Inspection on 11/06/07 for Colebrook Respite Unit

This inspection was carried out on 11th June 2007.

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

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

Other inspections for this house

Colebrook Respite Unit 20/05/08

Colebrook Respite Unit 31/10/06

Colebrook Respite Unit 14/02/06

Colebrook Respite Unit 31/08/05

Colebrook Respite Unit 07/03/05

Colebrook Respite Unit 09/09/04

Colebrook Respite Unit 19/01/04

Similar services:

Coton Hill House

Doddington Lodge

Far Croft

Churchill House Nursing and Residential Home

Field Farm House

Church Terrace Nursing & Residential Home

Fountain Court

The Forbury

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

CARE HOMES FOR OLDER PEOPLE Colebrook Respite Unit 291 Bosworth Drive Chelmsley Wood Solihull West Midlands B37 5DP Lead Inspector Deborah Shelton Unannounced Inspection 11th June 2007 09:00 X10015.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 Colebrook Respite Unit DS0000004527.V344140.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. 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. Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Colebrook Respite Unit Address 291 Bosworth Drive Chelmsley Wood Solihull West Midlands B37 5DP 0121 770 6133 0121 770 6144 colebrookdayunit@btconnect.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Family Care Trust (Solihull) Mrs Anne-Marie Yardley Care Home 7 Category(ies) of Dementia - over 65 years of age (7) registration, with number of places Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the home can accommodate up to 7 older people who also have dementia, on a respite basis. One person of the 7 accommodated at any one time may be between the ages of 55 and 65 years. 31st October 2006 Date of last inspection Brief Description of the Service: Colebrook Respite Centre is part of the Family Care Trust Organisation. They provide a respite service for people with dementia. Respite is usually offered for up to six weeks a year but can be extended depending on circumstances. Most residents are admitted after a planned admission programme however the centre can after consideration provide emergency placements. Four of the beds provided are funded by Solihull Social Services on a block contract and three beds are available for privately funded people or other local authorities. Residents are aged 65 years and over, although they have the facility to provide for one resident between the ages of 55-65 years at any time. Residents have to be independently mobile or walk with a walking aid. All accommodation is at ground floor level and accessible by people with disabilities. Two of the bedrooms have en suite facilities. The centre has an assisted bathing and a separate assisted shower facility. There are several communal areas that are shared with the day centre, which is also run from the same premises. One of these is a quiet lounge. Residents spend time in the day centre during the day if they wish and are assisted by day centre staff. The company has a minibus, which it uses to and from the day centre and for trips for residents. The cost of a week’s stay at the respite unit is between £383.00-£390.00 per week. The lower price has been negotiated for the contracted beds with Solihull Care Trust. Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following are the findings of an unannounced inspection visit that took place on Monday 11 June 2007 between the hours of 09:00am and 5.10pm. The unit manager came on duty specifically to assist with the inspection. An assistant manager was also on duty along with three care staff, a volunteer and three catering staff. Five people were staying at the respite unit and nine people visiting day care that is located on site. Three residents were ‘case tracked’, this involves finding out about the individual’s experience of staying at the unit by meeting with them, talking to them about their experiences, looking at their care files, looking at their environment, discussions with staff on duty and reviewing staff training records to ensure training is provided to meet resident’s needs. Documentation regarding staffing, health and safety, medication and complaints was also reviewed. The inspection process consisted of a review of policies and procedures, discussions with the manager, staff and residents. Other records examined during this inspection included, care records, staff recruitment records, training records, social activity records, staff duty rotas, health and safety and medication records. Notification of incidents received by us from the home and any other information received were also examined. The inspection process enabled the inspector to see residents in their usual surroundings and see the interaction between staff and residents. The inspector was introduced to a majority of the people staying at Colebrook respite unit and conversations were held with two people. Further information to identify the outcomes for residents’ was also gained through observation of residents and staff. The inspector wishes to thank the manager and her staff for the hospitality on the day of inspection. What the service does well: The atmosphere at the unit was jolly and friendly. Residents appeared at ease in their surroundings and in the company of staff. A large percentage of the resident’s day is spent joining in activities if they wish and chatting amongst each other and with staff. The manager and staff appear to be dedicated to meet the needs of those who they care for and had a great deal of knowledge of individual wants and needs. Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 6 Everyone spoken to was positive about the unit and what it achieves. Some of the comments received from residents are detailed below: “I wasn’t too happy when respite was suggested to me because I thought they were trying to get rid of me, but I think it is the best thing I could have done. I am happy to be here but equally happy to go home. I will happily stay again” “there is plenty to do in the day and I am never bored”. “I am glad to stay here because it means my wife can have a rest” “the staff are nice, the food is good, everything is OK”. What has improved since the last inspection? What they could do better: A number of issues remain outstanding from previous visits and some new issues for action identified during this visit. Pre-admission assessments should be used to find out as much information as possible about the potential service user before their stay. This should include Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 7 information about their usual routines at home. This enables the transition from home to respite and back home to run as smoothly as possible. All information in care files should be dated and signed by the person completing the records. If this is not done it is difficult to evidence who completed the information and when. Care plans do not contain sufficient information to guide staff regarding the care needs of residents. To record “full assistance required” does not give specific information regarding timings, the type of assistance and how many staff are required to assist. Risk assessments were not up to date and were not linked to a care plan were a high risk was identified. This puts residents at risk of having health care needs missed. Errors were noted on medication administration records. The pre-printed information on medication bottles had not been transferred to medication administration records and some medications were not being given in accordance with the GP instructions. The items stored in the arts and crafts room should be moved to a more suitable location to enable residents to use this room more freely. The complaints leaflet should be available in large print to assist those with sight impairments and contact details of the Commission for Social Care Inspection should be included. All criminal records bureau checks (CRB) should be up to date and relevant to the job of employment and be undertaken by the Family Care Trust. One CRB on file had been undertaken by a different employer for a different job. The manager is aware of the need to change some carpets which are worn and marked and is planning to change these shortly. The manager is considering various options to disguise the noise from the loud extractor fan. Work should be undertaken in this bathroom to give a more homely, welcoming feel. Ensuite toilet doors should be colour coded to aid resident’s orientation and knowledge of their purpose. New staff should undertaken Skills for Care induction training upon employment. Currently staff only undertake in-house induction training. Mandatory training must be undertaken on a regular basis to protect both staff and residents from harm. Although quality assurance documentation has been devised it has not been implemented. Quality assurance systems must be introduced to enable the Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 8 manager to be sure that the quality of the service provided meets the needs and expectations of those who receive the service. Staff supervision should be undertaken on a timelier basis. 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. Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Pre-admission practices ensure that residents are assessed as being suitable to stay at Colebrook Respite Unit. Limited information is available regarding usual routines at home to enable these routines to continue while in respite care. EVIDENCE: Pre-admission documentation was looked at to evidence the process followed and to ensure that before people stay in the unit information is collected about them. As people are only staying for a short period of time and then returning to their own home, the unit must be able to ensure that enough information is gathered to enable staff to meet individual needs whilst maintaining as much independence and usual daily routines as possible. Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 11 The manager confirmed that a majority of those who stay for respite care already attend the day care facility that is located on site. A pre-admission assessment is undertaken before people attend the day care centre. This information is then used when a person wishes to stay for respite care. Care plans are available for those that attend day care, these are updated and information from these care plans would be used during any respite stay. The records of three residents staying in the respite unit at the time of the inspection were looked at. The information found was inconsistent. The manager or assistant manager undertake pre-admission assessments. Information is obtained from family members regarding routines whilst at Home. From files seen it was evident that some families provide extensive information whilst others provide none. Therefore, in some files there was no information regarding daily routines whilst living in their own home. It is important to collect good information on the person’s home lifestyle as this can assist the unit to ensure that routines are kept. This will assist the resident’s return to their homes after their stay. At the time of the visit all of those staying for respite care had either stayed at the Home before or currently attend the day care centre. There was therefore no pre-admission documentation available in their files. Standardised blank documentation was reviewed. Using this documentation sufficient information regarding health and social care needs could be recorded, however there was limited evidence to demonstrate that the persons usual routines whilst at Home are taken into consideration whilst on a respite stay. Potential service users are able to visit the Unit for a meal and/or join in activities. Family members can also visit and speak to staff and other service users. Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The recording of resident’s health, personal and social care needs do not give staff detailed guidance to enable them to meet the care needs of those that live at Colebrook Respite Unit. Residents are treated with respect and their rights to privacy and dignity are maintained. Some improvements are required to medicines management to protect residents from risk of harm. EVIDENCE: The care files of three respite service users currently staying at the unit were looked at. Information recorded in care plans was brief and mainly consisted of tick lists without further comments recorded to guide staff of the action to take to meet identified health and social care needs. For example one care plan recorded “personal hygiene – needs assistance with all tasks of personal care and dressing”. The care plan should record preferences of times of Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 13 bathing or showering, the type of assistance required and the number of staff required to assist. One care plan identified an issue regarding sleeping patterns, “does not sleep very good throughout the night”, however there is no further information recorded to say how this should be managed. Care plans did not contain sufficient detail regarding who is to complete the task (how many staff), what is to be done (action staff are to take to meet a need), when is it to be done (time of day), where (what part of the body, what room etc) and why this should be done (benefits to the resident). Care files contain a morning and evening report sheet which details any personal care provided. Standardised documentation is ticked when any task has been undertaken, this is timed, dated and signed by the staff member who undertook the task. These sheets record information such as teeth cleaned, feet creamed and details of any District Nurse input. One of the evening report sheets seen did not record that any oral hygiene is being completed. The oral hygiene section in the care plan records that the resident has dentures but does not give any information regarding who cleans them and if it is the staff that are to clean them what they should use. There is therefore limited evidence to demonstrate this resident’s oral hygiene needs are being met. The manager confirmed that care plans are constantly under review and they are finding it difficult to find a care plan system that is suitable to meet the needs of respite residents, some who may stay for a few days whilst others stay for a few weeks. Daily records did not consistently record that the District Nurse had visited a resident or that their blood sugar levels have been monitored. From discussions with the manager it was noted that the District Nurse visits twice per day. Documentation is particularly important in this dementia care unit as the person themselves may not be able to communicate what has happened during the day. One care file seen contain comprehensive information provided by the family which gives a step by step guide of the routine upon going to bed, getting up and the action that staff are to take if the resident gets upset. The unit should ensure that they have this type of information for all who stay for respite care. Residents are being weighed as a minimum at the beginning and the end of their stays. This is good practice and identifies the weight gain or loss during their respite stay. Risk assessments are undertaken regarding pressure areas, falls, manual handling, weight and nutrition. A risk assessment identified that the resident was at a high risk of developing a pressure area but no care plan was available to detail actions to be taken to minimise the risk of the resident developing a sore. Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 14 Some of the information recorded on standardised documentation was blank. Not applicable should be recorded as necessary otherwise it appears that this information has not been obtained. Some of the records were not signed or dated by the person completing the information. Currently there is no care plan audit. The manager agreed to devise a care plan audit so that she can review information and leave constructive comments for staff to improve care planning. A monitoring form has been developed and is used to find out the religious and any cultural or ethnic needs of residents before their respite stay. This process was introduced because of a requirement made at the last inspection of the Home. The receipt, storage and administration of medication was reviewed. Medication is received in original boxes and in “medidose boxes” which have been filled by the pharmacist. Medication is checked with a GP before each admission to ensure that the medication is correct. A member of the management completes an audit of medication to ensure that the medication is correct on a daily basis. The medication administration records (MAR) for the three residents being case tracked were reviewed. One MAR chart recorded that the resident should take one calcium carbonate tablet each morning. The pre-printed label on the bottle of tablets records that one tablet should be taken twice daily. Other discrepancies were noted on MAR charts regarding movicol and mometasone cream. The manager stated that the only explanation is that staff have recorded on the MAR chart the information given by relatives and not that as recorded by the GP. Staff must ensure that they always follow the pre-printed instructions on medication labels as provided by the service user’s GP. Each Medication Administration Record has a photo of the resident to aid staff identification. Staff administering medication have had appropriate training. It was a requirement of the last inspection that a minimum, maximum thermometer is purchased for recording the temperature of the medication fridge. This is now in place. Care staff appeared to have an excellent relationship with respite service users. The atmosphere at the unit was relaxed and friendly. Staff were observed laughing, chatting and joking with service users. Privacy, dignity and respect were maintained throughout the inspection process. Residents were appropriately dressed and attention had been paid to their personal hygiene needs. Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents are able to undertake regular social and leisure activities and maintain contact with family and friends as they wish. Meals are well presented, wholesome and provide residents with a nutritious and balanced diet. EVIDENCE: Colebrook respite unit cares for up to seven people on a respite basis. A day centre is located on the premises and shares some of the same facilities as the respite unit. Respite residents are able to join in day centre activities and appear to benefit from the interaction with day centre clients and the activities available. Doors to activity rooms are left open so that residents are able to come and go as they please. Doors to the gardens are also left open and residents were seen wandering outside. There are three main activity rooms at the unit, a games room, arts and crafts and a quiet room. DVD players are available for each TV as is free view. A wide variety of activities take place on a daily basis both morning and Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 16 afternoon. Activities such as reminiscence, board games, watching TV, listening to the radio or other music, singing and dancing, arts and crafts, quiet reading all take place regularly. Also dependent upon staffing levels games such as dominoes, scrabble, cards can also be played with small groups of residents. Activities take place seven days per week. A hairdresser and chiropodist visit when needed. A clients committee is held, these meetings are used to find out likes and dislikes regarding activities and meals any comments made by residents are recorded in the Clients Committee Record Book. There were no minutes of recent meetings available. Daily records in care files record whether a resident has participated in an activity and if not what they have done during the day. Fund raising takes place to raise money for trips. All residents went out for a meal at a public house recently. Photographs are on the walls showing activities that residents participate in. The manager reported that the ethos of the Home is to maintain and encourage independence ready for the service user’s return to their own Home. Staff were seen promoting and encouraging independence and choice, however care plans contained limited information regarding this. There is an open visiting policy, but visits are not encouraged during lunchtime, as this can be distracting for residents. The kitchen provide meals for the respite residents, the day centre attendees and other day centres. The kitchen is well equipped to provide the meals. The respite centre has a set menu and residents are offered one main meal per day but are able to have alternatives such as salad, omelette, and sandwiches if they do not like the meal available. The chef records any alternatives from the menu that individual’s request. Menus seen were nutritionally balanced and varied. The kitchen was clean and hygienic and appropriate cleaning, fridge and food temperature records were available and up to date. Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users are confident that their concerns will be listened to and acted upon. Systems in place to protect residents from the risk of abuse require improvement, this will increase resident’s feelings of safety and their quality of life in the home. EVIDENCE: No complaints have been received by the unit or us since the last visit. A comments, compliments and complaints book is available but no comments or complaints have been recorded. There is a lengthy complaints procedure and a shortened version in a leaflet to assist those that wish to complain. This comments, suggestions or complaints leaflet “your right to be heard” is given out to service users and their families and copies are left in the reception area for people to take as necessary. The leaflet could be enhanced by larger print, as many of the residents or their representatives will have sight impairments and (for the use of residents of the respite unit) the contact details for the Commission for Social Care Inspection should be recorded. Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 18 Details of a complaint received over twelve months ago, investigation and outcome are recorded in a complaints folder. This demonstrates the process followed when complaints are received. All paperwork was completed in a satisfactory manner. There have been no adult protection issues. All staff have criminal records bureau (CRB) and protection of vulnerable adults (POVA) checks in place before they start work at the unit. One of the CRB checks on file was for a different employer and a different type of employment. The manager should ensure that all staff have up to date CRB checks that they have undertaken. Currently four staff are undertaking protection of vulnerable adults training. Changes have now been made to the adult protection procedure as requested at the last inspection. The procedure now informs staff that dependent upon the level of seriousness of an allegation, discussions are to be held with Social Services before any decision regarding action to take is made. Social Services have the responsibility to co-ordinate actions regarding allegations of abuse. The respite unit take an inventory of a resident’s possessions on admission, this is important especially in a respite unit where stays can be for short lengths of time. Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The standard of the environment within this Home is generally well maintained providing an attractive, hygienic and homely place to live therefore improving the quality of life for residents. EVIDENCE: The centre is purpose built and is well decorated, clean and fresh. Information leaflets and copies of inspection reports are available for inspection in the main reception area. Communal areas were clean and hygienic. Residents have access to the gardens, which provided a pleasant space for people to enjoy the sunshine. Communal rooms are shared with day centre visitors. A games room, arts and crafts and a quiet room are available. Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 20 Changes have been made as requested at the last inspection visit to the location of the hazardous substances store and staff lockers. Hazardous substances are no longer accessible to residents. Double doors have been fitted in the corridor to block residents gaining entrance to the walk in freezer. Residents are not able to enter this area without staff assistance. No changes have been made to the carpets yet, however the unit has recently been awarded some grant funding and intends to change carpets as soon as the money is received. Bedrooms were clean and tidy. Residents are encouraged to bring items that are important to them when they stay. Some rooms seen had pictures provided by the unit, whilst other residents had bought pictures and ornaments. Bedroom floors have a fitted alarm system that can tell when residents are up and walking about in the room during the night. Bedroom doors have a picture of the resident to assist them in remembering which is their room. Bathrooms were clean and hygienic. An extractor fan in one bathroom was extremely noisy. The manager said that they are considering having piped music throughout the unit, including bathrooms, this should detract from the noise of the fan. Other options have been considered to reduce the noise but none appear to be satisfactory. Cloth wardrobes have been purchased since the last inspection. These are stored in the assisted bathroom and are used to store spare clothing for day centre visitors. These have been purchased because of a requirement made at the last inspection. Consideration should be given to changing the decoration of the bathroom as the clinical appearance of the room, together with the exposed pipes could make it distressing for some residents rather than a relaxing experience. Toilet doors in en suite rooms on the unit would benefit from being the same colour and different to surrounding walls to assist residents in knowing their purpose. Appropriate laundry facilities are available, disposable gloves and aprons were readily available to maintain infection control. Laundry buckets are used to transport soiled items to the laundry. Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The number of care staff with a National Vocational Qualification (NVQ) level 2 will help to ensure that the skill mix of staff on duty will support meeting the needs of residents. Improvements are needed to the amount of induction and ongoing mandatory training undertaken. Although systems have now been devised they have not been implemented. Lack of ongoing training might reduce the care staffs’ competence. EVIDENCE: Copies of duty rotas were taken for review. These demonstrate that sufficient numbers of staff are on duty on a daily basis. During daytime hours Monday – Saturday staff work across the day care and respite unit. Staff allocated to only work in the respite unit work shifts in the evenings and all day Sunday. Three staff files were reviewed to evidence whether the unit follow robust recruitment practices and obtain relevant details before employment of staff. All files seen contained information such as application forms, references, copies of training certificates, evidence of criminal records bureau checks, contracts of employment and c.v. Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 22 Staff spoken to said that they enjoyed working at the unit and particularly liked the fact that they spent quality time sitting and chatting with residents every day. All of the assistant managers have either a National Vocational Qualification at level three or four. All apart from two staff have obtained or are currently undertaking their National Vocation Qualification at level two. This amount of trained staff goes some way to ensuring that staff employed have the necessary skills to meet the needs of those under their care. No new staff have been employed at the unit recently. Upon employment all staff will undertake the organisation’s induction training plus training regarding the Code of Conduct for Social Care Workers. Skills for Care Induction information has now been received. However, no new staff have been employed since the last inspection, therefore this documentation has not as yet been used. Copies of individual training certificates were held on staff files and a training matrix for the respite unit has been developed. The matrix details the date the training was undertaken, how long the course is valid for and the date of the next training. Records show that although some training has been offered on a regular basis, mandatory training such as moving and handling, fire safety, basic food hygiene are out of date and update training is required. Both residents and staff could be at risk of injury or harm if training is not provided on a timely basis. Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The Home has an experienced manager who has an in depth knowledge of the needs of those under her care. Systems need to be put in place to ensure that the quality of the service provided meets the needs and expectations of the Service users who live at the Home. Not all health and safety issues have been addressed to ensure that residents live in a safe environment. This could put residents at risk. EVIDENCE: The registered manager of the respite unit has recently achieved a National Vocational Qualification at level four in care and has achieved the Registered Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 24 Managers Award. In addition has a Diploma in welfare studies. The manager has had long experience as an auxiliary nurse and a support worker. The manager has had training both with the organisation and externally in the care of people with dementia. Quality assurance documentation is being produced and will be available for use shortly. Questionnaires have been developed but not sent out. These will be forward to the respite residents when they have left the placement. No method of obtaining feedback whilst the resident is staying at the unit has been considered. Quality assurance systems were identified as an issue for action at the last inspection of the Home and work is still outstanding. The manager discussed some audits that take place, for example a six monthly internal audit covering aspects of finances, staffing and environment takes place. Social services also undertake an annual contract audit. The notes of a resident’s committee meeting were reviewed. The last minutes available were dated February 2006, the manager said that other meetings have taken place but the minutes of these meetings are not available yet. The unit was having visits from a representative of the registered provider but these did not always result in at least a monthly report with a copy being sent to us. The respite unit tends not to keep money for residents as they are on short stay. No funds were being kept on behalf of residents at the time of the visit. The manager confirmed that residents do not usually bring any money with them when only staying for a very short period of time. A discussion was held regarding staff supervision. The manager confirmed that the frequency of supervision needs to be improved. The assistant managers supervise care staff and the manager supervises the assistant managers. This issue is outstanding from the last inspection when it was also noted that staff are receiving insufficient amounts of supervision. Legionella test and hot and cold-water temperature records were reviewed and found to be in good order. Weekly fire alarm, means of escape and fire door test records were not up to date. The last check recorded was 29 May 2007 (13 days before inspection). Fire drills are now being undertaken on a six monthly basis. A risk assessment provided by West Midlands Fire Service is available. The unit also have to complete another risk assessment that was not up to date as it recorded that the unit only have five bedrooms. Training records did not demonstrate that all staff have undertaken fire training recently. It was noted at the last inspection that one of the activity rooms was being used as a storage area. Equipment that had been in an outside shed and other Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 25 items are being stored. The activity room was still full of items being stored in this area. Colebrook Respite Unit DS0000004527.V344140.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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13(1) Requirement All risks identified must have actions in the care plan to minimise them. (Outstanding since 31/10/06) 2 OP7 12(2&3) Care plans must reflect the current needs of residents and clearly inform the care staff on care to be given or action to be taken regarding all aspects of health and personal care. (Outstanding since 31/10/05) 3 OP9 13(2) Medication administration records must detail information as recorded on pre-printed medication labels and original prescriptions. All staff must receive adult protection training and a record of that training must be on the staff file and the training matrix. (Outstanding since 31/10/06) 5 OP19 23(2)(d) An audit of carpets must be DS0000004527.V344140.R01.S.doc Timescale for action 13/08/07 23/07/07 23/07/07 4 OP18 13(6) 13/08/07 13/08/07 Version 5.2 Page 28 Colebrook Respite Unit undertaken and action taken to remove staining. (Outstanding since 31/10/05) 6 OP21 23(2)(f) The bathroom ventilation fan, equipment, storage and decoration must be reviewed to ensure that residents have an appropriate and comfortable bathing facility. (Outstanding since 31/10/06) 7 OP30 18(1)(c) (i) The manager must ensure that 13/08/07 all staff undertaking work in the respite unit have all of the mandatory training and updates within the designated time limits. (Outstanding since 31/10/06) 8 OP33 24 A quality assurance system must be available in the respite unit part of the centre. (Outstanding since 31/05/06) 9 OP37 17(3)(a) The respite unit must ensure all documents including residents’ assessments, reviews, and the unit’s fire risk assessment are dated and signed. (Outstanding since 31/10/06) 10 OP38 23(4)(d) All staff must receive fire training 23/07/07 at least every 6 months, a record must be kept of this. (Outstanding since 31/10/06) 23/07/07 13/08/07 13/08/07 Colebrook Respite Unit DS0000004527.V344140.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 OP3 Good Practice Recommendations Pre-admission assessments should collate as much information as possible about the residents’ usual routine whilst living at home. This enables a smoother transition into respite care and then back to their home environment. Daily records should be completed to record any important information such as District Nurse visits as and when they occur. It is recommended that the organisation’s complaint leaflet inform residents and their representatives how to contact the us. It is also recommended that the organisation review their complaints leaflet view to increasing the print size. Staff supervision should be provided in a timely manner. Documentary evidence should be available to demonstrate that appropriate staff supervision is undertaken. 2 OP7 3 OP16 4 OP36 Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Colebrook Respite Unit DS0000004527.V344140.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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