Inspection on 23/06/09 for Chy Byghan

This inspection was carried out on 23rd June 2009.

CQC found this care home to be providing an Adequate service.

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

Other inspections for this house

Chy Byghan 23/09/08

Chy Byghan 22/04/08

Chy Byghan 07/06/07

Chy Byghan 05/06/06

Chy Byghan 08/02/06

Chy Byghan 20/06/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 12/10/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Chy Byghan Sunny Corner Lane Sennen Penzance Cornwall TR19 7AX Lead Inspector Alan Pitts Key Unannounced Inspection 23rd June 2009 09:00 DS0000062587.V376165.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chy Byghan Address Sunny Corner Lane Sennen Penzance Cornwall TR19 7AX 01736 871459 01736 871423 rosemarydeane@hotmail.com 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) Mrs Jacqueline Brown Mrs Rosemary Ann Deane Mrs Rosemary Ann Deane Mrs Rachel Mary Vaughan Care Home 19 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (19) of places Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd September 2008 Brief Description of the Service: Chy Byghan is a registered care home providing accommodation and personal care for up to nineteen older people. Up to six of the residents may require care because they experience confusion. The home also provides day care for up to three older people. The home is detached and is located in the village of Sennan, approximately 11 miles from Penzance. It is situated slightly off the main road and has car parking for approximately 6-7 vehicles. The building consists of two storeys, with most of the accommodation provided on the ground floor. Several of the residents bedrooms have French doors that open directly onto an outside patio. All the bedrooms currently have single occupancy but two rooms can be shared if required. The home provides a comfortable sun lounge, a smaller second lounge and a well-decorated, spacious dining room. The registered providers live adjacent to the care home and one provider is the registered manager. One of the providers, Mrs Deane, plays an active role in running the home on a day-to-day basis. Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was carried out on 23rd June 2009 by two inspectors. We were assisted by an expert-by-experience, who spent approximately three hours talking with residents. Medicines were inspected by our Pharmacist, Brian Brown, on the 25th June 2009. We also received eight surveys from relatives, or representatives of the people that live there. The inspectors met with the registered provider, Mrs Deane, staff, and residents, examined documentation (including surveys) and toured the premises. This home provides individualised care that the people that live there clearly appreciate. The overall rating of an adequate service reflects the requirements and recommendations made. We recognise the significant improvements made since the last inspection in addressing the majority of the requirements made at that time. If the level of effort and commitment demonstrated since the last inspection continues then there is no reason why the home’s rating cannot improve again at the next inspection. There were no direct concerns about the actual care provided. The issues identified in this report were discussed in detail with the registered provider, Mrs Deane. We carried out this inspection over a cumulative period of approximately twenty hours. We spoke with residents, the registered manager and staff. We looked round the home including the rooms of the people that live there. We inspected the homes’ documentation. Fees range from £300 to £370 per week. Fees do not include costs for chiropody, hairdressing, national newspapers (though local papers are provided. Although the overall rating for this home has remained at adequate, it is recognised that there has been significant improvements since the last inspection. Further improvements and continued commitment are now needed to progress the home forward towards a good rating. Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 6 What the service does well: Comments from the people that live there and/or their relatives were predominantly positive. One resident saying they “wouldn’t want to live anywhere else”. There has been significant improvement made since the last inspection, with the number of requirements dropping from 8 at the last inspection to 3 this time. What has improved since the last inspection? What they could do better: The home could improve its Statement of Purpose and Service User Guide (combined document). The home could improve its pre-admission assessment. More can be done to ensure care plans give clear direction to staff. More could be done to involve residents in their care plans and to ensure forms are properly completed and planned interventions carried out consistently. The registered provider should ensure a proactive approach to meeting the care needs of the clients, including liaison with relevant agencies where necessary. Staff could improve entries in the daily notes to reflect the daily lives and activities of the people that live there. The menu should show the alternatives available, and a record should be kept of the choices made. The cleanliness and maintenance of the property could be improved. Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 7 Staffing levels could be increased to better serve the residents. The registered providers should continue with and expand the use of quality assurance questionnaires, publishing a summary of the findings and any action taken as a result. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home does provide residents with the information they need. Prospective residents are assessed prior to admission, though this can be improved. The home does not provide intermediate care. EVIDENCE: There is a new Statement of Purpose and Service User Guide, but this combined document is not dated. This information is provided to residents or prospective residents and is present in every bedroom. Discussion took place with the Mrs Deane as to how this could be improved (e.g. alternative formats: audio/video, and the inclusion of a summary of the findings from quality assurance surveys). Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 10 The care documentation for the most recent admission to the home showed that a care needs assessment had been carried out prior to admission. Mrs Deane confirmed that they also obtain assessments from external agencies if they are involved in the referral. Discussion took place with Mrs Deane as to how the home’s pre-admission assessment could be improved (e.g. include a personal history, and likes and dislikes). Comments received from clients or their relatives told us that they felt they were kept well informed, and had the information they needed. The home does not provide intermediate care. Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are in place, but these are not comprehensive and do not provide clear direction. Arrangements are in place to meet health needs, but a more proactive approach would improve the service. EVIDENCE: Each resident has a care plan intended to inform the staff of the needs they have and the best way of providing the care and support they require, but the care plans do not do this. The care plans seen were not comprehensive and make use of generic instruction (e.g. “needs assistance with washing and dressing”) rather than stating what assistance is needed). Care plans do not show that the client is routinely involved in care plan reviews, and care plans can differ from the information provided in other documentation. One care plan sad the client was dependent on staff and aids to mobilise, but the moving and handling assessment (which had not been reviewed since 2007) indicated the Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 12 client could mobilise independently. Also, where issues are identified the care plans and supporting documentation do not show that the matter has been addressed. So, for example, if a client does not like having their dentures in the home should be trying to find out why, perhaps with a dental referral). The staff are not regularly weighing clients, and should liaise with other agencies to obtain equipment to do so. The people that live at the home would benefit from a more proactive approach to their health care needs. We observed staff on several occasions interacting with residents, they came across as kind, conscientious and efficient. The people we spoke with had no complaints about the way they were treated and were extremely happy to be living in the home. The records indicate that District Nurses and General Practitioners regularly visit different residents. Residents spoken with were complimentary of the staff and care provided. Comments received from staff and residents included: • “All staff show great care, patience, and skill” • “Everyone is looked after well (first class!)” We looked at the storage of Controlled Drugs and found that this complied with the current regulations. We also found that when we checked the stock of these held against the balances recorded in the Controlled Drugs register that they were correct. We did however find that one of these medicines had been opened for longer than specified by the manufacturer although the person receiving it had not received any doses after the expiry date. It was agreed that a replacement supply would be obtained as this person still need the medicine. We found that when people are prescribed medicines with a variable dose that the actual dose administered is not recorded only that they have received some of the medicine. This means that it is not always possible to provide feedback to the prescriber or other healthcare professional about how effective the medicine is for the person. We found that medicines requiring refrigeration are stored in an unlocked box within the domestic refrigerator. This means that they are not stored securely. At present there are no medicines that require storage within a specified temperature range but the home should consider how they would monitor this if needed. We found that staff administering medicines had received training and been assessed as competent to administer the medicines some time ago. There were no recent records to indicate that the competency of these people had been reviewed. We were told that further training has been planned for people who have not yet received training and they will be assessed as competent before administering medicines. We found that the home does have policies Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 13 relating to the control and administration of medicines but that these have not been reviewed recently and do not reflect current best practice guidance. We also found that whilst a record is made of the receipt of the monthly medicines supply, that no record is made of any medicines received at other times. There is also no record made when medicines leave the home. Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. More can be done to show that residents are able to participate in a range of social and recreational opportunities at the care home and in the local community. A varied and nutritious menu is in place that reflects the residents’ needs, preferences and choices. EVIDENCE: Residents confirmed that staff are helpful and assist them in maintaining their social life, sometimes established before admission to the home. People said that tea is brought to them in their room around 8am and breakfast is at 9am. The residents we spoke to thought this was agreeable. People can choose what time they retire to bed. Several of the residents go to church regularly with friends who collect them from the home and a Methodist Lay Preacher visits the home monthly with an Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 15 organ player, a service is given in the dining room for anyone who would like to attend. A chiropodist visits monthly. Fingernails are manicured by the staff and the ladies can have their nails painted if they ask. A hairdresser visits the home once a fortnight. Mrs Deane buys a daily paper for the residents and if they request other papers or magazines the residents order and pay for them themselves. Sennen has three communal buses that are used for outings by residents. Mrs Deane has passed a test to enable her to drive one of the buses and does occasionally take residents out on trips. Every Wednesday several of the residents are taken to the First & Last pub for a meal with the local lunch club. The bus driver calls at the home on a Tuesday morning for anyone who would like to go to the farmers market. One resident said that if she wanted to go shopping then it would be arranged. Residents said that their privacy is respected and people do knock before entering their rooms. There is an activity board displaying planned activities. A musician visits occasionally. Games are played on a Sunday afternoon. Quizzes are often organised by the staff. Mrs Deane has discussions with residents, they talk about the past and what they would like to do in the future (outings, etc). One resident said that they enjoy this time as it gets them talking together. There is a collection of videos and we were told that they frequently enjoy watching old films. One resident does a lot of knitting. The mobile library visits monthly. The daily records made by staff do not reflect the frequency of activity indicated by the activity board. Daily records also indicate that those more able residents benefit from greater recreational opportunities than those less able, and we discussed how this balance might be addressed with Mrs Deane. Comments received via surveys included: • “I feel there is a lack of things to do” • “More stimulation required on a daily basis” There is a portable telephone available to residents and two people have their own telephone. The visitors’ book near the entrance shows frequent and regular visitors to the home, and Mrs Deane confirmed that there is open visiting. Residents said that visitors were always welcomed and well received by the staff. Residents look after their own finances or have a relative doing so for them. Mrs Deane confirmed that the registered providers are not appointees for anyone at the home. The registered providers do hold some money securely on Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 16 site for residents. Mrs Deane confirmed this is transferred to individual accounts if it accumulates. There are appropriate individual records and receipts kept. There is a 4-week rolling menu, which is adjusted with the seasons. The menu only shows one choice, and does not show that alternatives are available. There are two cooks, one working 4 days/week the other 3 days/week. The main cook confirmed that alternatives are available, but undertook to ensure that residents are advised of the alternatives and to ask (and record) the residents for their choices. We discussed with the cook how this could be arranged on a more formal basis. The kitchen uses a mix of fresh and frozen vegetables, and fresh herbs are grown outside for use in cooking. Homemade cakes are provided at tea every day. The kitchen was seen to be clean and orderly and we were advised that it had been inspected by an Environmental Health Officer two weeks earlier. The cook confirmed that the home adheres to a kitchen cleaning schedule. We observed staff during lunch, some residents needed help with their meal and a member of staff was there to assist those who were not able to cope. A menu is shown to residents for the meals to be served the following day. One resident said that if someone does not like certain food then an alternative is offered. Everything is cooked on the premises and was well presented. Most of the residents cleared their plates. We were told that fresh fruit is available if requested. A piece of lemon curd sponge, made by the cook, was delicious. The residents have their own individually named napkin rings. The dining room was light and pleasantly furnished with patio doors on to a courtyard containing a fishpond, potted plants and seating. Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents said they would feel able to make any concerns known. Residents are protected by staff who have received relevant training in safeguarding. EVIDENCE: The home’s complaints procedure is displayed discreetly in every resident’s room and is included in the home’s Service User Guide. Mrs Deane undertook to review the contact details for the Care Quality Commission (CQC) and the Department for Adult Care Support (DACS). The Commission has received no complaints since the last inspection, though there is a current and ongoing safeguarding investigation. A comments/complaints book has been installed near the entrance. Comments from relatives and residents told us that people did know how to make a complaint, and were confident in the registered providers’ response. Most of the staff have received safeguarding training. There is an appropriate safeguarding procedure giving staff clear direction as to what to do in the event of an allegation of abuse. Mrs Deane undertook to include the contact details for the Department for Adult Care Support (DACS). Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment is clean and hygienic and provides comfortable facilities for the residents. There are signs of wear and tear that require monitoring to make sure that standards are maintained. EVIDENCE: The home does not employ a maintenance person. There are areas throughout the home that need attention such as, for example, patio doors that do not close or open properly. At the previous two inspections Mrs Deane said she would do a complete audit of the premises in order to produce an action plan of maintenance and repair work including priorities and timescales. Mrs Dean said she would forward a copy to the Commission. This has not happened. The benefits of employing a maintenance person were discussed with Mrs Deane. Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 19 The property is detached and has sea views on two aspects. The majority of the accommodation is located on the ground floor and this includes the two sitting rooms and the dinning room. It was noted again at the last inspection that some of the flooring in the communal corridors is covered with duck tape where carpets join and this is still the case. This could present a potential tripping hazard. Two of the bedrooms are located on the first floor with a bathroom and toilet within a close proximity. The stairs or a stair-lift access these rooms. A bathroom is also located on the first floor. Bathroom and toilets are also situated throughout the ground floor and within a reasonable distance from residents’ bedrooms and the communal areas. Some of the bedrooms are also provided with en-suite facilities. The residents’ bedrooms are well proportioned and many of the residents have personalised their rooms. Most of the rooms are very light, some with amazing sea views. Several have a balcony with seating and potted plants and some have a patio door enabling the resident to sit in privacy outside their room. They are painted in pastel shades and the residents have adapted them to their own personal needs. Several of the rooms have large fitted cupboards, giving them plenty of storage space. There was a television in each of the rooms that we saw. The rooms viewed had a sink with a bathroom directly outside. One had a sink and toilet and a heated towel rail for warm dry towels at all times. A laundry is also provided on site that is suitably equipped. The laundry was seen to be clean, but care needs to be taken to keep clean and dirty laundry separate. Gloves and similar protective equipment should be provided in this area. Mrs Deane confirmed that the home uses red sacks for fouled laundry. The laundry has domestic-style drying and washing machines. A range of disability equipment is provided at the home to assist residents to maintain their independence and also to promote their safety. In addition individual residents are provided with disability equipment where this is required and following an appropriate specialist assessment. Mrs Deane provided an invoice for work carried out in fitting thermostatic valves throughout the home. The registered provider showed the inspectors to a vacant bedroom to be used as an office during the inspection. Discussion again took place with Mrs Deane about the merits of having dedicated office space. Mrs Deane said that she would divide the large garage to provide an office so that managerial duties could be more easily carried out, and meetings could be held in comfortable privacy without imposing on residents’ accommodation. The home was adequately clean, with some exceptions and attention is needed in respect of infection control and maintenance: Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 20 • • • • • • • • • • An effective infection control procedure is needed Paper towels should be provided alongside liquid soap Two commode pans were seen (one dirty, one clean in appearance) in a bath, with 3 brushes and a floor cleaning cloth on the side of the bath in a bathroom used by residents Commode pans were soaking in another bathroom used by residents Reference should be made to the Control Of Substances Hazardous to Health (COSHH) guidelines The carpet in the upstairs bathroom needs cleaning Fire doors must be kept clear of obstruction There should be an oxygen sign on display on the outside of the garage entrances The fire escape should be maintained to provide a non-slip surface The doors onto the fire escape in upstairs rooms should be secured in a manner that complies with any fire brigade requirements Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff numbers are just sufficient to meet the needs of the residents, but the numbers do not currently allow for sufficient managerial time. Residents’ needs are largely met, but could be improved. Training and training records have improved. EVIDENCE: Shifts are arranged: 8am-2.30pm 2.30pm-9pm 9pm-8am There are usually three care staff on duty in the morning, two in the afternoon, and one at night (supported by the registered providers who live in the adjoining building and are available as needed). At the time of the inspection there were 3 staff and 15 residents. Staff carry out multiple roles (caring/cleaning/laundry). Additional staff can be provided at peak hours where required to make sure that residents have the level of care and support they require at all times. A number of residents said that they would not want to live anywhere else, and all were very complimentary about the owner, the Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 22 time that she spends talking with them, listening to the suggestions they put forward for future activities, and the way that they are treated. There is insufficient staff to carry out the cleaning and maintenance needed. Sufficient managerial hours are not shown on the duty rota. The registered manager is too often working as one of the care staff. This report identifies requirements and recommendations that require the registered manager’s attention. The registered providers share on-call cover at night, covering 7 nights a week. Mrs Deane said she would also be looking at including the deputy manager in the on-call rota. NVQ certificates are displayed in the entrance. There are 7 care staff (not including the registered providers) of which 6 have achieved NVQ Level 2 or above, or equivalent. Staff training records have improved and Mrs Deane has introduced an ‘at a glance’ training matrix. This uses a colour code to indicate training done, planned, or arranged. As discussed this record would benefit from the addition of dates of training. At the last inspection the registered provider, Mrs Deane, agreed to review the staff application form to allow more information to be asked for and provided (such as responsibilities in previous posts), and also to ensure that dates are provided by applicants, and referees details also include position/role/rank. Employment files seen were generally satisfactory, though Mrs Deane said that there had been no new staff since the last inspection. Mrs Deane is aware of the need for new staff to undertake a National Training Organisation compliant induction programme (www.skillsforcare.org.uk). Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Comments from the people that live at Chybyghan show that the home is run in the best interests of the residents, and since the last inspection there is increasing evidence to be confident in the management of the home. EVIDENCE: Both providers are involved in the running of the care home and both provide direct care, but Mrs Deane has an active daily involvement. One of the Providers, Mrs Deane, is also the registered manager and has successfully completed the Registered Managers Award. Mrs Deane has made significant improvements since the last inspection, but further continued improvement is needed. Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 24 The registered manager is too often working as one of the care staff. This report identifies requirements and recommendations that require the registered manager’s attention. It is clear that residents are regularly consulted about the quality of the service and facilities provided. From the consultations that take place the indications are that residents are satisfied. We were shown two returned quality assurance questionnaires. Mrs Deane agreed to continue with and expand the use of these questionnaires, publishing a summary of the findings and any action taken as a result (probably in the homes’ Service user Guide). The providers will assist residents to manage their personal allowances if this is required and suitable records are maintained. The records detail the transactions that have taken place and a running balance is maintained. The registered provider, Mrs Deane, has bought some bound notebooks and said she would be replacing the current loose-leaf records with these. Money and valuables are stored securely. Staff comments at the time of the inspection and staff files confirm that they are being supervised, though as yet not at the frequency required. This was discussed with Mrs Deane who said they would adhere to the 6 times/year frequency. The staff supervision records seen were detailed and informative. Staff supervision is supported by an annual staff appraisal. There is sufficient and appropriate insurance cover for the service. Fire equipment and appliances at the home are monitored and maintained and staff are regularly trained. There is a comprehensive fire risk-assessment in place. Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 X 3 3 X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 3 3 Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 14 Requirement The registered provider must review the care plans to ensure they accurately reflect the care needs of the residents, and clearly instruct staff on the interventions needed to meet those needs. The registered provider must involve the resident, wherever possible, in the development and review of their care plan. This requirement was made at the previous inspection. Arrangements must be made to 01/09/09 ensure that all medicines are stored securely including those requiring refrigeration. This is to ensure that they are kept safely and only authorised people have access to them. 01/09/09 Arrangements must be made to ensure that there is a record of the receipt, administration and disposal of all medicines received into the service. This is to ensure that medicines are handled safely and reduces the possibility of any diversion DS0000062587.V376165.R01.S.doc Version 5.2 Page 27 Timescale for action 01/09/09 2 OP9 13(2) 3 OP9 13(2) Chy Byghan 4 OP26 13, 16 5 OP27 18 occurring The registered providers must seek professional advice and develop an infection control policy and procedure suited to the care home. The registered providers must ensure that the registered manager’s managerial hours are increased and shown on the duty rota (as distinct from care hours). The registered provider must arrange for sufficient staff to carry out the cleaning and maintenance needed. 01/09/09 01/09/09 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 OP1 Good Practice Recommendations The registered providers should consider how to improve how information about the service, and how it is made available to people that use it (e.g. dated, alternative formats: audio/video, and the inclusion of a summary of the findings from quality assurance surveys). The registered provider should review the pre-admission assessment form to include information about the persons’ history, important contacts, and preferences. The assessment should allow for detailed comment in addition to the use of the tick (√) boxes. The registered provider should ensure a proactive approach to meeting the care needs of the clients, including liaison with relevant agencies where necessary. It is recommended that when variable doses are prescribed that there is a clear direction about how the dose to be administered is determined and then the actual dose administered is recorded. It is recommended that the home review their current DS0000062587.V376165.R01.S.doc Version 5.2 Page 28 2. OP3 3. 4 OP8 OP9 5 OP9 Chy Byghan 5 OP9 6 7 8 9 OP12 OP15 OP26 OP33 medicine policies with regard to current best practice guidance and also review how competency of those administering medicines is assessed and recorded. It is recommended that the home look at how they will monitor the temperature range of the fridge should they have medicines prescribed that need to be stored in this way. The registered provider should ensure that the daily entries reflect the lifestyle of the residents and the social/recreational activities available to all. The registered provider should include alternatives available on the menu, and keep a record of the choices made by the people that live there. The registered provider should ensure there are sufficient resources to maintain cleanliness and maintenance of the property. The registered providers should continue with and expand the use of quality assurance questionnaires, publishing a summary of the findings and any action taken as a result. Chy Byghan DS0000062587.V376165.R01.S.doc Version 5.2 Page 29 Care Quality Commission South West Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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