Inspection on 02/04/07 for Deansgrove Residential Care Home

This inspection was carried out on 2nd April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Deansgrove Residential Care Home 27/05/08

Deansgrove Residential Care Home 24/04/06

Deansgrove Residential Care Home 12/10/05

Deansgrove Residential Care Home 04/05/05

Deansgrove Residential Care Home 12/07/04

Deansgrove Residential Care Home 07/04/04

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

CARE HOMES FOR OLDER PEOPLE Deansgrove Residential Care Home 38 Bluebell Lane Huyton Knowsley Merseyside L36 7XZ Lead Inspector Daniel Hamilton Key Unannounced Inspection 2nd April 2007 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 Deansgrove Residential Care Home DS0000021481.V334901.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. Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Deansgrove Residential Care Home Address 38 Bluebell Lane Huyton Knowsley Merseyside L36 7XZ 0151-489-1356 0151 489 8289 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) Mr James Edward Jenkins Mrs Amanda Jane Byrne Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29), Physical disability over 65 years of age of places (29) Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 29 OP and up to 29 PD(E) The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 18th December 2006 Date of last inspection Brief Description of the Service: Deansgrove is a residential care home, which is registered to provide personal care and support for up to 29 older people, including older people with a physical disability. It is located in an established residential area of Huyton within approximately a mile of the town centre. The home was not originally purpose-built but was adapted from existing properties to provide 17 places. During 2005, the side of the premises was redeveloped, to provide an additional 12 bedrooms with en-suite facilities. The home is situated on two floors. Access to the upper floors is gained via a passenger and stair lift. On the ground floor there are two small lounges, a conservatory / dining room, a kitchen, office, laundry and some bedrooms. The first floor consists solely of bedrooms. The care home is equipped with a call bell system and has adequate assisted bathing and toilet facilities, which are spread evenly throughout the premises. There is a large garden to the rear of the home, which can be accessed via the conservatory. Parking facilities are available at the front of the property. Care Home Fees range from £327.46 to £347.46 per week. Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day and lasted approximately 9 hours. Twenty-three residents were living in the home at the time of the visit. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The owner, Registered Manager, four staff and seven residents were spoken to during the visit. Survey forms “Have your say about…” were also sent to 11 residents prior to the inspection, to obtain additional views / feedback about the home. All the key standards were reviewed and previous requirements and recommendations issued at the last random inspection in December 2006 were reviewed. What the service does well: What has improved since the last inspection? Since the last inspection, a number of staff had completed Moving and Handling, First Aid, Food Hygiene and a range of care related training courses, to enable staff to work safely and competently with residents. The manager reported that she had completed the level 4 National Vocational Qualification Registered Manager’s Award and was waiting to receive her certificate from the training provider. Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 6 Staff reported that they had started to receive formal supervisions from the Manager and records were available to confirm staff were supervised and supported in their role. What they could do better: The home had developed an assessment and care planning system. Some assessments viewed were incomplete and key information relating to the religious and cultural needs of residents had not been assessed. Furthermore, some care plans did not detail how the needs of residents were to be met and some health care records had not been updated following appointments. These issues must be addressed in order to ensure the people living in the home receive the care they need. Although some progress had been made, a number of staff had not completed all the necessary Safe Working Practice Training. This matter must be addressed as a matter of priority to ensure the health and safety of staff and residents is safeguarded. Furthermore, the home should continue to ensure that all staff complete training in the protection of vulnerable adults to ensure they understand how to recognise and respond to abuse. No progress had been made in developing a system to review the competency of staff responsible for medication and examples of poor record keeping were noted during the visit. The manager should review the competency of all staff responsible for medication at regular intervals to ensure best practice. Some residents continued to express concern regarding the range of activities in the home. For example, a resident reported; “There is not much variation really. They have started to organise bingo sessions recently.” Another resident stated; “We don’t really have many activities other than a lady who comes on a Wednesday for exercises. The main activity seems to be watching television.” The home should continue to develop its programme of activities in consultation with residents and maintain a record of activities and participants. This will help the home to demonstrate how it meets the recreational needs of residents. Residents expressed mixed views about the quality of food provided in the home. Some residents were happy with the meals and others expressed concern regarding the choice of evening meals. One resident stated; “There is not much variation for tea time meals. We get the same alternatives day in day out. It would be nice to see some change.” The home should address this matter in consultation with residents. No progress had been made in the development of the home’s quality assurance system. Minutes of Regulation 26 visits were not available for inspection and there had been no formal meetings with residents as a group since 2004. Some residents confirmed that they had received a brief questionnaire during December 2006 however the results of the survey had not been published and made available to current and prospective residents, Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 7 their representatives and other interested parties. The home should give priority to developing its quality assurance system, to improve consultation with the people using the service. In order to safeguard the health and safety of the people living in the home, it is recommended that visual inspections of the fire extinguishers are undertaken on a monthly basis and that night staff receive fire refresher training every three months and day staff every six months. The home’s building risk assessment should also be reviewed and a legionella risk assessment produced. 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. Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Assessment practice is not robust as the needs of prospective residents are not always fully assessed before they choose to move in. EVIDENCE: The home had a ‘Referral and Admissions Policy’ in place. The manager reported that no new residents were able to move into the home until an assessment of needs had been undertaken. The files of three residents were viewed during the visit. Two files were for residents who had moved into the home since the last key inspection and one was for a resident who had lived in the home for approximately 5 years. Each file viewed contained an assessment of needs and a contract. Assessments viewed were well structured and generally contained appropriate information on the needs of the people living in the home. Two of the assessments viewed lacked key information on equality and diversity issues. For example, information regarding the religious and cultural Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 10 needs of residents had not been included and there was no information on resident’s social interests and hobbies. Similar issues were noted at the previous inspection. Concern was noted from a number of residents during the inspection regarding the availability and range of activities within the home (see standard 12). Copies of assessments and care plans completed by social workers had also been obtained for reference. A copy of the home’s Statement of Purpose was available in the reception area of the home and a copy of the Service User Guide had been placed in each resident’s room for reference since the last visit. The manager reported that the home was able to produce the documents in alternative languages including brail, subject to individual need. No other formats were available for inspection at the time of the visit. Feedback received from residents and their representatives via discussion and care home surveys confirmed the people living in the home had received a contract, information on the home and that they had been encouraged to visit the home prior to admission, to assess the quality, facilities and suitability of the service. At the time of the visit the home did not provide intermediate care. Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. 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. Some care plans and associated records did not detail how the needs of residents were to be met. This could have an adverse affect on the health, personal care and welfare of residents. EVIDENCE: The home had developed a policy on care planning for staff to reference. The manager reported that since the last inspection the responsibility for care plan development had been shared with senior staff that had completed appropriate training. The files of three residents were viewed during the visit. Each file contained a care plan that was based upon the initial assessment of needs for individual residents. Two care plans viewed were completed to a good standard however one lacked detail of how the needs of residents were to be met. For example, the care plan detailed “Religion” as an assessed ‘Need’ and “Not Known” had been recorded as the ‘Action to be taken’. Likewise, there were no details of the aims and objectives for the plan and it had not been kept under monthly review. Other examples were discussed with the owner and manager Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 12 during the visit. All care plans had been signed by residents and / or their representatives. Supporting documentation including; daily report sheets, personal care and weight records, dietary preferences, declaration of wishes in relation to medication and a range of risk assessments to address individual risks e.g. falling, nutritional intake and pressure areas were also in place, subject to individual need. Medical appointment records showed that residents had accessed a range of health care professionals, when required. At the time of the visit individual records of Chiropody appointments had not been maintained and the manager was requested to establish these records and to include details of the outcome of visits. Feedback received from residents via care home surveys and discussion confirmed they received the medical support they needed. The home had developed a range of medication policies and procedures to provide guidance to staff. At the time of the inspection only one resident selfadministered medication. A risk assessment had been completed but it was brief and required more information, to safeguard the welfare of the resident. Staff responsible for administering medication confirmed they had completed medication training via an external training provider and copies of training certificates were available to view. Since the last key inspection, a copy of guidance issued by the Royal Pharmaceutical Society of Great Britain had been obtained for staff to reference and declaration of wishes /consent forms for the administration of medication had been completed by each resident and / or their representative. Furthermore, a record of staff responsible for the administration of medication, together with sample signatures had been developed and a controlled drugs register had been purchased. Details of the date, quantity and initials of the person receiving medication into the care home had also been recorded. No progress had been made in establishing a system to review the competency of staff responsible for administering medication. Overall, Medication Administration Records (MAR) viewed had been correctly completed however two issues were noted during the inspection. One MAR had not been signed to confirm that two types of medication had been administered to a resident on one occasion and an error was noted with the home’s resident identification system for medication i.e. the surname of one resident did not match the photograph on file. Both issues were discussed with the manager and the identification system was corrected during the visit. Medication was stored safely and staff spoken with demonstrated a good understanding of how to correctly record, handle, administer and dispose of medication. Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 13 The home had developed a policy on Privacy and Dignity to provide guidance to staff. Staff spoken with during the visit demonstrated an awareness of the principles of good care practice and the need to treat individuals with respect and dignity when providing personal care. Feedback received from residents and their representatives confirmed the people living in the home received the care and support they needed and were valued and respected by staff. Staff were observed to interact with residents throughout the day and appeared sensitive and caring towards the needs of residents. Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The range of social activities and evening meals is limited and does not satisfy the preferred lifestyle of some residents. EVIDENCE: The home had developed a ‘Policy on Therapeutic Activities’. Details of activities were recorded on a white board in the dining room. A programme of activities based upon the recreational needs and interests of residents had not been developed as previously recommended and there was no record of activities or participants. Key information on the recreational needs and interests of new residents had not always been taken into consideration as part of the home’s pre-admission assessment process. The manager reported that residents had been asked about their preferred activities via a questionnaire that was circulated during December 2006 and that many of the residents did not wish to participate in activities. At the time of the visit, the home organised ‘Bingo’ on a Monday and Saturday, ‘Hairdressing’ on a Tuesday, ‘Movement to Music’ on a Wednesday and ‘Beauty / Pampering’ sessions on a Friday. An outside entertainer also visited the home on a monthly basis. The manager reported that church visitors and / or Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 15 ministers from different denominations visited the home to meet with residents, subject to their individual religious beliefs. A volunteer was observed to play dominoes with two residents during the visit and a game of bingo was facilitated in a communal lounge during the evening. Some residents spoken with expressed concern regarding the range of activities provided and the lack of community based activities. Comments included; “We don’t really have many regular activities other than a lady who comes on a Wednesday for exercises. The main activity seems to be watching the television” and “There is not much variation really. They have started to organise bingo sessions recently.” Two residents spoken with had no knowledge that church representatives and ministers of religion visited the home. These issues were raised with the manager during the visit. The home had developed a ‘Policy on Visiting and Visitors’ and the Statement of Purpose detailed that; “Visitors are welcome at any time.” Residents spoken with confirmed that they could receive visitors at different times of the day and that they were able to exercise choice and control over their daily lives. One resident stated that in her opinion; “It’s very similar to living at home.” A range of policies had been developed regarding food safety and nutrition and the manager had obtained a copy of the ‘Food Standards Agency Guidelines.’ The home had a four-week rolling menu, which provided a choice of meals for breakfast, dinner and tea. Mealtimes were considered to be a social occasion and food was served in the home’s dining room at set times. Some residents were observed to eat their meals in their bedrooms and the manager was advised to record individual wishes in care plans. Residents expressed different views on the meals and quality of food provided. A number of residents were of the opinion that the choices for evening meals were limited and repetitious as ‘sandwiches or soup’ were offered as an alternative for most teatime meals. Comments included; “The food has been alright so far but the choices for evening meals are not very satisfactory” and “There is not much variation for tea time meals. We get the same alternatives day in day out. It would be nice to see some change.” The dining room was pleasantly furnished and tables were equipped with condiments and tablemats. Although meals were served at set times, arrangements were flexible to suit individual needs. The manager reported that the home was able to cater for different religious, cultural and dietary needs upon request. At the time of the visit the home was providing soft / puree, sugar free and seedless diets were being provided. Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 16 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. The service had developed policies and procedures to enable residents to express their concerns. Some staff lacked knowledge of adult protection policies and how to recognise and respond to suspicion or evidence of abuse. EVIDENCE: The home had developed a complaints procedure, a copy of which was included in the Service User Guide and the home’s Statement of Purpose. The manager was advised to display a copy of the policy in the reception area of the home, to ensure the procedure was more visible to residents and visitors. Pre-inspection records detailed that no complaints had been received since the last inspection and this was confirmed by checking the home’s record of complaints. The Commission for Social Care Inspection had received no complaints since the last visit. Feedback received from residents via discussion and care home survey forms confirmed the majority of residents were aware of how to complain and who they could speak to if they were unhappy. Residents spoken with raised no complaints or concerns during the visit. One resident stated; “You can complain to Mandy. She will sort any problems out.” The home had policies and procedures in place to protect residents from abuse. Pre-inspection records detailed that no adult protection referrals had been made since the last visit and this was confirmed in discussion with the manager. Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 17 Since the last visit the home had obtained a copy of the local authority adult protection procedures and staff had been issued with a copy of a “No secrets” alert card, which included information on how to recognise and report abuse. Furthermore, 12 staff had completed Protection of Vulnerable Adult training and a training date had been scheduled for a further three staff to attend training during April 2007. As noted at the last inspection, staff demonstrated different levels of awareness regarding adult protection. Staff who had completed Protection of Vulnerable Adult (POVA) training were able to describe the different types of abuse and reporting procedures. Staff who had not completed POVA training had limited understanding in this important area. Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. 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. Overall, the standard of the environment within this home is good providing residents with an attractive and homely place to live. EVIDENCE: The home continued to employ a full time maintenance worker who was responsible for maintaining the home and grounds. Contractors were hired for major and specialised work as and when required. Pre-inspection records detailed that a new dining room extension had been built since the last visit and the hallway had been redecorated. Furthermore, new communal furniture had been purchased for the lounge areas and all the residents rooms had been redecorated / refurbished. Rooms viewed had been personalised by residents with furniture, pictures and personal belongings. Maintenance issues identified at the last key inspection had also been addressed. Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 19 Areas viewed were generally well maintained and the owner and manager confirmed that the home continued to receive ongoing investment as required. At the time of the visit the kitchen floor was damaged and was in need of replacement. The manager confirmed that action was being taken to address this matter. The location and layout of the home was suitable for its stated purpose (please refer to the ‘Brief Description of the Service’ section for more information on the premises). Rooms viewed were personalised and residents were observed to have access to personal mobility aids, subject to individual needs. Infection control policies and procedures had been developed. The home employed two part-time domestics and areas viewed appeared clean and hygienic. Feedback received from residents via care home surveys and discussion confirmed the home was always clean and fresh. Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 20 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. Residents are supported by staff who are correctly recruited and inducted however some staff have not completed all the necessary training to ensure safe working practices. EVIDENCE: Discussion with the manager, inspection of rotas and direct observation confirmed that the staffing levels had increased since the last visit. Four care staff were on duty from 8.00 am to 10.00 pm. During the night, three waking night staff were on duty. The manager was supernumerary. The home also employed a number of ancillary staff including a cook, two parttime domestics, and a full time handyman. At the time of the visit the home had one vacancy for a part-time waking night staff. The manager was advised to include details of the capacity in which staff are employed on the rota. Residents spoken with reported that they felt the staff team were sensitive to their needs and kind and considerate. Staff were observed to spend time with residents during the visit, offering support as and when required. Likewise, information received from residents and / or their relatives via care home surveys confirmed the people living in the home received the care and support they needed and that staff were available when required. The home had a ‘Policy on Recruitment’ which included equal opportunities. The manager reported that five staff had commenced employment at the home since the last inspection. The five files were examined and all were found to Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 21 contain the necessary records required under the Care Home Regulations 2001. One application form viewed did not include details of the dates of previous employment and this matter was brought to the attention of the manager. Since the last inspection the manager had started to provide formal supervision to staff and records were available on files viewed. At the time of the visit the home employed 24 care staff (including the deputy manager). Records showed that 16 (66.6 ) staff had completed a National Vocational Qualification at Level 2 in Care or equivalent. A further two (8.3 ) staff had completed the award and were waiting to receive certificates and five staff (20.8 ) were working towards the award. Once certificates have been received for the outstanding staff, the total number of qualified staff in the home will be 23 (95.83 ) Since the last visit, the manager had made arrangements for all existing staff to complete the Skills for Care Induction course. Evidence of induction training was also on file for staff recruited since the last visit. The home’s training matrix had been updated to include approximate dates when staff were next due to complete refresher training. The manager was advised to record the dates when training was last completed and the dates that staff commenced employment, to provide a clear audit trail. Pre-inspection records showed that staff had completed a range of training since the last key inspection. Records showed that 10 staff had completed (manual handling and first aid), 12 staff (food hygiene), 7 staff (medication), 3 staff (care planning) and 10 staff (protection of vulnerable adult) training. No details of fire or infection control training had been included in the preinspection questionnaire and the home’s training matrix and records viewed showed that a number of staff had still not completed all safe working practice training. The manager was able to demonstrate that she was monitoring the outstanding training needs of the staff team in consultation with training providers. Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 22 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 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’s quality assurance and consultation processes require further development to demonstrate the home is appropriately managed and run in the best interest of residents. EVIDENCE: The home was managed by Mrs Amanda Byrne who was registered with the Commission for Social Care Inspection. Mrs Byrne had been in post since January 2006. Mrs Byrne reported that she had recently completed the level 4 National Vocational Qualification (NVQ) Registered Managers Award and was waiting to receive her certificate. Mrs Byrne advised that she was planning to enrol on the level 4 (NVQ) in Care during May 2007. Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 23 Since the last key inspection, the manager had completed Moving and Handling and Protection of Vulnerable Adult training. Training records showed that the manger had also completed First Aid, Basic Food hygiene, Infection Control, COSHH and Care Planning training. Records showed that the manager had not completed any Medication or Health and Safety training and Fire refresher training had not been updated since September 1995. The manager confirmed that she was in the process of addressing these outstanding training needs. The Registered Provider did not commission an external organisation to undertake a quality assurance assessment of the home. The manager reported that the owner had completed visits and produced reports in accordance with Regulation 26 however these were not available for inspection. The owner agreed to store the records in the home for future inspections. Discussion with the manager, residents and staff confirmed that no Resident’s Meetings had been coordinated. Some residents spoken to during the visit thought that this would be a useful way to share information and develop the home. The manager reported that the home had sent questionnaires to residents and / or their representatives during December 2006. The manager had prepared a brief report on the findings dated February 2007. This had not been displayed for prospective and current residents to view. The home had recently purchased a new “Quality Audit System” from an external provider in order to improve the home’s quality assurance system and questionnaires. The manager was advised to focus on outcomes for residents. The home had established a system for fees to be paid directly into the home’s business account. The majority of residents looked after their financial affairs with support from family members / appointed representatives. Pre-inspection records showed that the owner acted as an appointee for one resident. The home looked after the personal spending money for three residents only. Individual records had been established to record transactions and receipts were available for expenditure. Pre-inspection records detailed that equipment and services within the home had received regular maintenance / safety checks. Fire records were inspected. Records showed that the fire alarm system had been tested on a weekly basis and that monthly visual inspections of the emergency lighting had been completed. No monthly visual inspection of the fire extinguishers had been recorded and there were no records to confirm that staff had received fire refresher training at regular intervals. A fire risk Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 24 assessment had been completed and certificates were in place to confirm the fire alarm system and extinguishers had been appropriately serviced. The manager was advised to complete a legionella risk assessment and to review the home’s building risk assessments. Progress had been made in supporting staff to compete safe working practice training however some staff had not completed all the training required. This issue is addressed in Standard 30. Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 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 2 X 2 X 3 3 X 2 Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 15 (1) Requirement All people using the service must have an up-to-date detailed care plan. This will ensure that residents receive person centred support that meets their needs. All staff must complete Moving and Handling, Fire Awareness and Infection Control training to ensure the health and safety of service users and staff are protected. Timescale for action 02/05/07 2 OP30 18 (1) a 02/07/07 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 2 3 Refer to Standard OP3 OP8 OP9 Good Practice Recommendations Information on the religious and cultural needs and social interests and hobbies of prospective residents should be obtained as part of the pre-admission assessment. Records of Chiropody appointments should be maintained and the outcomes of all health care appointments recorded. Risk assessments for self-administration should be DS0000021481.V334901.R01.S.doc Version 5.2 Page 27 Deansgrove Residential Care Home 4 5 6 7 8 9 10 OP9 OP12 OP15 OP16 OP18 OP27 OP30 11 12 OP30 OP33 13 14 15 16 OP33 OP38 OP38 OP38 reviewed to ensure they contain information on the assessment and monitoring of identified risks. The competency of individual staff responsible for the administration of medication should be reviewed by the manager on a regular basis and records maintained. A programme and record of activities should be developed in consultation with residents and the range and frequency of activities provided should be improved. The tea-time menu should be reviewed in consultation with residents to offer more choices and variation. The complaints procedure should be displayed in a prominent position so that it is visible for residents and their representatives to view. All staff should complete training in the Protection of Vulnerable Adults from Abuse. The capacity / position of staff should be detailed on the staffing rota. All staff should complete Safe Working Practice training as a matter of priority and records maintained to confirm they understand how to Basic Food Hygiene and how to provide First Aid. The home’s training matrix should be updated to include the dates when staff commenced employment and last completed training. The home should continue to develop its quality assurance system and ensure that a summary report of the results / findings is produced for current and prospective residents and / or their representatives to view. The home should consult residents regarding the establishment of resident’s meetings. Monthly visual inspections of the fire extinguishers should be undertaken and records maintained. The home’s building risk assessment should be reviewed and a legionella risk assessment produced. Night staff should receive fire refresher training every three months and day staff every six months and records maintained. Deansgrove Residential Care Home DS0000021481.V334901.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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. 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