to do this issued at the unannounced inspection visit on 24th January 2004. However, this has been achieved partly by the recruitment of two new staff and partly by ‘borrowing’ care staff from another home owned by the Proprietors on an ‘as and when’ basis. The result sometimes limits the way residents needs are met. The Manager has made the way new staff are recruited safer, with detailed checks and clearances obtained before they start work at the home, though this still needs further improvement. What they could do better: The management and staff of the home must make sure that residents and their families or supporters have a clear and active involvement in the decisions about whether this home can properly care for them. They should be fully aware and involved in assessments , care planning and review meetings. Recording in care plans, and assessments of risks must be improved and contain fuller details. A member of senior care staff was able to talk knowledgeably about medication administration at the home, however, further minor improvements must be put in place to make the medication system as safe as is possible. The manager and staff must talk to all residents to find out what activities they would enjoy and make sure that sufficient time and opportunities are created to provide social stimulation. One family commented that they were surprised but happy to hear from the resident that a new member of staff had taken the trouble to play dominoes with her. Although she had never played before she found it great fun. The home has created new menus after talking to residents about their likes and dislikes, which is very positive. Residents were particularly pleased to be able to have kippers, omlettes and homemade cakes and pies on the menus again. However the menus must be displayed in a way which helps residents to make their choices and remember what is being offered for each meal. The Camelot Rest Home Version 1.10 Page 7 menus must not be continually changed because the food shopping does not correspond with the menus. The shopping must follow good housekeeping rules. The Proprietors must make sure that there is sufficient catering support so that the time spent by care staff does not mean residents have less time being cared for. The records of how complaints are dealt with and whether people who complain are satisfied must be more detailed. Progress must be made to train all staff so that they know how to protect residents and respond to any situation where there is aggression. The proprietors and manager must put together a record of plans with detail of general redecoration, including the redecoration of residents bedrooms and replacement of equipment, especially giving residents a choice of duvets or blankets. The proprietors and manager must continue with the recruitment of sufficient numbers of care staff and with the recruitment of catering and cleaning staff. The manager and staff team must be given clear managerial support from the proprietors, which gives them the time and authority to develop the home to improve the quality of life for the residents. The manager must be given the training to improve the management of risks within the home and all other areas which concern health and safety of the residents. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Camelot Rest Home Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Camelot Rest Home Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 No progress has been made to revise and renew contracts of residency resulting in the practice of unfair terms and conditions. Unless the assessment covers all areas of residents needs, there is no assurance that these needs will be met. EVIDENCE: The contract of residence on one person’s case file related to the previous Proprietor and had not been reviewed and revised to reflect the home’s change of ownership. Some changes to terms and conditions have been made such as communal newspapers are no longer provided on a daily basis. Residents who enjoyed reading them, miss this activity. The contracts provided by the new Proprietors have not been revised in accordance with the Office of Fair Trading publication (Unfair Terms in Care Homes Contracts) and may contain terms and conditions, which are considered unfair. The record of assessment information for three residents, whose case files were inspected did not demonstrate the active involvement of them and/ or their representative. A requirement was made at the previous inspection visit Camelot Rest Home Version 1.10 Page 10 for records to be signed and dated by the resident and person undertaking the assessment. There was no evidence that this had been actioned. The home does not provide intermediate care, therefore standard 6 is not applicable. Camelot Rest Home Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11 Progress has been limited to implement more comprehensive care planning, which are needed to ensure that all healthcare needs are properly recorded. These omissions have the potential to place residents at risk. EVIDENCE: Each resident has a care plan in place, however, none of the sample of plans examined had been signed by the resident and/or their family or supporter. Discussions with the residents whose care was tracked during this visit and with a visiting family member confirmed the lack of active involvement in developing and reviewing care plans. No one spoken to was aware of their key workers name. One resident had developed a medical condition, which greatly increased his care needs. Whilst staff spoken to were aware of what those needs were and were able to describe the support being given from the Macmillan nursing service, there was no mention of this condition or the support measures in the care plan. As the home is currently dependent on using staff ‘borrowed’ from other homes in the group, meeting this persons needs depends entirely on good verbal communications. Camelot Rest Home Version 1.10 Page 12 Discussion regarding a recent Regulation 37 notification about a serious injury to a resident and examination of the persons care plan, risk assessment, daily notes and accident records highlighted that this person was at risk of sustaining such an injury. This person did not have a falls risk assessment in place. There was no evidence that an analysis of events and revision of the risks together with improved control measures had been undertaken. The lack of progress was partly accounted for with the manager still having to cover some direct care shifts as well as spending a considerable amount of time ringing around to find care staff to cover the shifts on an ongoing basis. In addition the manager spends a considerable time each week undertaking administrative tasks, especially the payroll. The home has comprehensive medication policies and procedures and all staff administering medication have received accredited medication training. Until the previous unannounced inspection visit there was a robust and rigorous medication system, which safeguarded residents. However at the last inspection visit a number of areas required improvement. The manager has taken remedial action and the medication system has improved. There are a small number of minor improvements, which have been identified at this visit, about expanding policies and involving GP’s to ratify homely remedies and ensuring that they carry out medication reviews. Camelot Rest Home Version 1.10 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 There has been little progress in making planned and spontaneous activities available on a regular basis. Residents are not able to take advantage of and develop socially stimulating opportunities. There continues to be good contact maintained with family and friends for the majority of residents. Meals are thoughtfully and sensitively planned, despite difficulties with food deliveries. EVIDENCE: Residents spoken to confirmed that, while there are now more staff on duty, they have little time to spend talking to them or to provide regular activities or outings. One person stated that until recently he had enjoyed going out unaccompanied, however, because of his physical deterioration this was no longer an option. There was no evidence that alternative options have been discussed with him to provide him with opportunities for going out. As and when individual members of staff have the time and take the initiative some activities such as Dominos, board games or sing-a-longs take place. New menus have been put in place following discussions with residents as to their likes and dislikes. These are currently hand written in an A4 book in the kitchen. There is no opportunity to residents to view the menus, which would help them make choices and be aware of what the meal choices are for each day. The deputy manager who currently undertakes the majority of cooking duties has to continually amend the menus when the food ordered is not Camelot Rest Home Version 1.10 Page 14 accurately delivered. The staff were seen to have to spend time explaining to residents that the mealtime choices had changed and to ask them to make an alternative choice. Although time consuming the practice of consulting and involving residents is commendable. The majority of residents spoken to said that they were very happy with the quality of the meals and were pleased that some favourites had been made available again. Camelot Rest Home Version 1.10 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Complaints are listened to and action is taken to look into them, however there is a lack of clear recording of investigations, outcomes and lessons learned or of communication to complainants about improvements made. There has been no progress to review the procedures for the protection of vulnerable adults and staff training has still not taken place. EVIDENCE: The Home has a complaints procedure, which is clearly displayed in the reception area and contained in the service user guide. There has recently been one complaint made directly to the Registered Proprietor. Although the Manager had been interviewed there was no record in the Home’s complaint’s log. There was no evidence that the resident had been contacted by the Proprietor. The relatives who had made the complaint visited the home during the inspection visit and were consulted. They confirmed that they had made the formal complaint on behalf of the resident and had received a verbal response from the Proprietor and felt satisfied it had been resolved. From discussions there was anecdotal evidence that the issue had arisen because of relationships between residents and intervention strategies had been needed. However there was a lack of detail in the care plans and daily notes; and certainly a lack of communication with relatives. The relatives were not aware of any named key worker responsible for the resident’s care, nor had they been involved in drawing up the care plan or Camelot Rest Home Version 1.10 Page 16 regular reviews. They did comment very favourably about the kindness and care given by the staff generally. The previous requirements to review and revise policies and procedures for the protection of vulnerable adults and provide appropriate staff training has not been met. Camelot Rest Home Version 1.10 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,21,24,25,26 Improvements to the internal decor to the communal areas of the home have been continued. There has been limited progress to improve the decor and facilities of residents bedrooms. There continues to be a lack of adequate cleaning. The outstanding issues do not promote independence and privacy for people living at the home. EVIDENCE: Since the last inspection visit work has continued to improve the communal bathing facilities, though is not yet quite complete. The ground floor corridors have been redecorated with dark wood panelling painted white, which has created the impression of brightness. This change was much appreciated by the staff and residents spoken to. However the proprietors and registered manager have not yet produced a documented programme for the planned ongoing redecoration, refurbishment and replacement programme. During a tour of the home a number of areas were identified as needing attention, in particular: Camelot Rest Home Version 1.10 Page 18 The decor of a number of residents bedrooms is looking worn and shabby with badly chipped window sills and skirting boards and faded and torn wallpaper The audit of facilities in each persons bedroom has not yet been undertaken, with the result that some people have not been provided with bed side or over bed lamps, two comfortable chairs, lockable facilities or sufficient electrical sockets in the double rooms Consultations have not yet been undertaken to find out the wishes of each person as to whether they would like duvets or blankets The audit of pillows and bed linen has not yet been undertaken, from which prioritised replacement programme must be commenced to replace some of the poor quality bedding and towels the radiator covers in residents bedrooms have not been modified to provide access for the person living in the room to adjust the thermostat on the radiator, they are therefore unable to adjust the temperature in their own room Although the standards of cleanliness in the home have marginally improved, there are still areas which require the cleaning to achieve a pleasant environment and adequate infection controls to safeguard the residents. A number of other improvements discussed at this visit and which must be actioned are detailed at the requirement section of this report. Camelot Rest Home Version 1.10 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29, Although the staffing levels have improved there are not adequate numbers of staff employed for this home to provide a satisfactory level of continuity of care for the number of residents with complex care needs. The recruitment processes for new staff have improved, providing more acceptable safeguards for the protection of vulnerable people. EVIDENCE: There is a stable core group of long serving care staff, however six staff have left the home’s employ since September 2004. The home has only managed to successfully recruit two new care staff at the time of this inspection visit, though the manager expects to be able to employ a further two carers when satisfactory clearances are received. The home is managing to meet the immediate requirements issued at the previous inspection visit to provide a minimum of 4 care staff on the early shift and three care staff on the late shift. This has been achieved by ‘borrowing’ staff from other homes within the group of homes owned by the current Proprietors and the Registered Manager covering care shifts, thus foregoing time to monitor and support carers and undertake other managerial tasks. There were records for all staff working at the Home and the staff files for new and existing staff, though still not very well organised contained an improved level of the information needed to make recruitment and retention processes robust. There is still no formal supervision system or comprehensive training plan developed. Camelot Rest Home Version 1.10 Page 20 Residents and visitors consulted during the visit spoke warmly about the staff, their helpfulness and kindness. They were pleased that there were more staff about and though they were still very busy at times, there was not such a wait for attention, as there had been until recently. A number of staff were knowledgeable about residents needs and demonstrated a friendly rapport with both residents and visitors. Camelot Rest Home Version 1.10 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,36,37,38 There has been no progress to clarify lines of responsibility and accountability and to provide formal professional managerial support and supervision. There has been limited action to ensure continuity of care, this results in the possibility that practices do not safeguard the health, safety and well being of people using the service. EVIDENCE: The new Proprietors took responsibility for the home in October 2004. Since that time the staff and manager have been unclear, unsure and apprehensive about the lines of responsibility and accountability, though everyone spoken to stated that the Proprietors were kind and pleasant people. However there are no Regulation 26 Reports of findings and guidance from the Proprietors / Responsible Individuals visits to the Home. There were a number of areas identified at the previous inspection visit, which needed to be improved in relation to health and safety. These included the Camelot Rest Home Version 1.10 Page 22 auditing, analysis and evaluation of accidents involving residents, there was no evidence that this has taken place. This meant that assessment of the records and management of accidents was not possible at this visit. No progress has been made to provide the manager or senior staff with training to effectively promote the management of risks and health and safety. Additional improvements to record keeping and a number of areas of health and safety were identified and discussed during this visit to be actioned. The details can be seen at the requirements section of this report. Camelot Rest Home Version 1.10 Page 23 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 x 2 x x 2 x 2 STAFFING Standard No Score 27 2 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 x 2 x x 2 2 2 Camelot Rest Home Version 1.10 Page 24 Yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 4 Schedule 1 Requirement Timescale for action 31/05/05 2. 1 5 3. 2 5(1) To expand the Homes Statement of Purpose to demonstrate compliance with all elements of Schedule 1; To expand the complaints procedure; include details of any therapeutic techniques used; and include date of issue and date of next review, forwarding a finalised copy to the CSCI Area Office and notify the CSCI of the reviewed document within 28 days of the review date (Timescale of 24/1/05 not met) To expand the Service User 31/05/05 Guide to meet all elements of 1.2 of this standard, to include revised and expanded terms and conditions; and provide copies to service users / representatives in suitable formats, with a finalised copy to the CSCI Area Office within 28 days of the review date (Timescale of 24/1/05 not met) To review the contract / terms 31/05/05 and conditions using the publication from the Office of Fair Trading: Guidance on Unfair Terms in Contracts in Care Homes (Timescale of 24/1/05 not met) Version 1.10 Page 25 Camelot Rest Home 4. 3 14(1) 5. 4 14(1)(d) 6. 5 14(1) 7. 7 15(1) 8. 7 15(1) To ensure that the homes preassessment pro forma is completed with all relevant information and signed by the person undertaking the assessment (Timescale of 24/1/05 not met) The written confirmation from the Registered Manager to the resident / representative must be expanded to include their identified assessed needs To provide documentary evidence on each person’s case file that trial visits have been offered prior to admission, recording outcomes. To ensure that the service user’s plan includes: - A recent photograph, greater detail of resident’s preferred activities/hobbies and religious needs, detail of the chosen regimes for rising, retiring, bathing and the signature of the service user and/or their representatives (Timescale of 24/1/05 not met) To ensure that all areas of risk associated with individual service users are clearly documented, such as moving and handling, challenging behaviours, falls, personal safety within the Home’s environment and on any activities where the Home has a duty of care. To ensure that documented risk assessments and risk management strategies relating to the service users and the environment are reviewed, expanded and implemented.(Timescale of 31/03/05 not met) Service user plans must contain details of changing needs, short Version 1.10 31/05/05 31/05/05 31/05/05 31/05/05 31/05/05 9. 7 15(1) 31/05/05 Page 26 Camelot Rest Home 10. 8 13(4) term needs with clear guidance for staff to ensure that action is taken to meet and monitor each persons health and wellbeing, for example weight loss and falls The Registered Person must ensure that all residents have a recorded falls risk assessment in place, which is reviewed and evaluated on a regular basis Access must be provided to sit on scales on a regular basis for residents unable to stand and weight bear To devise procedural guidelines for the administration of PRN medication to be documented and implemented as appropriate as part of individual plans (Timescale of 31/03/05 not met) The homes medication procedures must be expanded to include: - guidance for staff when residents repeatedly refuse medication -the homely remedies policy / procedure must be revised to include documented ratification by GPs - presciptions and MAR sheets with as directed dosages must be clarified with the prescriber and / or pharmacist 31/05/05 11. 9 13(2) 31/05/05 12. 9 13(2) 31/05/05 13. 9 13(2) - action must to be continued to ensure that residents medication is reviewed by GPs in accordance with health guidance The excessive temperature of 31/05/05 the medication fridge must be investigated and resolved to ensure the temperature is consistently maintained between 2C- 8C Version 1.10 Page 27 Camelot Rest Home 14. 9 13(2) 15. 9 13(2) The controlled drugs must be stored in a locked container, which is bolted to a solid wall, within a locked cupboard The GPs ratification must be obtained for the Valarian herbal homely remedy self administration by HR A documented risk assessment must be devised and implemented for the self administration of Valarian The prescribed Fortisip drinks must be labelled with date of opening if not immediately consumed, refriderated and discarded in accordance with manufacturers instructions (a fortisip was removed from room 21 on request) The decisions of residents and / or relatives relating to final wishes must be recorded in sufficient detail in their service user plan to enable preferences to be followed To conduct a documented audit of residents preferences for activities, from which a programme of activities must be devised and implemented and displayed in appropriate formats to encourage participation (Timescale of 31/03/05 partly met) To conduct a documented audit of service users food preferences and ensure menus are planned to reflect service users preferences and to ensure a balanced diet is provided(Timescale of 31/03/05 partly met) To ensure supplies of food are purchased and made available to the home in accordance with 31/05/05 31/05/05 16. 9 13(2) 6/04/05 17. 11 15(1) 31/05/04 18. 12 16(2)(n) 31/05/05 19. 15 16(2)(i) 31/05/05 Camelot Rest Home Version 1.10 Page 28 planned menus and identified shopping needs(Timescale of 31/03/05 not met) To ensure that the new menus are displayed in formats appropriate to residents understanding Details of complaints received by the home must be documented in the homes complaints log, be fully investigated, with the outcome formally notified to the complainant To revise the new whistle blowing policy introduced by the new Registered Proprietors to include the expanded information (Timescale of 31/03/05 not met) To remove the clinical procedure relating to nursing practices(Timescale of 31/03/05 not met) To devise and implement policies and procedures to safeguard the management of service users finances, which need to be crossreferenced to the staff employment handbook(Timescale of 31/03/05 not met) To provide staff training relating to responding to suspicions of abuse; and dealing with challenging behaviour(Timescale of 31/07/04 not met) The Registered Persons must conduct a documented audit of the premises, from which a prioritised programme of repairs, redecoration and replacement of equipment is devised and implemented, incorporating the Version 1.10 20. 16 22 31/05/05 21. 18 13(6) 18(1) (c) 31/05/05 22. 19 23(2)(b) 30/06/05 Camelot Rest Home Page 29 23. 21 23(2)(j) redecoration of residents bedrooms within an identified timescale To ensure that the newly 31/05/05 refurbished shower room on the first-floor has the following: Heating installed A privacy blind/curtain installed A supply of liquid soap and paper towels(Timescale of 31/03/05 not met) To ensure that the showerhead in the ground floor shower room is throughly cleaned and that this is done on a regular basis To ensure that there is a ready supply of paper towels in the WC adjacent to room 11 24. 24 16(2) To undertake an audit of each bedroom documenting where all elements of this standard are met and recording reasons where it is not met. (Timescale of 31/07/04 not met) All residents must be provided with lockable facilities in their bedrooms, these must be adequate to store medication (self administration if prefered) To discuss the service users choices relating to the provision of bedside lights and comfortable chairs in their bedrooms, ensuring decisions are documented on individual plans (Timescale of 31/03/05 not met) To ensure all service users are offered the option of choosing their preferred bedding, for example duvets or blankets (Timescale of 31/03/05 not met) 31/05/05 Camelot Rest Home Version 1.10 Page 30 To undertake a documented audit of pillows, and devise a prioritised replacement programme as required (Timescale of 31/07/04 not met) To ensure that the furniture belonging to the service user in room 8 is documented on an inventory on her individual file and that all other inventories are appropriately updated(Timescale of 31/03/05 not met) To audit all door locks, ensuring suitability for each persons ability and that there is an overide facility To ensure that all radiator covers provide appropriate access for service users to controls to allow individual adjustment(Timescale of 31/03/05 not met) 25. 24 16(2) 23(2) Bedroom 10 (shared room) must be redecorated, including repair to the ceiling, which is cracked and stained Bedroom 11 (shared) must be redecorated, including the renovation of skirting boards and window sills Bedroom 11 (shared) must be provided with additional electric sockets and residents must be offered the option of individual bedside or overbed lights Documentary evidence that both people have agreed to share a bedroom must be obtained and details of privacy arrangements recorded on each persons plan Bedroom 16 must be provided Camelot Rest Home Version 1.10 Page 31 31/07/05 with replacement / repaired door handle for the en suite Bedroom 18 must have the stained carpet and chair cleaned To carry out a lighting assessment of rooms to ensure sufficient light is available, with particular regard to area over the stair-lift on the ground floor(Timescale of 31/07/04 not met) To ensure that all radiator covers provide appropriate access for service users to controls to allow individual adjustment(Timescale of 31/03/05 not met) To repair the defective fan in the ground floor shower room near to the treatment room To provide suitable sluicing facilities(Timescale of 31/07/04 not met) As an interim measure the carpet must be removed from the sluice and an appropriate flooring provided A readily available supply of disposable gloves, aprons, liquid soap and paper towels must be provided in the sluice To devise and implement a cleaning schedule for the laundry area, to ensure that floors are mopped daily(Timescale of 31/03/05 not met) The home must be consistently cleaned in all areas to achieve satisfactory standards of hygiene and infection control the kitchen cleaning schedule Camelot Rest Home Version 1.10 Page 32 26. 25 23(2)(p) 31/05/05 27. 26: 38 23(2) .31/05/05 must be consistently recorded. 28. 27 31 18(1)(a) To provide additional catering support to maintain satisfactory standards of food hygiene. To allocate sufficient time to the deputy Manager, who is undertaking the majority of catering duties, to undertake Managerial tasks such as staff supervision, NVQ assessments etc.Timescale of 31/03/05 not met) To provide increased staffing levels to ensure that there are a minimum 4 carers, including a designated senior on the morning / early afternoon shift and a minimum of 3 carers, including a designated senior on the evening shift, with immediate effect (Timescale of 25/01/05 partly met) To provide additional ancillary hours to undertake cleaning, laundry and catering duties to ensure the firm is maintained to an acceptable level of cleanliness and infection control, especially whilst redecoration work is in progress (Timescale of 25/01/05 not met) The Registered Persons must ensure that the Registered Manager has sufficient supernumerary hours to undertake managerial tasks to a satisfactory standard (Timescale of 25/01/05 partly met) To ensure that a Regulation 37 notification is completed and forwarded to the CSCI Satellite office - Halesowen for ANY time that the care staffing level falls Camelot Rest Home Version 1.10 Page 33 31/03/05 29. 29 37 17(2) Schedules 2 and 4 19(1) below 4 care staff during the morning shift or 3 for the remainder of the waking day, identifying contingency measures in place (Timescale of 25/01/05 partly met) Ensure that a written reference is obtained from applicants last employer (as one of the two written references obtained) (Timescale of 31/03/05 not partly met) To record all interviews with prospective staff and develop a suitable person specification for specific posts. (Timescale of 31/03/05 not met) To complete the process of obtaining all information required for staff files to meet the documentation identified in Regulation 17(1) Schedule 2 and 4. (Timescale of 31/03/05 not met) To obtain copies of the public liability insurance and CRB clearance from the hairdresser and any other independent practitioner who provides services to residents in the Home. (Timescale of 31/03/05 partly met) To ensure that staff files are reorganised with dividers and indexing.(Timescale of 31/03/05 partly met) Staff files must contain copies of up-to-date and accurate job descriptions and copies of contracts of employment Records of staff training on files need to be reconciled to the staff 31/05/05 Camelot Rest Home Version 1.10 Page 34 training matrix (Timescale of 31/03/05 partly met) To review and update the disciplinary and grievance procedures and staff contracts in view of the introduction of the protection of vulnerable adult abuse (POVA) register. (Timescale of 31/03/05 not met) 31/07/05 The registered person must ensure that there is a staff training and development programme, which meets National Training Organisation workforce training targets and ensures that staff fulfil the aims of the home and meet the changing needs of service users.(Timescale of 31/07/04 not met) All newly recruited staff must receive induction training to National Training Organisation specification within six weeks of appointment to post, with foundation training within six months of appointment.(Timescale of 31/03/05 partly met) The in-house induction checklist must be completed with dates and signatures 17 (1) To provide appropriate, regular 18 (1) (c) profession documented supervision sessions for the Registered Manager (Timescale of 31/03/05 not met) To ensure that there are clear lines of accountability both within and externally to the home and that these are well understood by everyone (Timescale of 31/03/05 not met) 30. 30 18(1)(c) 31. 31 31/05/05 Camelot Rest Home Version 1.10 Page 35 To implement appropriate management systems, which allow the Registered Manager to discharge regulatory responsibilities for the day-today running of the home (Timescale of 31/03/05 not met) To provide the Registered Manager with the new contract of employment /terms and conditions, which clearly reflect responsibilities including any oncall arrangements and extra duties(Timescale of 31/03/05 not met) 32. 33 24 To implement an annual development plan for the home based on a systematic cycle of planning – action – review, reflecting aims and outcomes for service users. (Timescale of 31/07/04 partly met) To review and expand the discharge procedure to include reference to Notification of Termination of accommodation, as required by Regulation 40(Timescale of 31/03/05 not met) To review all policies and procedures to ensure that they are individualised to relate to this home(Timescale of 31/03/05 partly met) To ensure that documented Regulation 26 visit from the organisation’s nominated representative are conducted consistently as prescribed on a monthly basis, with reports to the Home and the CSCI Satellite Office – Halesowen. (Timescale of 31/03/05 not met) The homes certificate of Public Liability Insurance, with the policy number and schedule of Version 1.10 31/07/05 33. 33 24 31/07/05 34. 33 24 31/07/05 35. 33 24(1)(2) 26(2) 31/05/05 36. 34 25 31/05/05 Camelot Rest Home Page 36 37. 36 18(1) (c) 38. 39. 37 38 17(1) (a) Schedule 3(2) 13 (4) 18(1)(c) the level of insurance must be available and displayed in the home To progress the formal 31/05/05 documented supervisions sessions for all care staffTo devise and implement a documented annual schedule of supervision sessions, to be displayed to encourage staff participation in the processTo ensure staff supervision notes include a demonstration of action (Timescale of 31/03/05 not met) Each residents file must contain 31/05/05 their photograph To arrange accredited risk management training for all persons involved in undertaking risk assessments as soon as is practicable or engage the services of a ‘competent’ person to provide documented risk assessments, with control measures and risk management strategies. Timescale of 31/10/04 not met) To provide documentary evidence that approved risk assessment awareness training has been arranged for all staff to be delivered within an identified timescale. (Timescale of 31/10/04 not met) To undertake regular documented analysis of accidents relating to service users to identify trends and remedial action required such as revised risk assessments and keep separate file of accident records, appropriately and securely stored, for ease of auditing (Timescale of 31/03/05 not met) 31/05/05 Camelot Rest Home Version 1.10 Page 37 40. 38 23 (4) (d) (e) 13(4) 17(2) 41. 38 To devise and expand laundry procedure and guidelines, to be displayed in the laundry area and ensure that personal protective equipment for staff, such as disposable gloves and aprons, are available at all times in the laundry and sluice (Timescale of 31/03/05 not met) To ensure all staff attend fire drills and fire training twice yearly as the minimum (Timescale of 31/03/05 not met) The following improvements to health and safety must be actioned: - A Landlords Gas Safety Certificate must be obtained - An asbestos assessment must be undertaken by a competent person - Weekly visual checks of hoists and slings must be documented - The recorded excessive hot water temperature (50C ) must be rectified, with a risk assessment put in place as an interim measure - Wheelchairs must be checked on a monthly basis with outcomes documented - The clean towels stored in the cupboard without doors in the ground floor shower room must be removed or doors must be fitted to the cupboard A documented risk assessment must be devised and implemented for the member of staff who is pregnant, with her alternative duties clearly Version 1.10 31/05/05 30/06/05 42. 38 13(4) 18(1)(a) 30/04/05 Camelot Rest Home Page 38 recorded on the staff rota RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 12 12 Good Practice Recommendations That for easier and monitoring and evaluation that a weekly activity planner is devised and implemented for each person.(Timescale of 31/03/05 not met) That the decision to cease to provide a supply of communal newspapers, obviously valued by service users, be reviewed; and should the decision stay, the contract, service user guide may need to be revised to reflect the change in provision.(Timescale of 31/03/05 not met) That rotas identify service user dependencies and occupancy levels, and that a regular documented review of staffing levels, using the staffing tool, is conducted That the Manager signs and dates photocopies of qualifications held on file to evidence that originals have been seen. 3. 4. 27 29 Camelot Rest Home Version 1.10 Page 39 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Camelot Rest Home Version 1.10 Page 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!