Inspection on 20/10/08 for Cloverdale Care Home

This inspection was carried out on 20th October 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cloverdale Care Home 21/11/07

Cloverdale Care Home 17/08/06

Cloverdale Care Home 03/03/06

Cloverdale Care Home 21/10/05

Cloverdale Care Home 20/01/05

Cloverdale Care Home 13/07/04

Cloverdale Care Home 06/02/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Cloverdale Care Home 68 Butt Lane Laceby Grimsby North East Lincs DN37 7AH     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Wilma Crawford     Date: 2 0 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. 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 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 35 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 35 Information about the care home Name of care home: Address: Cloverdale Care Home 68 Butt Lane Laceby Grimsby North East Lincs DN37 7AH 01472877000 01472877010 surinder.khurana@ntlworld.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Dryband One Ltd care home 40 Number of places (if applicable): Under 65 Over 65 15 40 dementia old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home 0 0 Cloverdale Care Home is registered for the care of forty people with residential care needs. The home is situated on the outskirts of Laceby village, in North East Lincolnshire, about six miles south of the town of Grimsby. The home is purpose built, with accommodation being provided at ground level. All forty bedrooms are single and thirty-nine have en-suite facilities. The home has four bathrooms with toilets and an assisted shower room. There are also four single toilets throughout the home strategically placed for ease of access. The home has two lounges, a spacious conservatory and a dining room; since the nosmoking regulations came into force in July 2007 the home provides people with a specific smoking area. Cloverdale Care Home is set in its own grounds and enjoys a pleasant aspect of open countryside. A paved walkway surrounds the home and there are ample parking Care Homes for Older People Page 4 of 35 Brief description of the care home spaces to the front of the building. The home is well maintained, clean and has a homely feel. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the manager of the home. A copy of the latest inspection report for the home is also available from the manager. Information given by the home administrator on 20/10/08 indicates the home charges a fee from 345.45 to 394 pounds per week and that there are no additional charges other that those for hairdressing, private chiropody treatment, toiletries and newspapers/magazines. A full list of prices for these additional services is available from the manager. Care Homes for Older People Page 5 of 35 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last key inspection of the home on 21st November 2008, including information gathered during a site visit to the home. The site visit was Care Homes for Older People Page 6 of 35 unannounced and took place over eight hours including preparation time. The main method of inspection used was called case tracking which involved selecting three people living in the home and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. The premises were looked at and the records of three people living in the home and two staff were inspected. Four staff and five people living in the home were also spoken with.The comments and views of people spoken with are included within this report. An aqaa document asking for information about home was sent out before this visit and information from this was included as part of the inspection process of this service. Surveys were sent out, completed and returned by 2 professionals,5 relatives,5 staff members and 5 people living in the home. The comments from these are also included in the report. The fees charged were from 345 pounds to 394 pounds at the time of the visit on 20th October 2008. Due to unforeseen circumstances the report took six months to be published and it is recognised that the home may have taken action to address the areas identified in this inspection report during this time. This would be confirmed at the next key inspection visit. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking Care Homes for Older People Page 8 of 35 following this report, you can contact them using the details set out 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. Care Homes for Older People Page 9 of 35 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 35 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Overall people who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to the service. The majority of people are provided with enough information about the home to assist them to make an informed choice about the service. Information about the home has not been made available in other language formats for people from other ethnic minority groups, although people from these groups access services from the home. The information documents have not been updated to reflect management changes or how to contact the CSCI. People have their needs assessed before moving into the home although this assessment needs to be continued following admission to ensure all individualised care needs are identified and met. Care Homes for Older People Page 11 of 35 Evidence: The home, has a detailed statement of purpose and service user guide which gives clear information about the services provided,however the copy available did not include details of the current management arrangements or the correct contact details for the Commission for Social Care and Inspection. The team leader was able to confirm that people living in the home are given copies of these documents when they are considering moving into the home. The home provides a service to people from different ethnic backgrounds, the documents are not provided or available in other formats. Three care plans were examined and each contained a copy of individual community care assessments, a pre asessment and a copy of a letter from the home confirming that their needs could be met. People who completed our surveys, except for one said that they had received enough information prior to moving into the home. Staff spoken with, confirmed that people considering a move to the home and their relatives are invited to visit, before making a decision about the home before they moved in. Evidence from the Annual Quality Assurance document and discussion with the staff team identified that the majority of staff have completed mandatory training, but have not had access to a range of more specialised training so they have the skills and knowledge to deliver the specific care needs associated with the ageing process. Care Homes for Older People Page 12 of 35 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service experience adequate quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Care plans are in place to support the areas of need for the individual, however some of the plans are not sufficiently individualised to support a person centred care approach , not all care support has been recorded to protect peoples health and welfare. Evidence: Three care plans were looked at, the first was for an individual from an ethnic background which did not use English as their first language, none of their care plan was available to them in their first language or signed by the individual. Staff spoken with said that they could use non verbal communication with the person and that two staff members were able to converse with the individual to a degree in their own language. The care plan was not signed by the individual or their representative. There was no evidence to support that this had been discussed with the individual or that an advocate or translator had been accessed to ensure that the individual had been Care Homes for Older People Page 13 of 35 Evidence: involved in the development of the care plan or had agreed the content of it. The other two care plans seen had been signed by the individual or their representative. The care plans examined did not offer guidance to staff on how to support individuals when people presented challenging behalviour or declined to accept support from staff with care tasks. There is good evidence that regular evaluation of the care plans takes place, the majority of records seen contain a good standard of specific information relating to peoples preferences to their care support however this information needs to be incorporated into the plans themselves. Daily records of care were well maintained and up to date. However, the quality of some documentation was inconsistent. Some entries were detailed and explicit, fully describing the care delivered whilst others were minimal. There is a need for staff to be clear about the level of information to be recorded in line with the individuals support plan. One member of staff spoken with said that they had not had the opportunity to read any care plans , but were guided by their colleagues as to what care needed to be delivered. Staff should be aware of the content of the care plans for all individuals whose care they are involved with, in order that people using the service can be supported in risk taking appropriately and safely. Risk assessments are carried out to identify any risks to the individual. Identified risks a care plan is produced to minimise the risk. Nutritional screening records are in place and these are completed on admission to the home. Records of individuals weights gain or loss and food charts are completed for staff to monitor peoples nutritional intake. There was evidence to confirm that any concerns relating to this are referred to the G.P. Tissue viability assessments are also in place to identify peoples individual needs and how they were managed. Professionals stated that overall their instructions were followed, but there were occassions where they felt their instructions were not adhered to. People living in the home and their relatives said that overall they were happy with the standard of care , but there was some room for improvent. Examples given included, having to wait for long periods for assistance during busy times and items not being returned from the laundry. People living in the home said that the staff were good and patient with them. Individual files seen showed that reviews are carried out regularly with the individual and their relatives, giving them the opportunity to input into their care plans. Staff were seen to respect the privacy and dignity of people in the home, and were seen to respond to individual requests, however during busy times people were approached and an explanation given as to how long they would be before their request could be met. Observations on the day were that staff were mindful of peoples needs and supported Care Homes for Older People Page 14 of 35 Evidence: people in a respectful manner at all times. The medication was checked and found, the home uses an approved Monitored Dosage System for the administration of drugs. Medication records showed that all drugs administered were recorded on the individuals records sheet. There were no gaps in recording seen. Procedures are in place for the appropriate storage , disposal and recording of all medicines. The senior staff have responsibility for the administration of all medicines in the home and use a monitored dosage system. Transcribed medicines are signed for by two staff members. Controlled medicines were found to be appropriately stored and stock levels checked corresponded to the records maintained by the home Care Homes for Older People Page 15 of 35 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service experience adequate qualiy outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Activities provided in the home are limited to the more able bodied people living in the home, resulting in the people with more specific identified needs being offered little opportunity for stimulation or recreational activities to suit their needs. food and drink provided are of a good standard and people are enabled to maintain contact with their rlatives and friends as they wish. Evidence: There is a programme of ativities in place in the home, including bingo, games cards and dominoes,puppet making and line dancing. One lady was observed making a puppet during the visit. An activities coordinator is available one hour each day. A previous requirement was made identifying the need for more for appropriate activities for people unable to join in group activitiess or who are less abled bodied. Although plans for this had been discussed previously, there was no evidence of this being in place. people said they had the choice of joining in with activities or not, some found the range of activities more suitable than others. Some people said that they would prefer smaller groups or more one to one activities, for example the opportunity Care Homes for Older People Page 16 of 35 Evidence: to go out. Three people attend the WRVS club and another attends the Friday club, transport is provided to enable this. There is also a range of DVD,s that people can choose to watch in in a lounge or in their own rooms. Participation and preferences of activities was not found to be recorded in individuals files, therefore it is difficult to establish what selection of activities are offered to the people who have more complex physical needs. Information from peoples files indicate that there are a number of individuals who follow different spiritual faiths. People living in the home and staff said that there are regular church visitors to the home on a monthly basis. One person has the opportunity to attend church each week. Another had expressed a wish to pursue their faith and although an agreement had been made to enable this, there was no evidence of this taking place. The home provides special meals and cakes for birthdays and celebrates the major Christian festivals, e.g Christmas and Easter. People spoken with said that overall they are able to choose their daily routines and how care is delivered. They were aware of their rights and many said that they had family members who acted on their behalf and took care of their finanaces. Visitors were seen visiting the home and made welcome by staff. People living in the home could either meet with their visitors in the privacy of their own room or in one of the lounges. A range of information is available in the entrance hall offering advice on advocacy and other relevant matters. Comments from people living in the home and their relatives were overall positive about their standard fo care and the staff in the home. There is a four week menu in place in the home, which offers a choice of two hot meals and desserts each day. Breakfast , tea and supper also provide a choice of meals to people living in the home. Dietary needs are catered for and documented within individual care plans. Relatives and people living in the home felt that the quality and choice of meals provided were good. Care Homes for Older People Page 17 of 35 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service experience adequate quality outcomes in this area. We have made this decision using arange of evidence including a visit to the service. The home has a good complaints system, with some evidence that peoples views are listened to and acted upon. Visitors and people using the service are confident about reporting incidents and that these will be acted upon. Evidence: The home has a complaints policy and procedure that is included in the statement of purpose and service user guide. The majority of the responses from surveys sent out, show that people are aware of how to raise concerns and feel confident that these would be dealt with apprpriately. The Commission for Social care Inspection have received four formal complaints since the last visit on 21st November 2007. Two of these have resulted in safeguarding referrals being made, investigations taking place and these being upheld. The first referral led to the home dismissing the home manager and reviewing their risk assessments for the use of bed rails within the home. No decision has as yet been made in regard to the second allegation being upheld and the action the home will be expected to take. The other two complaints were given to the provider who has taken appropriate action in relation to these. Staff spoken with said that they would pass any concerns onto the senior staff. Care Homes for Older People Page 18 of 35 Evidence: Although senior staff had received safeguarding training, other staff members had not. Staff spoken to were unsure of the procedure they should follow, where abuse may be suspected.This information could not be checked against staff training files as these were unavailable in the acting managers absence. Similarly details of complaints could not be checked against the homes records. Care Homes for Older People Page 19 of 35 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use 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. The home offers a safe, comfortable and clean environment for those people living there. Evidence: The home offers ground floor accommodation to people living in the home and office accommodation to the first floor. The corridors are wide, giving good access to wheelchair users and have hand rails inplace. The skirting boards have been replaced with UPVC skirtings to prevent scratches and damage. A new conservatory has been built during the last year and fitted with air conditioning to allow people living in the home the opportunity to use it throughout the year. Since this has been built, a large number of people living use and enjoy this facility. Carpets in the entrance,redecoration of bedrooms, recarpeting of ten bedrooms and the flooring to the dining area have been replaced as planned for in the maintenance plan submitted by the provider at the previous inspection. A strong odour was noted outside of a vacant bedroom, the team leader informed the inspector that the room was due for complete redecoration and refurbishement in order to eliminate the odour, the remainder of the home was odour free. Care Homes for Older People Page 20 of 35 Evidence: comments from surveys included that there could be problems with the laundry,items not being returned rather than the quality and finish of the items being laundered, so some people preferrred their families to do this for them. Another commented that lost property was piled in the entrance hall and resembled a jumble sale,this was observed by the inspector and when this was raised with the team leader they explained that an alternative was being sought to deal with this. Care Homes for Older People Page 21 of 35 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience adequate quality outcomes. We have made this decision using a range of evidence including a visit to this service. Not all staff have access to sufficient training, and development sessions to ensure that they have the skills and knowledge to meet the needs of the people living in the home. this could result in the health and safety of people living in the home being put at risk. Evidence: Staffing rotas were checked and corresponded to the number of staff on duty on the day. Currently there are six care staff in the morning and five in the afternoon, three staff are on duty during the night. additional staff are provided including cooks, kitchen assistants, domestic and administration staff. Comments from realtives, people living in the home indicate that the home is very busy and there are occassions where people have to wait to have their care needs met, during these times. However generally they felt that there was a good standard of care in the home and the staff were kind and caring . Information from the Aqaa document shows that 44 of the staff have an NVQ at level 2 or above. Although the Aqaa document states that there is an induction for new staff, not all had started this. Evidence from the Annual Quality Assurance document and discussion Care Homes for Older People Page 22 of 35 Evidence: with the staff team identified that the majority of staff have completed mandatory training, but have not had access to a range of more specialised training so they have the skills and knowledge to deliver the specific care needs associated with the ageing process. No records of staff training, supervision or recruitment could be accessed at the site visit due to the managers absence, so further checks could no be made to determine whether this had been commenced or not. Similarly staff were unsure if they had contracts as they had not seen them, some were unaware of their contracted hours and said that there was an expectation that all staff would work additional hours. Staff felt that they would benefit from additional training in managing challenging behaviours, but had been unable to access this.There were some people living in the home who could present challenges and staff found it difficult to manage this and found that care plans did not contain enough detail.This could compromise the care offered to people living in the home and could place them at risk. The majority of staff spoken with had received mandatory training, but not all could say when this had been or if it was still current. Certificates were on display in the home demonstrating that some senior staff has attended dementia, supervision and safeguarding training. Discussion with staff indicated that they only accessed supervision every six months. Staff meetings are also held on a six monthly basis.Staff felt that they would benefit from more frequent supervision to support them in their roles. Care Homes for Older People Page 23 of 35 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management systems within the home are not robust and must be improved to ensure the health, safety and welfare of the people living in the home and staff are maintained and protected. Evidence: There is no registered manager of the service at this moment in time. One of the providers Mrs Khurana is managing the home currently, but information submitted to CSCI indicates that she does not intend to do this on a permanent basis and the decision was made in January 2008 to become acting manager after unsuccessful appointment to the post. This has provided some consistency within the home, it is imperative that a registered manager is appointed to ensure that consistency can continue within the home and allow Mrs Khurana to return to her sustantive role within the organisation. She has extensive experience as a registered nurse and as a home Care Homes for Older People Page 24 of 35 Evidence: manager. The two other acting managers had resigned from their posts prior to this arrangement being put in place. An Annual Quality Assurance Document was requested by The Commission for Social Care and Inspection and this was completed and returned on time. On the day of the site visit the acting manager was not available. They had contacted the CSCI in good time, to inform them of their planned holiday, but this information was not passed on to the inspector until the day after the site visit took place. The team leader on duty made all documents she had access to , available to the inspector on request. However,a large number of documents and records could not be accessed as these were locked in the acting managers office and could not be accessed. No arrangements had been made to allow for the access of documents in the acting managers absence. A requirement was made that all appropriate documentation is available for examination within the home. As a result of this information given in the AQAA documents and shared in discussion with staff and people living in the home could not be checked. Information from surveys and discussion was inconsistent with some stating that the acting manager was approachable and kind, whilst others found her unpredictable and said they would not feel confident in approaching her. The AQAA document states that the home has a Quality Assurance sysytem in place and although some staff were aware of the surveys, they were unable to give examples of any actions that may have been developed as a result of these. Some staff said that they had attended training , including an induction, whilst others said they had not. staff also did not all have terms and conditions of employment and were unable to say what their contracted hours were. Staff spoken to said that they attended staff meetings and received supervision on a six monthly basis, this could not be checked against records, the AQAA document stated that supervision and appraisals were up to date. A requirement was previously made that all care staff receive at least six formal supervisions a year, this requirement will remain until evidence is available to demonstrate that this is being done. The following documents were not available for examination on the day of the site visit, a record of complaints, accident records, records of funds maintained for any peopel living in the home, a quality assurance sytem, maintenance records,staff recruitment files, staff training files, staff supervision records. Arrangements need to be in place to ensure that access to records is available to the CSCI during visits in the absence of the manager. Care Homes for Older People Page 25 of 35 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 1 4, 5Schedule 1 The registered provider must 01/02/2008 produce and make available to people an up to date statement of purpose and service user guide. So people receive enough information about the service and facilities to know if the home can meet their needs, before they decide to accept a placement. The registered provider must 01/02/2008 ensure the homes service user guide meets the criteria of Regulation 5 of the Care Home Regulations and includes the information asked for in The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2006 (for Regulation 5), which came into force on 1st September 2006. This is so people know how much they have to pay for their care, what they are getting for their money and the cost of any additional extra services they may wish to purchase. The responsible individual must make sure that staff, 01/04/2008 2 1 5(b)(c) Amended regulations20 06 3 4 12(1) Care Homes for Older People Page 26 of 35 individually and collectively, have the skills and experience to deliver the services and care which the home offers to provide. So people can be confident that their needs relating to old age and dementia are recognised and managed appropriately. 4 18 13 The responsible individual must make sure that the staff attend appropriate training in Safeguarding of Adults procedures, management of challenging behaviour and dementia care. To prevent residents from being harmed or suffering abuse or being placed at risk of harm or abuse. 01/04/2008 5 30 18(1)(a)(c) The responsible individual 01/04/2008 must ensure that there is a training programme in place that ensures staff fulfil the aims of the home and meet the changing needs of the people using the service. Specialist training on the elderly and diseases relating to old age and dementia must be included in the training programme. So the health, safety and welfare of the people in the home is protected and promoted, and staff have the skills and knowledge to provide a high standard of care. 6 33 24 (1)(a)(b), The responsible individual 01/04/2008 Care Homes for Older People Page 27 of 35 (2)(3) must make sure that effective quality assurance and quality monitoring systems are in place, which seek the views of people and measure the success in meeting the aims and objectives and statement of purpose of the home. So the home can demonstrate that it is offering a quality service and value for money to the people using the service, and is listening to their views and opinions and taking action to meet its aims and objectives and produce favourable outcomes for people. 7 36 18(2) The registered person must ensure that all care staff members are on track to receive at least six formal supervision sessions per year. (Previous timescale of 30/04/06 and 31/12/06 not met) So staff can receive feedback and support around their work practices and career development needs, and people using the service receive care from competent and experienced people who understand their roles and responsibilities. 01/04/2008 8 38 18(1)(a)(c) The responsible individual 01/04/2008 must ensure that there is a training programme in place that ensures staff fulfil the aims of the home and meet the changing needs of the people using the service. Specialist training on the elderly and diseases relating Page 28 of 35 Care Homes for Older People to old age and dementia must be included in the training programme. So the health, safety and welfare of the people in the home is protected and promoted, and staff have the skills and knowledge to provide a high standard of care. 9 38 13 The registered manager 01/01/2008 must be proactive in monitoring health and safety issues within the home such as fire risk assessments, generic risk assessments and bed rail risk assessments. This will ensure the health, safety and wellbeing of people living or working within the home is protected and maintained. Care Homes for Older People Page 29 of 35 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 5 The registered provider must ensure the homes statement of purpose and service user guide meet the criteria of Regulation 5 of the Care Standards Act 2000(Establishments and Agencies) (Miscellaneous Amendments) The statement of purpose and service user guide do not contain up to date information about the homes management arrangements or current information about how the Commission for Social Care and Inspection can be contacted. The documents are not available in a format for people from other ethnic backgrounds, where English is not their first language.This is required so people can receive enough information about the service and the 31/03/2009 Care Homes for Older People Page 30 of 35 facilities to know if the home can meet their needs. 2 7 15 The registered provider must ensure that all individuals care plans are set out and detail the action staff must take to meet all aspects of health, personal and social care needs of people using the service. This will ensure that staff have information that will help them to provide person centred care and support.People will receive the correct care to protect their health and well being, in order to respect their wishes, choices and rights as individuals. 3 12 16 The registered provider must ensure that a range of appropriate activities and staffing to facilitate this, are provided that are suitable to meet the needs and choices of all people living in the home All people living in the home would benefit from social stimulation and have the opportunity to interact with others in the home. 4 18 13 The responsible individual must ensure that all of the staff team attend appropriate training in the Safeguarding of Adults procedures including those used by North East Lincolnshire. 31/03/2009 31/03/2009 31/03/2009 Care Homes for Older People Page 31 of 35 To prevent people living in the home from being placed at risk of harm or abuse. 5 29 19 The responsible individual 31/03/2009 should ensure that all staff employed have a contract of employment. Staff members will be aware of the position they hold, the work that they are expected to do and the number of hours they are contracted to work. 6 30 19 The responsible individual 30/01/2009 should ensure that staff attend appropriate training in challenging behaviour, dementia and conditions relating to old age.this would ensure that staff fulfil the aims and objectives of the home and meet the needs of the changing needs of the people using the service. staff will become more confident in dealing with difficult situations as they arise and gain the skills to promote a good quality of care to all people living in the home to offer a more person centred approach. 7 30 19 The responsible individual must ensure that all staff complete an induction to NTO standards within six weeks of their appointment to post. 31/03/2009 Care Homes for Older People Page 32 of 35 Newly appointed staff will be aware of what is expected of them and be supported to provide a good standard of care to people living in the home. 8 33 24 The registered provider 31/03/2009 must ensure that effective quality assurance and quality monitoring systems are in place, which seek the views of people and measure the success in meeting the aims and objectives and statement of purpose of the home. So the home can demonstrate that it is offering a quality service and value for money to the people using the service, and is listening to their views and opinions and taking action to meet its aims and objectives and produce favourable outcomes for people. 9 34 17 The registered person must 31/03/2009 ensure that all information listed in Schedule 2 & 4 are made available in the home in the managers absence. re So the home can demonstrate that it is following its policies and procedures and complying with relevant regulation as required to do so. Care Homes for Older People Page 33 of 35 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 26 The responsible individual should consider alternative methods of supporting people to find lost items, rather than leave them in the entrance hall, which people living in the home find unsightly. A review of the current staffing levels should be completed to ensure that there is adequate staffing levels provided to meet the assessed needs of people living in the home. The registered provider shall appoint an individual to manage the care home,where there is no registered manager in respect of the care home.A registered manager who is qualified and competent would ensure that the care home is able to deliver the service that it is intended to deliver in line with the homes aims, objectives and philosophy of care. 2 27 3 31 Care Homes for Older People Page 34 of 35 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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