CARE HOME ADULTS 18-65
Caritate Nursing Home Laninval House Treningle Hill Bodmin Cornwall PL30 5JU Lead Inspector
Diana Penrose Unannounced Inspection 18th October 2007 09:30 Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 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 Caritate Nursing Home DS0000068035.V353686.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 Adults 18-65. 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. Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Caritate Nursing Home Address Laninval House Treningle Hill Bodmin Cornwall PL30 5JU 01208 75628 01208 74921 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) Caritate Limited Position Vacant Care Home 27 Category(ies) of Physical disability (27) registration, with number of places Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Up to 15 service users may be over 65 years of age who require nursing care and accommodation by reason of old age or physical disability. Three named service users may be accommodated who require care and accommodation by reason of old age, not falling into any other category. 15th February 2007 Date of last inspection Brief Description of the Service: Caritate was previously known as Laninval House and is situated approximately one mile from the centre of Bodmin and is set in 16 acres of grounds. It is an older, privately owned property with an added extension. It offers nursing care to mainly younger adults with disabilities and is viewed as a home for life, if this is the wish of the person concerned. A number of residents are dependent on a wheelchair for mobility. The ground floor of the home provides mainly communal space and is divided into several separate and distinct areas. There are also two sun lounges where smoking is permitted. Bedroom accommodation predominantly comprises of single rooms. Stairs and a shaft lift provide access to all the floors and a range of disability equipment is available to assist residents. Externally there are very large grounds, much of which is level and accessible by wheelchair. There is a car parking area at the front of the house. Qualified Nurses and Care Assistants provide care within a relaxed and friendly atmosphere. Information about the home is available in the form of a residents’ guide, which can be supplied to enquirers on request. A copy of most recent inspection report is available in the home. Fees range from £550 to over £650 per week; this information was supplied to the Commission during this inspection. Additional charges are made in respect of private healthcare provision, hairdressing and personal items such as newspapers, confectionary and toiletries. Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An inspector visited Caritate Nursing Home on the 18 October 2007 and spent seven and a quarter hours at the home. This was a key inspection and an unannounced visit. The purpose of the inspection was to ensure that the needs of the people using the service are properly met, in accordance with good care practices and the laws regulating care homes. The focus was on ensuring that placements in the home result in good outcomes for people. It was also to gain an update on the progress of compliance to the requirements identified in the last inspection report dated 15 February 2007. The CSCI Annual Quality Assurance Assessment (AQAA) document completed by the provider has also been considered to support this inspection. All of the key standards were inspected. On the day of inspection 22 people were living in the home, 1 of these was receiving respite care. The methods used to undertake the inspection were to meet with a number of residents, visitors, staff and the registered provider to gain their views on the services offered by Caritate Nursing Home. Records, policies and procedures were examined and the inspector toured the building. This report summarises the findings of this inspection. The registered providers have made further improvements to the premises and the care provision for people using the service. Residents and visitors expressed satisfaction with the care and services provided at the home. Overall the home is providing an adequate quality of care to the residents placed there. What the service does well:
The registered providers have experience in the provision and management of care homes. Mrs Peach is a qualified nurse who also has social care and business skills. Staff, residents and visitors to the home said the home is well run and a lot of improvements have taken place. People said, “There is a good atmosphere here” and “The owners are here a lot”. The home ensures assessment documentation is received from external agencies. Care plans have been put in place for all residents and they said they are cared for well. Staff interact very well with residents in a kind relaxed way. The people using the service said they make decisions on how they spend their time and they decide when to get up and go to bed and so on. Some are able to direct their own care. Activities take place in the home, entertainers visit and the residents go out on trips and into town and so on. The home’s minibus has enabled residents to get out into the local community. Residents talked about going out to the pub and to the local shops.
Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 6 Residents said they have contact with their family and friends, the visitors book showed that people visit regularly. A new chef has been employed and he said is reviewing the menus with the residents. Everyone spoken with said the food is very good Special equipment including special wheelchairs is provided as needed and the home employs a physiotherapist. Specialist healthcare professionals including doctors, dentists, nurses and speech therapists, are accessed when required. Generally prescribed medicines are managed safely. Appropriate arrangements are in place to protect residents from abuse and to deal with residents’ complaints or concerns. The home offers a warm, comfortable, homely environment that is clean, well furbished and free from odours. In a relatively short period of time the providers have made significant improvements to the premises with an extensive refurbishment plan that is progressing very well. Residents can easily access the large garden, which is well maintained and equipped with garden furniture. 54 of care staff have achieved at least NVQ level 2 and a further 27 are working towards the qualification. Sufficient numbers of staff are on duty each day and night. A nurse is on duty at all times. Residents said the staff are kind and look after them well. What has improved since the last inspection? What they could do better:
Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 7 The providers must ensure that a complete needs assessment is undertaken for each prospective resident to make sure the home can provide the care and support required. The care planning paperwork must be fully completed for all residents to ensure that staff know exactly what to do to meet their needs. This is particularly important for those people who are unable to direct their own care. All staff must take responsibility for making sure that records are complete and be reminded that these are legal documents. There must be a written risk assessment completed for any identified risk. This includes any form of restraint such as bed rails and wheelchair straps. The restraint policy needs to be updated to include the types of restraint used in the home and the process for use. The medicines policy needs reviewing to ensure that it stipulates exactly what is required of staff. For example it should refer to the The royal pharmaceutical guidelines for care homes and NMC guidelines, state the procedure for washing the pots, the procedure for the use of creams and protocols for as required medicines and so on. If a medicine is not given for any reason a relevant code shoud be recorded on the chart, it should not be left blank. Any hand written instructions on the medicine charts must be witnessed and signed by two people. A copy of ‘the royal pharmaceutical guidelines for care homes’ must be available to nursing and care staff. Medicine pots should be discarded after use or washed appropriately. The medicines fridge must be checked to ensure it is working effectively and records of the temperature and defrosting should be maintained these were not available during the inspection. A health declaration must be obtained from new employees to evidence their physical and mental fitness to work. Evidence that new employees undergo appropriate induction to the home must be held in the home. Interview records should be held to ensure that appropriate vetting was undertaken in a fair and equal manner. A system for quality assurance needs to be developed and the registered provider has a system that she intends to use. The fire safety checks have not been kept up to date and the registered provider was aware of this. She said she is employing a full time maintenance person in November 2007 who will be responsible for these; to date she has been trying to do all the checks herself. Fire training must also be kept up to date. PAT testing and Legionella testing has to be done. Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 8 The contact details for CSCI need to be kept up to date in relevant documents. Some radiators are very hot and must be covered to prevent possible injury to residents. 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. Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Assessment documentation and care plans are received from external agencies. In addition all prospective residents should be assessed by a competent person from the home, prior to admission, with records maintained. This will ensure the providers have a clear picture of the individual’s needs and are confident they are able to provide the care and support required. EVIDENCE: Evidence was provided in the form of records, talking with staff and the registered provider. The files of two recent admissions were inspected and contained assessment documentation completed by the department of adult social care, nursing needs assessments undertaken by health authority nurses and information from hospital nurses. There was no evidence that assessments had been undertaken for these residents by the provider or a nurse from the home. There were completed Caritate assessment documents for some other residents. All prospective residents should be assessed by a competent person from the home, prior to admission, with records maintained. This will ensure the
Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 11 providers have a clear picture of the individual’s needs and are confident they are able to provide the care and support required. Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual care plans are being generated for each resident but need to be fully completed to guide and direct staff in the care provision. Residents make decisions about their lives; assistance and support is given where necessary. Residents are supported to live as independently as possible and risk management is improving to safeguard individuals. EVIDENCE: New care planning documentation has been implemented but the paperwork has not been fully completed for all residents. Those that are complete provide staff with reasonable information, direction and guidance about the care and support required. Staff said that residents are encouraged to participate in their care planning and some residents are able to direct the care and support they require. Where residents are not able to direct their care more detailed plans need to be in place. Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 13 The care plans in place are a vast improvement but all staff must take responsibility for making sure that records are complete and be reminded that these are legal documents. There is evidence that care plans are reviewed. Daily records are maintained separately by nursing staff and care staff that are informative. There are some gaps in the care staff records. Policies and procedures have been put in place to safeguard the people using the service. It is clear that staff care for residents and risks are managed though their knowledge and skills. Written risk assessments are still being developed and there were completed risk assessments for pressure sores seen. The registered provider said there is a risk assessment for the use of bed rails and the lead nurse said it is the same as the one used at a local hospital. A copy of the risk assessment could not be found. A written risk assessment must be completed for any identified risk. Any form of restraint such as bed rails and wheelchair straps must be risk assessed; consent should also be obtained and the decision should include all relevant people, for example relative, physiotherapist and maybe GP. The restraint policy needs to be updated to include the types of restraint used in the home and the process for use. The people using the service said they make decisions on how they spend their time and they decide when to get up and go to bed and so on. Breakfast time extended well into late morning and some people got up just before lunchtime. Some people went out in the afternoon. One resident went to the gym; he said he is getting fit for a sponsored wheelchair push. One resident goes out to a day centre. Residents talked about going out to the pub and to the shops. There was little written evidence to show that residents are supported to take risks to be as independent as possible. There needs to be robust arrangements to identify risks and put good measures in place that safeguard residents and staff. Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 14 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents take part in appropriate activities and are encouraged to maintain their independence and individuality. Links with the local community are good and allow residents the opportunity to socialise. Residents have appropriate contact with family and friends according to their wishes. Resident’s rights and individual choices and preferences are respected. Dietary needs of residents are well catered for with a varied selection of food available to meet their taste and preference. EVIDENCE: Evidence was provided in the form of documentation, records, observation, talking with the people using the service, staff and registered provider. Activities take place in the home, entertainers visit and the residents go out on trips and into town and so on. Activities include a weekly keep fit class, aromatherapy massage and art classes. Some residents were enjoying music
Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 15 and movement during the inspection and there was one to one socialising between staff and residents. The home’s minibus has enabled residents to get out into the local community. One resident attends a day centre. The registered providers hope to provide an occupational kitchen for resident’s use. Staff said that residents have contact with their families as they wish. The records show that contacts are made and that visits take place. One resident said she goes to stay with her mother sometimes. The daily routines are flexible and residents said they choose what they wear and how to spend their time. One resident has a key to his room and a nurse said others could have one if it is their wish. A new chef has been employed and he said is reviewing the menu again taking into consideration the residents likes and dislikes. At the moment the menu is written in a diary and typed up for display each day. It is a set menu but alternatives are available. Fresh fruit and vegetables are included and cakes are homemade. Food records are maintained. Residents and staff spoke highly of the new chef and all said the food is very good. The kitchen has been refurbished with stainless steel fittings. The walls have now got to be painted. Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is given to residents according to their needs, ensuring their individual preference is respected. Residents have access to health care services as necessary to ensure their physical and emotional needs are met. There is a suitable system in place for dealing with resident’s medicines: extra vigilance with records and a system for ensuring the fridge is in working order will assure resident’s safety. EVIDENCE: Evidence was provided in the form of records, observation, talking with the people using the service, staff and registered provider. The registered provider and staff said they ensure that appropriate personal support, care and encouragement are provided in such a way as to respect resident’s privacy and dignity. Residents said they are treated as individuals by the staff. Special equipment including special wheelchairs is provided as needed and the home employs a physiotherapist. All residents are registered with a GP and specialist health care workers are consulted as necessary, for example speech
Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 17 therapists, occupational therapists, dentists and doctors. A key worker system has been introduced and staff said it is working well. There is a suitable medication system but the policy needs reviewing to ensure that it stipulates exactly what is required of staff. For example it should refer to the The royal pharmaceutical guidelines for care homes and NMC guidelines, state the procedure for washing the pots, the procedure for the use of creams and protocols for as required medicines and so on. A monitored dose system is in use. Medicines received are entered on the charts and the disposal records are satisfactory. There are some gaps in the administration records and this was discussed with the registered provider and lead nurse. If a medicine is not given for any reason a relevant code shoud be recorded on the chart, it should not be left blank. Any hand written instructions on the medicine charts must be witnessed and signed by two people. Patient information leaflets are kept and the registered provider said she has a copy of ‘the royal pharmaceutical guidelines for care homes’ but it could not be found during the inspection. Medicines are stored safely and securely. The system for managing controlled drugs is appropriate. Medicine pots should be washed in the kitchen or in a bowl (not the hand wash basin) with washing up liquid then dried with paper towels; the lead nurse agreed to address this. The registered provider has included appropriate medications training in the induction programme. Training was provided for the monitored dose system but attendance was poor. There is a new medicine fridge, that contained eye drops, the temperature read 20ºC. The nurse said she would ensure this is checked and put right and that records of the temperature and defrosting are maintained. Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a suitable complaints procedure that ensures complaints will be listened to and acted upon. Arrangements are in place for the protection of residents safeguarding them from harm or abuse. EVIDENCE: Evidence was provided in the form of documentation, observation and talking to the registered provider. There is a suitable complaints procedure in place that is available to the residents and their relatives. The contact details for CSCI need to be updated. The residents were relaxed in the home and said they can air their views openly. There have been no complaints to the home or the Commission. The home has a written adult protection and whistle-blowing policy. The adult protection policy must include the local authority procedures and should include CSCI and DASC contact details. The registered provider and some staff have attended the ‘No Secrets’ training and obtained a copy of the local inter agency procedures. There has been some in house training and the registered provider has some leaflets about abuse to distribute to residents. There is no money held on behalf of residents. Any purchases are listed and receipts kept. The resident’s relative or representative is then sent a bill each month to reimburse the registered provider. The registered provider is appointee for three residents and records are kept.
Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 19 Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 20 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered providers have improved the environment for residents and they are determined to offer accommodation that exceeds the minimum standards. The home is clean and free from offensive odours making it a pleasant place to live in. EVIDENCE: Evidence was provided in the form of a tour of the building, observation, AQAA and discussion with the registered provider. The home provides a warm, comfortable, homely environment. It is clean, well furbished and free from odours. Some dust and cobwebs are inevitable at the moment due to the building and refurbishment work taking place. In a relatively short period of time the providers have made significant improvements to the premises to make sure it is watertight and to provide quality accommodation for residents. They have an extensive refurbishment plan that is progressing very well. They say they intend to exceed the National Minimum Standards and the work to date proves their intentions.
Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 21 At the moment the library, next to the dining room, is being refurbished, the respite room and adjacent area is being developed to give extra space in the corridor. Most of the bedrooms have been refurbished and the kitchen has been fitted with stainless steel equipment, it now needs to be decorated. The providers hope to include an occupational kitchen for residents use. There is suitable lighting and ventilation. Some radiators are very hot and must be covered to prevent possible injury to residents. Resident’s rooms are personalised with their own possessions. There are two sun lounges dedicated for residents who wish to smoke. Residents can easily access the large garden, which is well maintained and equipped with garden furniture. Residents and staff talked about the recent celebrations that took place to mark the anniversary of the providers owning the home. A large marquee was erected in the grounds and everyone that was able and wished to took part. The laundry facilities are situated in the garage and appropriate washing machines and driers have been installed. Protective clothing and suitable handwashing facilities are provided for infection control purposes. The home is clean and hygienic and residents are satisfied with the standards maintained by the present providers. Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 22 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels appear to meet the needs of residents and staff are motivated to provide a high standard of care. Residents are in safe hands and they benefit from the 54 of care staff trained to NVQ level 2 in care, or above. The new owners have improved recruitment practice however record keeping in this area must improve. The home provides training for staff to help them be more competent in their roles and this is being developed further. EVIDENCE: Evidence was provided in the form of documentation, records, observation, talking with the people using the service, staff and registered provider. Many of the care staff have worked at the home for a considerable time and they appear to have a good knowledge of the residents accommodated. They interact well with residents and spend time talking with them. Staff said the training provision has improved and they appreciate the extra responsibility given to them recently. 54 of care staff have achieved at least NVQ level 2 and a further 27 are working towards the qualification.
Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 23 The duty rota showed that a qualified nurse is on duty at all times. There was no evidence as to how staffing levels are calculated. On average there are four or five carers during the day and evening and one at night. There are periods between 08.00 - 09.00 and 20.00 - 21.00 when only three care staff are on duty with a nurse. Staff said they thought there were probably enough staff, they all said they work well as a team. Residents said the staff are kind and look after them well. The providers have developed a recruitment system with an equal opportunities policy. Three staff files were inspected and contained most of the records required by legislation. The registered provider said that contracts of employment were being distributed to staff. She said that supervision takes place but is not documented at the moment. There were no interview records, completed induction records or any evidence of a health declaration from staff. Only one of the three files had a photograph of the employee. There is a structured induction programme with a checklist to be signed. The lead nurse was supervising a new Polish nurse during the inspection as part of her induction. A training programme is being established. A physiotherapist is responsible for moving and handling training, fire training has been done but is due to be done again, health and safety training has been done and some staff are trained in first aid. Infection control training forms part of the induction training and an update is being organised for 2008. The provider said that food hygiene training is in hand, catering staff have done this. A nurse said that “as nurses we are responsible for keeping up to date and the registered providers support us with this”. She had attended an update on Huntington’s Disease recently. Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered providers are competent and experienced and residents benefit from a well run home. The home is run in the best interest of the residents and they benefit further when the Quality Assurance systems are in place. The registered providers promote the safety of the residents however fire safety checks have not been kept up to date and some other checks need to be undertaken to ensure the health, safety and welfare of residents and visitors to the home. EVIDENCE: Evidence was provided in the form of documentation, records, talking with the people using the service, staff and registered provider. The registered providers have experience in the provision and management of care homes. Mrs Peach is a qualified nurse who also has social care and
Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 25 business skills. She is competent to run the home but has found the past year stressful. Staff, residents and visitors to the home said the home is well run and a lot of improvements have taken place. Comments include “I get on well with the owners”, “Sometimes there seems to be a lot of changes all at once, but it is all good”, “There is a good atmosphere here” and “The owners are here a lot”. The registered provider has purchased the Blue Cross quality assurance system but it has not been implemented yet. She intends to utilise the CSCI Annual Quality Assurance Assessment document as part of the system. She said that informal audits take place but there are no written records. There are environmental risk assessments for the home. The fire risk assessment has also been completed and fire drills take place regularly. Hazardous substances are stored safely and some data sheets are available for COSHH purposes, they are not complete. There have been few accidents in the home; accidents are not formally audited. The fire safety checks have not been kept up to date and the registered provider was aware of this. She said she is employing a full time maintenance person in November 2007 who will be responsible for these; to date she has been trying to do all the checks herself. The electrical wiring assessment has been done and an action plan is in progress. PAT testing is due and Legionella testing has to be done. The registered provider said the boiler was serviced last week and she is awaiting the certificate. There are plans to install a new fire system and a new call system. Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 YA6 Regulation 15(1) Requirement The care planning paperwork must be fully completed for all residents to ensure that staff know exactly what to do to meet their needs. Timescale for action 30/01/08 2 YA9 13 Sch 3 Good risk assessments and a risk 30/01/08 management plan must be in place for any situation that could potentially compromise the health, safety or well being of a service user. This includes risk assessment for any form of restraint such as bed rails and wheelchair straps. • The medicines policy must be reviewed to ensure that it stipulates exactly what is required of staff If a medicine is not given for any reason a relevant code shoud be recorded on the chart, it should not be left blank. Any hand written instructions on the medicine charts must be witnessed and signed by two people. The medicines fridge must be 30/01/08 3 YA20 13(2) • • •
Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 28 working effectively with records maintained of the temperature. 4 YA34 19 Sch 2 • New employees must provide a health declaration to evidence their physical and mental fitness for the work. There must be a photograph of each employee held in his or her personal file. 30/01/08 • 5 YA35 18 Evidence that new employees undergo appropriate induction must be held in the home. • • PAT testing and Legionella testing must be undertaken. The fire training and safety checks must be kept up to date 30/01/08 6 YA42 13 30/01/08 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 Refer to Standard YA39 Good Practice Recommendations Good and reliable formalised quality assurance measures should be in place. Caritate Nursing Home DS0000068035.V353686.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Caritate Nursing Home DS0000068035.V353686.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. 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!
