Inspection on 28/11/06 for Cleggsworth Care Home Ltd

This inspection was carried out on 28th November 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cleggsworth Care Home Ltd 15/06/09

Cleggsworth Care Home Ltd 15/07/08

Cleggsworth Care Home Ltd 12/07/07

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Cleggsworth Care Home Ltd 7/11 Little Clegg Road Smithybridge Littleborough Lancashire OL15 0EA Lead Inspector Mary Corcoran Unannounced Inspection 28th November 2006 08:45 X10029.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and 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. Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cleggsworth Care Home Ltd Address 7/11 Little Clegg Road Smithybridge Littleborough Lancashire OL15 0EA 01706 379788 01706 378330 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) Cleggsworth Care Home Ltd Mrs Audrey Bolton Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 38 service users to include: *up to 38 service users in the category of OP (old age not falling within any other category). 19th June 2006 Date of last inspection Brief Description of the Service: Cleggsworth House was previously owned by the Aegis group of care homes; since September 2006 it has been owned by Cleggsworth Care Home Ltd and is therefore classed as a new registration. Cleggsworth House is registered to provide personal care and accommodation for 38 older people. It caters for both long term and respite stays. The home is located in Smithybridge village which has a variety of shops and other amenities close by. It is near to public bus routes and the train station is in close proximity. The home consists of a two-storey building with purpose built extensions having more recently been added. With the exception of one double room, all rooms were single. Ensuite facilities were provided in 8 of the bedrooms. There is ramped access to the front entrance and a passenger lift is provided. Garden areas are provided to the rear of the building. The home’s Service User Guide advised residents and their relatives that the most recent Commission for Social Care Inspection (CSCI) report was available in the entrance area. Copies were seen to be displayed there. At the time of this inspection weekly fees ranged from £331.42p to £450 per week. Additional charges are made for hairdressing, podiatry and newspapers. Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report has been written using information held on CSCI records and information provided by people who use the service, their relatives, professionals who visit the home, the manager and staff at the home. A site visit to Cleggsworth House on 28 November 2006 took place over 8 hours. In addition to the lead inspector, a CSCI regulation manager spent 4 hours at the home. The home had not been told beforehand when the inspectors would visit. Inspectors looked around the building and looked at paperwork that had to be kept to show that the home is being run properly. To find out more about the home the inspectors spoke with 3 residents, 2 visitors, one senior carer, two carers and the manager. Questionnaires/comment cards asking residents, relatives and professional visitors what they thought about the care at Cleggsworth House had been given out a few weeks before the inspection. Three residents, five relatives and six GP’s filled the cards in and returned them to the CSCI. Their comments will be included in this report. What the service does well: What has improved since the last inspection? Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 6 Supervision of staff is now ongoing but is not yet as frequent and consistent as it could be. Training is in place for senior staff who will be supervising care staff. More staff have been trained in fire safety, food hygiene, infection control, moving and handling and first aid. A new induction process from Skills for Care has been obtained and will be used to make sure new staff are fit to work with the residents. A new assessment (Skills Scan) has been introduced which looks at all areas of a staff member’s skills and highlights which areas need more training. The manager is going to use the basic assessment when she is recruiting new staff so that she can be confident of their ability to do the work. A pressure relief plan is now in place for residents which is kept in their bedrooms. The plan sets out how to minimise the risk of pressure sores. Safety locks are now on bedroom doors. What they could do better: 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. Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users have enough information to be confident that the home can meet their assessed needs. EVIDENCE: The manager said that a statement of purpose and a service user guide is given to everyone who enquires about the home. Relatives and service users confirm this, one service user said ‘ my daughter got it all.’ The service user guide and statement of purpose have all the required information in them, Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 9 including information about complaints and are being updated to reflect the change in ownership, although there is no information about the qualifications and experience of the new owner. All the people who returned questionnaires said they had received enough information about the home. Service users have a copy of the guide in their bedroom and there is a signed contract of terms and conditions in the three personal files that were looked at. One relative said that the contract had been updated and ‘changed for the new owner’. One resident said that her family ‘does all the money, they tell them how much it is but it comes out of my money!’ There were copies of letters in the relevant files giving good notice about increases in charges. At the time of the inspection, the manager said that all information is available in the normal printed format but if anyone wanted it, they could look into translating it into Braille. It would be good practice to look at different ways of presenting the information and actively asking people what format they would prefer. Three service user files were looked at and all of them had full assessments of need which were carried out before the person came to live at the home. The assessments are very thorough and are carried through to the careplan. The care plans are reviewed every month or more frequently if needed and are signed by the service user and/or a relative. Risk assessments are in place and are also reviewed regularly. Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that on the whole, their personal and health needs are met and that their privacy and dignity is respected. EVIDENCE: The Pharmacy Inspector inspected medications systems on 17 November 2006. A separate report is available for this visit. Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 11 The three care plans that were inspected were found to be thorough and followed the assessments of need. Following a hospital consultation, a consultant had advised that one service user was provided with a glass of full cream milk at every meal. The care plan stated this need and the milk was observed to be taken to the service user. A relative also confirmed that this was happening. The same consultant recommended a sensor pad for the bed so as to alert staff when the service user wanted to get out of bed and lessen the risk of falls. Two sensor pads are currently being repaired and an interim measure has been put in place with a signed authorisation from a relative. The sensor pad should be repaired as soon as possible or another one bought. The care plans are quite repetitive and not always easy to follow, for example it was difficult to find weight monitoring which was eventually found in two separate places. The manager said that she is looking into a more user friendly careplan system. One relative said “Although I sometimes feel there is not enough staff, my mum always has excellent care, I couldn’t be more happy! I am always made to feel welcome”, another relative who was visiting at the time of the inspection said ‘they always let me know if there’s a problem, the staff are exemplary.’ All the people who returned questionnaires said that that they were happy with the overall care of their relatives and all the service users who responded said that they received the care they needed. One relative said ‘ I would also like to comment on the vast improvement in his mental state over the last 12 months in your care.’ The three service users that were spoken with said they were happy, one person said ‘it’s not like home but they do look after you.’ All the residents looked clean and well cared for and wore appropriate clothing. One service user was observed in the ground floor dining room after breakfast, waiting for 20 minutes for assistance. In the upstairs dining room, residents were seen to be assisted within appropriate timescales. At the time of the inspection, there was only one person who was responsible for her own medication. She has a lockable cabinet in her room for safe storage. There is a risk assessment in place which is not very comprehensive and gives no real indication of levels of risk. It is recommended that the manager researches a more relevant and safe risk assessment for self medication. Discussions with staff showed that they understood the principles of dignity and respect. During the inspection, the manager and staff were observed to be respectful, knocked on doors and were discreet in assisting with personal care. Pressure relief plans are in place, with requirements for monitoring turning and movements to lessen the chance of pressure sores. There needs to be a clear system for recording that how the plan is being carried out. Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users maintain links with family and the local community and have choices about how they live but have a restricted choice of activities in and out of the home. EVIDENCE: Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 13 Service users who were spoken to said that they were happy in the home and could do more or less what they wanted. Some people preferred to stay in their rooms, others preferred to sit in the lounge. There is an activity programme on the notice board but at the time of the inspection there was no organised activity taking place. Most of the service users were dozing, watching television or talking with their visitors. One service user said ‘thank goodness for television or we’d all be sat looking at each other.’ Three people were asked what they’d be doing during the day, all three said they’d be doing nothing much. When asked what they’d like to be doing, one person said ‘having a good feed’, one person said ‘I like drawing and painting and playing the organ’ and one person said ‘anything really’. Of the three service user questionnaires returned, one said there was always something to do, one said there usually was and one said there was never anything to do. The service user guide says that suggestions or offers of support can be discussed with the care manager or the activities co-ordinator but there is no activities co-ordinator at the home. An ‘A’ on the rota indicates which staff member is responsible for the day’s activity. Staff spoken with say that they are understaffed and do not have time for activities. One member of staff said ‘activities are important for stimulation but personal care needs come first.’ One staff member said there is no time to sit and chat with people and that the residents notice this. Although the assessments and careplans identify people’s preferences, there is little opportunity to support them in the home. The manager said that there had been trips to Blackpool and a garden centre but apart from this, the only time that most service users get out is when family or friends take them out. One person continues going to a day centre which she attended before moving into the home; the manager said she had to fight for this because of funding issues. There is a monthly church service provided by a local church minister and communion, but one person who used to go to church on Sundays cannot now go because there are not enough staff available for support. At the time of the inspection the manager said there were no residents from a minority ethnic background. One relative who was spoken to said that there wasn’t much going on but that his relative was ‘not a good mixer and usually stayed in her room anyway.’ Service users are encouraged to keep in contact with their relatives and friends. During the inspection, several visitors arrived at the home, they were warmly welcomed by the manager and staff and were able to visit service users in the lounge or in the bedrooms. The manager made time to speak with visitors and answer any queries they had. One relative said he could visit his mother in the lounge, her bedroom or the ‘quiet lounge’ and ‘Yes, I can come anytime I want and I’m welcome every time.’ All five relatives who returned comments cards said that they can visit their relatives at any time in private and are made welcome. One service user said that her family often came to visit and that they took her out for tea which she always looked forward to. Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 14 The menu was varied and nutritious with choices at each meal. The menus were on the table and staff were observed to be supporting people to make a choice. Breakfast was ongoing so that people could eat when they wanted. Service users can have their meals in their bedrooms if they prefer but are encouraged to eat in the dining rooms so they can socialise. On the day of the inspection, breakfasts were varied and un rushed. Lunch was attractively presented, nutritious home cooked food. There was a choice between meat pudding or meat balls, potatoes and two veg, (cabbage and a root vegetable) and baked egg custard. The tea menu was soup or fruit juice, tongue salad or sandwiches and jelly and cream. The manager said that the menus take into account service users preferences. Special diets are catered for. There is a chart on a clipboard hanging on the wall of the dining room to show what certain residents have eaten or what they haven’t eaten. It would be good practice to move the chart to a more discreet position. One service user said ‘the foods good, it always is.’ One relative said ‘the food is superb, good quality.’ A member of staff was observed asking the manager for one resident’s a supplement drink as she often ate a bit more if she had the drink during her meal. Several people needed either full or part assistance with their meal. Assistance was offered respectfully but as there were only two members of staff on the ground floor, one person was left sitting at the table for some time before she was assisted with her meal. Staff spoken with confirmed that sometimes there is only one carer on duty and a senior doing medication so that if three service users need assistance at mealtimes, they have to wait. At breakfast there were no tablecloths; the manager said that there weren’t enough tablecloths for every meal but that they were used at lunch and tea time. Clean, ironed tablecloths were used at lunchtime on the day of the inspection. The teapot being used was large and institutional looking which didn’t fit with the homely feel to the rest of the setting. The manager should provide smaller, more homely teapots for each table. Residents were asked if they wanted to use an apron to protect their clothes, these were mostly the same colour which didn’t allow for individuality. Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users and their relatives feel that they are protected by the home following its policies and procedures. EVIDENCE: The complaints procedure is included in the service user guide and the statement of purpose and is displayed on the notice board in reception, although it is amongst other notices and is not easily noticed. Staff files show that staff have signed that they have read the home’s policies for complaints and POVA (protection of vulnerable adults) and most staff have now been trained in POVA including nine staff since the last inspection. Four more staff are booked on the POVA course on January 2007. A whistle blowing procedure is in place as is a copy of Rochdale social services department’s inter-agency protection procedure. In discussions with staff, it was clear that they could recognise different types of abuse and knew the procedure for dealing with it. One member of staff Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 16 included ‘doing things for people when they can do it themselves’ as a kind of abuse, ‘taking away their independence.’ The home’s complaints file contains hard copies of all complaints. There have been two complaints since the last inspection, the outcomes being unclear, with none received by CSCI. The complaints log could be improved by having a chart in the front of the file which shows clearly the progress and the outcome of each complaint. Service users who returned questionnaires said that they always or usually knew how to make a complaint and who to speak to if they were unhappy. Four relatives who sent in comments cards were aware of the complaints procedure and two had actually made complaints. One relative said that “Things have sometimes gone missing and I have had to report these issues, ie glasses, clothes in other people’s rooms”. The manager said that she asks that all clothes are labeled but sometimes new clothes are brought in and not labeled and can therefore be mislaid. Residents and relatives who were spoken with all knew how to complain, they said ‘I’d speak to Audrey’ or ‘tell staff’ and ‘the complaints guidance is in the contract.’ New staff are not taken on until all the necessary safety checks are carried out. Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21, 23, 24, 25, 26. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users can feel that with extra security measures they can live in a clean, safe, well maintained and homely environment. EVIDENCE: Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 18 There is ramped access and a small parking area to the front of the home. The inspector walked around the home. There is a lounge downstairs and a dining room. There is a further lounge/dining room on the first floor. Both lounges were spacious with adequate seating and adequate occasional furniture. The lounges and dining room were clean, warm and nicely decorated. There were enough toilets and bathrooms to meet the needs of the residents. Toilets were in close proximity to bedrooms and communal areas. Each toilet and bathroom had a lock on the door to ensure privacy and the facilities were clearly marked. Thermostatic control valves were in place on immersion baths It was evident that there continues to be an ongoing programme of redecoration and refurbishment. There were some small windows open to allow fresh air into the lounge. There was a slight odour in the reception area in the morning but was not noticeable later in the day. At lunch and tea (but not breakfast) there were clean, well ironed tablecloths on the tables and small vases of flowers. The majority of bedrooms were bright and clean and service users had brought some of their own possessions to make their rooms more homely. The staff all said there was enough bedding so that there was never a problem in people having clean bedding when they needed it. Hand washing facilities are in place in bedrooms, bathrooms and toilets. The water temperature at the hand basins in the toilets is excessive and requires attention. A regular supply of paper hand towels is available. Good hygiene was observed with staff using different coloured aprons for different tasks. The used linen trolley did not go through living or dining areas on its way to the laundry. Clinical waste was handled appropriately and the manager informed the inspector that the home was in the process of negotiating a new contract for the removal of clinical waste. A copy of this contract will need to be sent to the inspector. The laundry was small and clean and well organised. There had been a complaint about clothes being put in the wrong room; the manager said she asks that all clothes are labelled but sometimes new clothes are brought in without staffs’ knowledge and they slip through the net. The manager said that service users do not have their own individual linen baskets because the laundry was too small. Adequate equipment was in place and protective clothing was available. At the last environmental health inspectors visit the home was asked to undertake a risk assessment in relation to infection control within the laundry and a risk assessment for ventilation in the ironing room. These need to completed. The home had a detailed Health & Safety Policy. Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 19 Residents were observed to be able to get around the home fairly easily. Appropriate aids and adaptations are fitted in bathrooms, toilets and corridors so that residents can remain as independent as possible. There was a choice of two dining rooms and two large communal ares for residents and their relatives to use. There is a passenger lift and ramps throughout the building. Wheelchairs and portable moving and handling equipment is a hazard in the corridors, appropriate storage must be provided. Relatives who were spoken to were happy with the standards of cleanliness at the home, one person said that ‘it’s very well run and clean’ and two service users who returned questionnaires said that the home was always fresh and clean and one person said it usually was. The manager said that one particular carpet is shampood almost every day if necessary. There have been two recent instances of service users being able to go out of the home in the late evening and the early hours of the morning without staff noticing. Neighbours have brought the people back and were able to walk into the home. They both said that their reception was not welcoming and that they felt there was little empathy for the cold, confused residents. A doctor also said he was able to walk into the home and roam around unchallenged. The home is required to make the premises secure so that people who live at the home can be safe and secure. Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 28, 29. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users are protected and needs are met by the recruitment procedures and staff skills, but not by the numbers of staff on duty at any one time. EVIDENCE: Because of previous concerns about staffing levels, the home was asked to send staff rotas to CSCI every fortnight. This procedure has been reinstated in November 2006. There had been five phone calls to CSCI in October 2006 where people expressed grave concerns about the low levels of staff on duty, the effect is was having on staff health and shortcuts being taken which could put service users and staff at risk. Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 21 A minimum of 5 staff members on duty between 8am and 10pm was required at the last inspection with the manager being supernumary. At the time of this inspection there were four care staff on duty. The home was caring for 32 residents, eight people needed two staff to assist them to move, and four people needed assistance at mealtimes. As the home has bedrooms, lounges and dining rooms on two floors, staff were split into teams. Two staff in each team was not sufficient to respond quickly in the mornings. One service user was observed to be waiting for assistance in the dining room for 20 minutes after breakfast. There were also eighteen people who need assistance with continence management, with varying degrees of dependency. From the questionnaires received, one service user said that staff were always available when they needed them, two people said this is usually the case. Comments from relatives include ‘although I sometimes feel there is not enough staff, my mum always has excellent care’ and ‘not always a lot of staff but they do look after her.’ The staff rotas for the home showed that over the last two months staff levels have fallen consistently below the levels required to ensure the safety and wellbeing of service users and staff. Some members of staff have been working long hours without a break. This is confirmed by looking at the rotas and from telephone calls from staff members. Because of the low staffing levels, the manager has not been able to fully carry out her managerial duties of supervising staff, monitoring care plans and generally attending to the development of the home. In order to improve the situation the home must continue their recruitment drive until a full staffing complement is in place, negating the need to use agency staff. Bank staff should also be employed to cover staff sickness and annual leave. The manager must make sure no less than five staff are on duty at all times, not including the manager, with an additional staff member on duty in the morning whilst current residents’ dependency levels and the staffing situation continue. There has been an increase in staff training since the last inspection; there is a clear training matrix in place which shows that 9 more care staff have been trained in infection control, 15 more trained in moving and handling, eight more people have been trained in fire safety, 5 in health and safety, 14 in basic food hygiene, 5 more people in first aid and 2 people trained in POVA (protection of vulnerable adults) with 4 more people booked in for training in January 2007. In addition, 8 non care staff (kitchen, domestic and laundry staff) have been trained in infection control, 2 in moving and handling, 3 in first aid, 3 in basic food hygiene and 1 person in POVA. Discussions with staff and evidence in staff files confirms that the extra training has taken place. Inspection of three staff files showed that satisfactory recruitment and selection procedures are in place. The recruitment and selection policy had been reviewed and all senior staff issued with a copy. The home’s policy of Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 22 taking two written references prior to appointment and Criminal Records Bureau (CRB) checks were also in place. Recent photographs of staff were held on the files. Files showed that staff had undergone induction in all the required areas and staff spoken with were able to talk through the areas they had to cover before they were allowed to work on their own. A member of staff who had recently been employed at the home said she felt confident and competent to do her job after the induction. Staff files were tidy, well organised and easy to work with. There have been two recent instances of service users being able to go out of the building in the late evening and the early hours of the morning without staff noticing. Neighbours have brought the people back and were able to walk into the home. They both said that their reception was not welcoming and that they felt there was little empathy for the cold, confused residents. A doctor also said he was able to walk into the home and roam around unchallenged. A requirement is made that there are at least five staff at all times plus the manager and three staff on at night to minimise the risk to service users. Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 24 31, 33, 35, 36, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from the good character and fitness of the manager who runs their home, but their health, safety and welfare can not be ensured at all times. EVIDENCE: The registered manager of the home is well qualified with an NVQ level 3 and 4, registered managers award and has more than 20 years experience working with older people in a residential setting. She is highly thought of by staff and service users. One relative said they had picked this home partly because of the reputation of the manager. The manager is offered no professional supervision meetings. The manager is not able to fully carry out her managerial responsibilities because the staffing levels are such that she has to give out medications and work in a care staff capacity. This means that staff supervision, team meetings, monitoring of careplans and other organisational management duties can not always be fitted in during her working hours. One member of staff said that previously when the manager was occupied in managing the home and there were enough care staff on duty, the senior care staff ‘ran the shifts’ and administered medicines and organised staff. They now feel this has been taken away from them. Talking with service users, they said that they do have a say in how the home is run and they sometimes have meetings, all three service users that sent in questionnaires said that staff always listen and act on what they say. The manager says that there are residents meetings every three months and that questionnaires are sent out. Records were not looked at during the inspection. Personal money for some service users is kept in a locked cash box in a locked safe with the keys held securely. Each person’s money was seen to be kept in a separate, labelled wallet with clear evidence of transactions and a correct balance. Staff supervision was not consistent. Files showed that two staff members have had only had one supervision whilst another person has had three meetings since the last inspection. One staff member said that she used to have supervision until ‘that person left, now they’ve stopped’. Two staff members said they have team meetings sometimes, one staff said there were Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 25 senior carers meetings and then two way feedback at care staff meeting. Records of team meetings were not inspected at this time. Regular weekly checking and testing of fire detection system, fire exits and emergency lights was undertaken and documented. Any accidents that happen are properly recorded and monitored, though some of these incidents are not being reported to the CSCI under Regulation 37. Information records showed that the equipment and services within the home were serviced on a regular basis, in accordance with the individual requirements. In addition the Inspector checked the documentation in relation to the servicing of the fire alarm system, the 5-year electrical certificate and small electrical appliance testing were all up to date. The 5-year electrical certificate will need renewing and the fire risk assessment will require updating. An easy to follow record of all companies who service the home should be kept with a date that the next service is required. This needs to be done to ensure that no servicing is missed especially if the home is seeking new contracts with new providers. Since the last inspection, 16 members of staff have attended infection control training and staff spoken to were fully aware of infection control and hygiene procedures. Cleggsworth Care Home Ltd DS0000068123.V316127.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 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 3 2 3 3 3 4 x 5 x 6 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 ENVIRONMENT Standard No Score 19 2 20 3 21 3 22 x 23 3 24 3 25 3 26 3 STAFFING Standard No Score 27 1 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 x 33 2 34 x 35 3 36 2 37 x 38 2 Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? New service 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 OP12 Regulation 16, 2(m) and 2 (n) Requirement There must be an activity coordinator or sufficient staff employed so that people who use the service are offered a regular programme of activities in the home and in the local community taking into account people’s assessed needs and interests. There must be five care staff on at all times during the day, and three care staff on duty at night, not including the manager, to ensure that people who use the service are properly supported. Timescale for action 31/01/07 2 OP27 18, 1(a) 31/10/07 3 OP36 18, 2(a) All care staff must be supervised 31/12/06 regularly, at least six times a year and all other staff at regular intervals so that service users benefit from competent and supported staff. Appropriate storage must be provided for wheelchairs and moving and handling equipment to make sure that corridors are safe and free from hazards. DS0000068123.V316127.R01.S.doc 4 OP38 13, 4(a) 31/12/07 Cleggsworth Care Home Ltd Version 5.2 Page 28 5 OP38 37, 1(a to g) When any incident occurs at the home which might affect the service or the people who live in the home, the manager must notify CSCI as soon as possible in writing. The manager must send a copy of the contract for disposal of clinical waste to CSCI to ensure that procedures for protecting service users are being followed. The water temperature at the hand basins in the toilets is excessive and need attention so that the risk of scalding is eliminated. The external doors must be secure so that service users’ safety is promoted. 31/12/06 6 OP38 13, 3 31/01/07 7 OP25 13, 4(c) 31/01/07 8 OP19 23, 2(a) 21/12/07 9 OP9 13(2) 10 OP9 13(2) 11 OP9 13(2) The Registered Person must 01/12/06 ensure that all medication is administered as prescribed, at the right times, and in accordance with any special instructions e.g. ‘Before food’ to make sure they work properly. The Registered Peron must 30/12/06 ensure that complete and accurate records for administration of all prescribed medication (including creams) are maintained to support their correct use. The Registered Peron must 30/12/06 ensure that care plans fully describe the responsibilities of carers assisting with the safe administration of medication to help ensure residents receive the support they need. Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 29 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 OP7 Good Practice Recommendations Sensor pads must be repaired speedily or new ones purchased so that recommendations from hospital can be implemented and service users’ health and well being is promoted. Care plans should be simplified so that information is easier to find and is not duplicated, making it more efficient in meeting people’s needs. Risk assessments for people who take responsibility for their own medications should be more detailed and agreed and signed by the service user to ensure that medications are taken as safely as possible. Records on the dining room wall which reveal details of people who live at the home should be held discreetly so as to preserve dignity and privacy. Teapots used in the home are large and institutional looking, the home should consider providing smaller, homely teapots for each table, this along with using tablecloths at breakfast would ensure a more homely, personal atmosphere at mealtimes. The complaints file should be up dated so that it shows clearly the dates, progress and outcomes of any complaints that have been made. An easy to follow record of all companies who service the home should be kept with a date that the next service is required to ensure that the home is kept well maintained and safe. The Registered Person should ensure that the medication refrigerator is regularly defrosted. The Registered Person should consider making improvements to the medication storage. DS0000068123.V316127.R01.S.doc Version 5.2 Page 30 2 OP7 3 OP9 4 OP10 5 OP15 6 OP16 7 OP25 8 8 OP9 OP9 Cleggsworth Care Home Ltd 10 OP9 The registered person should audit the management of the medication rounds to make sure enough time is left between does of the same medicine and to make sure the trolley is locked when unattended. Cleggsworth Care Home Ltd DS0000068123.V316127.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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. 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