Inspection on 31/10/06 for Colebrook Respite Unit

This inspection was carried out on 31st October 2006.

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

The inspector 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 11/06/07

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 Jill Brown Unannounced Inspection 31st October 2006 10.00 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.V317894.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.V317894.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.V317894.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. 14th February 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 over 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 mobile independently or walk with a walking aid. All the centres 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. The centre has several communal areas that are shared with the day centre. 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. A day centre facility is also run from the same premises. 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 Social Services. Colebrook Respite Unit DS0000004527.V317894.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector visited the respite unit unannounced on a day in October and completed a key inspection where most of the standards were looked at. The inspection lasted about 7 hours. The report contains information that the Commission had received from the last inspection in February 2006 and this visit. During the inspection visit the inspector talked two of the three residents in the unit at the time of the inspection and observed staff working with residents. The inspector received 5 comment cards from relatives. She looked at all three residents care notes, the medication records and medication stock for two residents and toured the building. The inspector spoke to the manager, assistant manager (day centre) and the chef during the inspection. Records of the maintenance and inspections of services such as gas were looked at and the records for fire safety. Two staff files were looked at and training records for all the unit’s staff. The Commission had not received a complaint about the unit since the last inspection and the unit had not recorded any. What the service does well: Staff at the unit showed a good understanding in how to manage residents with dementia. The inspector saw staff not only showing patience and kindness, but also showing the ability to get residents that were becoming agitated to undertake a task or get involved in an activity. One comment card said that residents received ‘excellent care.’ Before coming into the respite unit a number of residents had attended Colebrook day centre and so the staff and the building were familiar to them. The unit kept very good daily records on how residents were. These records contain some information on their mood, what care has been given to them what activities they have enjoyed and what visitors they have had. This helps to let relatives know how the resident has been as well as helping track if a resident has become unwell. This is commended. Residents of the respite unit were physically well cared for with their personal hygiene needs met. Residents were seen to have clean hair and their nails attended to. All of the residents had put on weight since admission and maintaining or gaining weight can be difficult for residents with dementia. Colebrook Respite Unit DS0000004527.V317894.R01.S.doc Version 5.2 Page 6 The respite unit had maintained improvements in their administration of medication. There was a system to check with the GP that medication was correct on as they came into the unit. This was then checked on a daily basis. Residents seen and spoken to were showing signs of being settled and happy although not always able to say what they thought of the unit. The centre as a whole has excellent facilities for activities. Relatives thought they were treated well when they came to visit their relatives saying that they were given a drink and staff were friendly and caring. Residents were not overly restricted in where they could walk to in the building but residents’ safety the front door is locked and there is an enclosed garden to the rear. Residents’ records show that residents can get up as early and as late as they like. People attending the day centre sometimes have breakfast and residents will sometime join in with them. The unit has a one main meal but will make a number of different meals for residents that may not like the meal or want something different on the day. The chef is aware of the needs of the residents and has taken the opportunity on specific training. The building was generally clean and fresh on the day of the inspection. Almost all the staff on the respite unit have got a NVQ 2 in care and a basic first aid certificate and this ensured that residents receive good care. Records of residents money when held by the unit was recorded and accounted for. What has improved since the last inspection? What they could do better: The respite unit is not reviewing how they perform so improvements were slow and they were not showing that they were gaining views of residents and their carers in how they could improve. The unit needs to have ways that they can check every bit of the service they provide. The respite unit collects information inconsistently and this can lead to some gaps in information. For example two out of three care files had nothing about the resident’s religion or ethnic origin and this can affect how care needs to be Colebrook Respite Unit DS0000004527.V317894.R01.S.doc Version 5.2 Page 7 delivered. One care file did not have the risk assessments on falling, skin (for the chances of getting pressure sores), or moving and handling. This missing information can lead to gaps in how care is planned for residents and needs may not be met. Care plans did not always respond to the assessment so for example a resident was assessed as having a high risk of getting a pressure area and there wasn’t a plan in place to try and prevent it from happening. Records were not signed and dated and this made it difficult to see whether plans were being reviewed in a timely way. Complaints procedures needed some changes to make sure that they protected residents more fully and to ensure that residents can gain advice and protection outside of the organisation. There had been some changes to the building and this had not been fully risk assessed. This meant that there were some potential dangers for residents and day centre attendees. Whilst residents and people attending the day centre were well supervised, rooms storing lots of equipment, walk in fridge freezers on the corridor, unlocked areas containing hot appliances must have measures to reduce risks to residents. The lack of review has meant that fire drills have not been undertaken for 18 months, the unit couldn’t show that staff were receiving 6 monthly fire training and the fire risk assessment was not dated. Not all staff appeared to have up dates on in a timely way and a number of staff did not appear to have infection control or dementia awareness training. 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 UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4, & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information collected on residents was inconsistently recorded and risk assessments were not always completed and this could lead to residents needs not being met. Staff showed skills in managing the specific needs of people with dementia and further training in dementia would help this. EVIDENCE: The respite unit provided the Commission with their Services Users Guide and Statement of Purpose following the last inspection. These met the previous requirements made. People attend the respite unit for short stays only and often at short notice and there is not a contract with the respite unit in the usual way, although the Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 10 majority of the residents are paid for under the local Social Services contract. Before people take up residence in the unit the unit collects information about them. The inspector looked at the three residents case records of people in the respite unit at the time of the inspection. The information found was inconsistent. The respite unit collected good information on the person’s home lifestyle and that can assist the unit to ensure that these are kept to assist the residents return to their homes after their stay. One file had good information on food preferences, home circumstances, aids used, reason for admission, marks to the skin on admission, what care tasks the person would co-operate with and what activities the person enjoyed. However, there were a number of gaps in the information such as ethnic origin, religion, detail about the resident’s behaviour and assessments about the resident’s risks of falling, moving and handling, and risks of getting pressure areas were not always completed. These details are important in a respite unit that assists residents with dementia as the person themselves may not be able to communicate their difficulties. The respite and daycentre staff receive training on managing challenging behaviour and violence and aggression but records provided do not show that all staff have had training on dementia care. The staff were observed and they showed skills in managing behaviour of people with dementia during the inspection. They showed tact, and were able to divert a person from risky behaviour into activity that posed fewer risks. There were details in care records that showed where possible people have an assessment at the respite unit before coming there for a stay. Emergency admissions tend to be from people already known to the staff at the respite unit because they are attendees of the day care unit, which is part of the centre. Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents in the respite care unit were treated well, had their personal care needs met and showed signs of well-being. However the lack of plans to minimise risks and a number of needs identified could lead to needs not being met. Medication administration remained improved and good. EVIDENCE: Whilst the respite unit collected some information that was useful to inform staff how to deliver care to a particular resident it was not recorded in a way that they could get this information easily. The care plans do not assist staff to know how to approach individual residents and this can result in assistance in personal care being unsuccessful or taking away tasks that the resident can do for themselves. For example in a daily record it stated ‘able to clean teeth.’ Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 12 This was not in the care plan. A resident had several records of disturbed sleep did not have a plan to say how this was best managed. A resident with a physical health problem that affected their mobility and ability to move on waking did not have instructions to staff about this. A resident in respite had ‘monitor fluid intake’ on her care plan but there was no charting of this. Where skin and falls risk assessments showed a medium or high risk these did not always lead to actions in the care plan to minimise the risk. Moving and handling risk assessments still needed more detail for example of how the staff member would try to get the resident to do to assist themselves in getting out of a chair. Residents’ stays were starting to be evaluated and this process should lead to more detailed planning. It may be useful if the unit considered in these reviews what works with the resident when trying to undertake personal care tasks. Daily records were very good and this is commended. The inspector was able to see what personal care had been given and by which care staff. The daily records showed activities residents have enjoyed if they have had visitors mood and any issues. Residents of the respite unit were appropriately dressed and had attention to their personal hygiene needs. Staff were ensuring that residents were weighed as a minimum at the beginning and the end of their stays. Records showed that residents were appropriately putting on weight and this is commended. Residents did not have an undue number of accidents. One relative stated in a comment card that the care was ‘excellent.’ The medication administration remained improved; medication was checked with a GP before each admission to ensure that the medication was correct. A member of the management took responsibility to ensure that the medication was correct on a daily basis. Each Medication Administration Record has a photo of the resident. The counts of medication for a sampled resident were correct. Staff administering medication have had appropriate training. Residents at the respite unit have some communication difficulties caused by their dementia residents spoken to whilst not orientated to where they were, seemed happy. One for example talked about the unit as if it was a school they had attended as a child but thought it had always been very good and they was still judging if it remained good and wanted the inspectors view of it. Staff were observed being friendly and taking time with residents to ensure personal care task were attended to and residents were treated with respect. The unit produces a newsletter and this gives information on residents and staff such as staff changes, a resident’s birthday and those residents that have passed on. Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 13 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 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The respite unit benefits from having a day centre attached the arrangements for activities, visitors, choice and meals are excellent and these areas that improve the residents life. EVIDENCE: The arrangement for activities is excellent. The respite unit benefits from having a day centre attached to it and residents are able to choose to become involved or not. On the day of the inspection residents were involved in making pumpkin lanterns in the morning. In the afternoon the inspector heard staff asking residents about playing dominoes and what arrangements residents would like for Remembrance Day. A relative’s comment card said ‘they provide a good range of activities and entertainment.’ In one resident’s daily records there was mention of a musical morning, a video session, word association games, arts and craft and reminiscence activities. Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 14 Relatives were made welcome at the centre including the respite unit. Four comment cards talked about the friendliness of the staff and how they were made to feel welcome and were always given a drink. The inspector saw a relative arrive with a young child. It was clear that staff knew of the relationship between the visitors and the person on the unit and was able to assist in helping this person remember who the visitors were and why they were special without telling the person. This is a good skill and preserves the person’s view of himself or herself. Residents of the unit were allowed to join in activities, walk around both the day centre and the residential unit at will. There were spaces where residents could be quiet or sit with day centre attendees. Care notes suggest that whilst residents are checked throughout the night they have a choice about what time they get up. A number of residents and day centre attendees were having breakfast when the inspector arrived at 10.00 am. The kitchen at the centre 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 were offered alternatives. The chef was aware of the difficulties of residents not remembering choices of food they have made so they tend to offer one meal but offer a range of alternatives for residents and day centre attendees who don’t like that option or want something special that day. Records of what residents have eaten were not specific enough for the residents as it did not contain breakfast, tea and supper and didn’t record what and how much the resident had eaten, however there were no concerns about the residents in respite at the time of the inspection eating patterns. Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 15 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 &18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the respite unit has procedures to protect and listen to residents a more active approach to gaining residents views is needed. The respite unit needed to ensure that appropriate consultation with social services is assured by their adult protection procedure and that they can show that staff are appropriately trained in adult protection. These steps will assist ensuring that residents remain protected from abuse. EVIDENCE: The respite unit had no formal complaints recorded since 2003. The Commission has received no complaints about the respite unit. One out of the six comment cards said that they didn’t know how to make a complaint. Residents spoken to did not indicate how they would act if they were unhappy at the unit. The manager stated that the unit was not recording grumbles or suggestions of residents. The manager needed to consider how she could capture the views of residents on the service they receive at the time they are expressing it as this will help to improve the service. The organisation has a lengthy complaints procedure and has produced a shortened version in a leaflet to assist those that wish to complain. The tone of the leaflet is supportive; it could be enhanced by larger print, as many of the residents or Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 16 their representatives will have sight impairments and (for the use of residents of the respite unit) details of how to contact the Commission. The unit had many compliment cards displayed it is recommended that these be dated and be used as part of their quality audit. The respite unit had an adult protection procedure which whilst protecting residents needed to include that the level of seriousness of an allegation must be discussed with Social Services before any decision is made as they have the responsibility to co-ordinate any actions on allegations. The respite unit take an inventory of a resident’s possessions on admission to the unit and this is important especially in a respite unit where stays can be for short lengths of time. Staff training on abuse and adult protection was not shown on the matrix supplied by the organisation although many staff may have undertaken this in NVQ 2 in care training this needed to be indicated on the matrix to show that the unit had met the Department of Health’s ‘No Secrets’ guidance. Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 17 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): 19,21,22,23,25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The centre benefits from being purpose built but needed some improvements to ensure the environment is as safe and comfortable as residents would wish. EVIDENCE: The centre is purpose built and is well decorated, clean and fresh in all areas except for one toilet on inspection. The respite unit has yet to complete works in the building so the audit of carpets and replacement where needed remained outstanding. There were a number of health and safety concerns identified and these are reported under standard 38. The respite unit has an assisted shower facility and assisted bathing facility. Day centre attendees sometimes use these facilities. The shower facility did Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 18 not have a ventilation fan and although well appointed may be used more if floor to hip height screening were available to prevent carers getting wet. The large assisted bathroom is used more, however it is not the inspectors view a pleasant place to have a bath. The need to store spare clothing, the loudness of the ventilation fan, the clinical decoration and the exposed pipes could make it distressing for some residents rather than a relaxing experience. The space in the respite unit was being reorganised and the re-siting of the hazardous substances store and staff lockers were likely to be improvements when completed. The residents’ rooms were fit for respite these were minimally decorated with residents’ families encouraged to bring items that are important to residents when they stay. The rooms have the additional benefit of an alarm system that can tell when residents are up and walking on a night. 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. One bedroom hot water outlet on the wash hand basin was too hot. The unit showed that they were monitoring the temperatures but this had lapsed recently with the building work and this needs checking again as the building work comes to a close. The respite unit has appropriate laundry facilities, the unit has set up an infection control procedure to minimise any cross infection from laundry brought in to the respite centre for people the unit supports. A staff toilet had a fabric towel and this is not good infection control practice. Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 19 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The respite unit was appropriately staffed to provide good care to residents. The staff were achieving the NVQ2 in care and well trained staff are aware of needs of residents. Overall the unit has appropriate arrangements for training of its staff however a number of updates on training needed to be undertaken by staff to ensure that their practice remains good and not exposing residents to risk. EVIDENCE: The centre and the respite unit had an appropriate amount of staff on duty. It is sometimes difficult to calculate staff as a number of staff will work in the day centre and will assist in the respite unit when needed. The staffing rota showed that the respite unit had staff that were dedicated to it in the hours when the day centre was not open. One comment card received stated that although the unit has enough staff that on one occasion they hadn’t. The manager agreed that there had been an occasion when a number of staff had been ill and the managers worked as care staff to meet the shortfall. The manager stated that all staff hold first aid certificate states 95 staff have a NVQ2 in care. This is to be commended. Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 20 Staff records had improved since previous inspections. It was found that staff had checks with the criminal records bureau and where staff had been employed prior to the start of this process the organisation had taken steps to ensure staff went through this process. All staff have occupational health checks before starting work. The manager was able to show that they were working towards new staff receiving the appropriate induction as recommended by the Skills for Care Organisation. There were more copies of certificates of training held on staff files and the respite unit was able to supply a matrix of the whole staff team’s training. This showed that there was training been offered on a routine basis, but there were a number of gaps that could be identified moving and handling training was not being arranged in a timely fashion, a number of respite staff had to complete infection control and dementia awareness courses. Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 21 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): 31,33,35,36,37&38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Whilst the respite unit manages the care of residents reasonably well fire safety and changes to the building that could affect residents’ safety were not always adequately managed. The organisation made swift changes to remedy this after the inspection. The respite unit was not demonstrating that were assessing the service they were providing, looking at residents and relatives views and planning to improve. EVIDENCE: The registered manager of the respite unit has a NVQ level 2 in care and has achieved the Registered Managers Award. In addition has a Diploma in welfare Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 22 studies. The manager has started NVQ level 4 in care and has almost completed this course. 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. Since the last inspection the manager has been giving some support to the organisations Community Support service due to an unexpected loss of a manager there. The respite unit was unable to show that they have a quality control system throughout the whole of the service they provide. Although it has questionnaires they don’t have methods of collecting residents views on the service at they time they express it. This means they may lose information that may able them to plan future developments. The unit was having visits from a representative of registered provider but these did not always result in at least a monthly report with a copy being sent to the Commission. There was little sign of the respite unit checking records such as how accidents in the centre happen and if there any patterns to accidents. Not all injuries to respite residents resulted in a notification to the Commission as required. The respite unit tends not to keep money for residents as they are on short stay. The records they keep are satisfactory for the odd occasion when this happens. The unit was not looking at these records to ensure when it is not being used it is returned to the resident or their representative. The inspector found that a number of staff were receiving supervision and this was an improvement since the last inspection. However the unit needs to continue this to ensure that all staff at the respite unit have supervision six times a year. The respite unit’s documentation is improving however it is important that documents are dated and signed by the person completing the record. The respite unit was ensuring that the maintenance and inspection of a number of the unit’s services were undertaken such as checking the gas supply and equipment lifting equipment and so on. Whilst the respite unit had fire records it was seen that there had not been a fire drill for 18 months and this was not acceptable and an urgent letter was sent about this. The manager ensured a day time fire drill was undertaken the next day and that drills on a night were to be completed routinely. Staff at the unit did not from the training matrix have fire training in a timely way. The unit had a fire risk assessment but this was not dated and needs revision given changes to the building and fire regulations. The kitchen in the centre is increasing the number of meals that it provides and to do this requires more storage space. A walk in fridge- freezer has been created on the corridor between the daycentre and the respite unit. This is currently not in use and is locked. The intention is that when it use it will be Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 23 locked however the inspector is concerned about the risk posed to the vulnerable residents and daycentre attendees of this. The inspector viewed the arrangements for locking the laundry and the kitchen and thought these too needed review. An urgent letter was sent for further safeguards to be put into place. The home had put in extra coded doors between the fridge and areas that residents use before the writing of this report. The respite unit had some upheaval with changes of use to parts of the building and one of the activity rooms was being used a store. This contained equipment that had been in an outside shed and other items this door did not lock. The unit was not showing that they were looking at changes in the building and how they may affect the residents and day centre attendees. The respite unit must ensure that they have a building risk assessment and this updated as the building changes or as work starts on the building. Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 24 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 RESPITE UNIT Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 2 3 X 2 2 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 2 2 2 Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 25 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 OP3 Regulation 13(5) Requirement Moving and handling assessments must contain clear details of how residents are to be assisted. (Outstanding since 30/04/06) Information collected on residents’ behaviour must be in enough detail to assist the risk assessment and care planning. (Outstanding since 30/04/06) Assessments on moving handling, risks of falling and risks associated with pressure areas must be completed on every resident. Information about resident’s ethnic origin and religion must be collected to ensure that these are considered in part of the holistic care of the resident. The registered manager must ensure: Care plans reflect the current needs of residents and clearly inform the care staff on care to be given or action to be taken especially about resident’s behaviour and personal hygiene Timescale for action 10/12/06 2 OP3 14(2) 10/12/06 3 OP3 13(4)(c) 13(5) 10/12/06 4 OP4 12(4)(b) 10/12/06 5 OP7 15(1&2) 12(2&3) 10/12/06 Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 26 assistance needed. This aspect of the requirement remained outstanding since 31/10/05 and 30/04/06) All risks identified must have actions in the care plan to minimise them. 6 OP15 16(2)(i) A record of the food eaten by individual residents including amount must be kept for all meals. (This requirement remained outstanding 30/09/05 and 30/04/05) All staff must receive adult protection training and a record of that training must be on the staff file and the training matrix. 10/12/06 7 OP18 13(6) 31/12/06 8 OP19 23(2)(d) An audit of carpets must be 31/01/07 undertaken and action taken to remove staining. (These remain outstanding since 31/10/05 and 30/06/06) The bathroom ventilation fan, equipment, storage and decoration must be reviewed to ensure that that residents have an appropriate and comfortable bathing facility. The hot water outlets that residents have access must continue to be tested to ensure they maintain a safe temperature at all times. Fabric towels must not be used in communal toilet facilities. The manager must ensure that all staff undertaking work in the respite unit have all of the mandatory training and updates within the designated time limits. A quality assurance system must be available in the respite unit 31/01/07 9 OP21 23(2)(f) 10 OP25 13(4)(c) 10/12/06 11 12 OP26 OP30 13(3) 18(1)(c) (i) 10/12/06 28/02/07 13 OP33 24 31/01/07 Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 27 14 OP37 26 part of the centre. (Outstanding since 31/05/06) A Copy of the report of the monthly visits by the responsible individual must be sent to the Commission. (This remained partly outstanding since 31/10/05 and 31/03/06) The respite unit must ensure all documents including residents’ assessments, reviews, and the unit’s fire risk assessment are dated and signed. The registered person must ensure that a fire drill is undertaken and have arrangements in place that fire drills are undertaken routinely and no less often than 6 monthly. Urgent Requirement sent Responded to the next day 31/01/07 15 OP37 17(3)(a) 30/12/06 16 OP38 23(4)(e) 08/11/06 17 18 OP38 OP38 23(4)(d) 13(4)(c) All staff must receive fire training 10/12/06 at least every 6 months, a record must be kept of this. The registered person must 08/11/06 advise the Commission about the arrangements that you are making to guarantee the safety of residents in respect of: The walk in fridge freezer in the corridor. The accessibility of the kitchen and the laundry areas of the unit. Including the dates by which these risks will diminish. Urgent requirement sent and arrangements were made by the time of this report. The respite unit must have a building risk assessment that is updated to ensure the continued safety of residents whilst 19 OP38 13(4)(c) 10/12/06 Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 28 20 OP38 13(4)(c) changes are made to the building. All storage areas of equipment and hazardous substances must be locked. 10/12/06 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 OP16 Good Practice Recommendations It is recommended that the organisation’s complaint leaflet have an addition informing residents and their representatives how to contact the Commission. It is recommended that the respite unit develop ways of recording residents’ views of the respite unit. It is recommended that the organisation review their complaints leaflet view to increasing the print size. It is recommended that lower screening is made available in the shower room as well as a shower curtain to prevent staff from getting wet. It is recommended that the registered provider consider colour-coding doors to toilets bathrooms and en suites to assist residents. (This remained outstanding) It is recommended where residents’ money has not been used for a number of stays it is returned to either the resident or their representative. 2 3 OP21 OP22 4 OP35 Colebrook Respite UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 29 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 UnitDS0000004527.V317894.R01.S.docVersion 5.2Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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