Inspection on 24/04/06 for Deansgrove Residential Care Home

This inspection was carried out on 24th April 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

Deansgrove Residential Care Home 27/05/08

Deansgrove Residential Care Home 02/04/07

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 Unannounced Inspection 24th April 2006 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 Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 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.V290825.R01.S.doc Version 5.1 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 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.V290825.R01.S.doc Version 5.1 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. 12th October 2005 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 ensuite 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 adequate bathing and toileting 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 £320.00 to £340.00 per week. Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 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 a total of 10 hours. Fourteen residents were being accommodated 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 Registered Provider (Owner), Manager, three staff members, one visitor and six residents were also spoken to during the visit. Furthermore, satisfaction survey forms “Have Your Say About….” were distributed to a number of residents and / or their relatives prior to the inspection, to obtain additional views / feedback about the home. All the core standards were reviewed and previous requirements and recommendations from the last inspection in October 2005 were discussed. What the service does well: Since the last visit a new manager had been appointed to manage the home. The manager had made significant improvements in many key areas given the short time she had been in post and demonstrated a commitment to addressing outstanding requirements and recommendations in order to improve the quality of care in the home. The home had pleasant atmosphere and residents appeared relaxed, comfortable and well cared for. Staff appeared friendly and attentive to the needs of the people living in the home and were observed to spend time chatting with residents and offering individual help and support as required. Care files viewed evidenced good links with health care professionals including the district nurse service and resident’s doctors and residents confirmed their health care needs were met. One resident reported; “The staff would not hesitate to contact my doctor if I was unwell.” Likewise, another resident said; I have a lovely doctor and the staff arrange appointments with other professionals when you need them.” Residents confirmed they were treated with privacy and dignity and staff demonstrated a good awareness of how they promote and safeguard the rights of the people living in the home in their day-to-day practice. One resident stated; “The staff are very considerate and always knock on my door before entering” and another said; “The staff are very sensitive and caring when assisting me.” Visiting times remained flexible and residents confirmed were able to exercise choice and control over their lives. A visitor complimented the home and said; Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 Page 6 “I think this is a lovely home. I am always made to feel welcome whenever I visit”. Likewise, a resident said; “This home is ideal for me. My family and friends can visit whenever I want.” The home had a satisfactory complaints procedure in place and discussion with residents confirmed they were confident that their views would be taken seriously and acted upon. For example, one resident said; “Mandy [Manager] and Jackie [Deputy Manager] are great. I’m sure they would listen to me if I reported a problem.” Staff were deployed in sufficient numbers to respond to the needs of residents and a large number of the team had completed a National Vocational Qualification in Care. Residents complimented the staff team and one resident said; “The staff work very hard and are always there to help you.” What has improved since the last inspection? What they could do better: Records showed that medication had not always been administered in accordance with the prescribed instructions and Medication Administration Records (MAR) did not provide an explanation. Likewise, the date that medication was received into the home had not been recorded on MAR to Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 Page 7 provide an audit trail. These matters must be addressed to protect the health and wellbeing of residents. Additionally, medication disclaimers and a record of staff responsible for the administration of medication were not in place and the medication cabinet was not being secured to a wall when not in use. Furthermore, the home did not have a controlled drugs register in place or a copy of the Royal Pharmaceutical Society of Great Britain – ‘Guidelines on The Administration and Control of Medicines In Care Homes’. These matters should be addressed to ensure best practice. A programme of activities was not in place and some residents indicated that they would like to have more activities both within the home and the local community. For example; one resident said; “I have no restrictions put on my life but I would like to go out more.” Likewise, another resident stated; “I’d love the home to organise quizzes, bingo and trips.” The range and frequency of activities provided should be reviewed, to ensure the recreational needs and expectations of residents are addressed. At the time of the visit, it was not possible to check the cash balance of residents’ monies, as the financial records for each resident only detailed the bank balance. Records should be updated to include a cash balance and a record of all transactions from the bank. Although the provider was investing substantial money into the home some areas required priory attention. For example one residents room was in need of redecoration following building work and some floor coverings were loose and presented a trip hazard to residents. One room also had an offensive smell. Some staff had not received all the necessary induction or safe practice training or formal supervision. These matters must be addressed to ensure staff are appropriately trained and supported to undertake their role effectively. Furthermore, all staff should complete training in Abuse, to increase staff awareness of how to safeguard and protect vulnerable adults. No significant progress had been made in developing the homes quality assurance system. A questionnaire had been distributed to residents during February 2006, however a summary of the findings was not available. The home is required to develop a system to review the standard of care in consultation with residents and their representatives. Arrangements must be made to test the fire alarm system on a weekly basis and to maintain records of the test. Likewise, the temperature at each hot water outlet used by residents should be tested and recorded each month, to ensure the temperature is regulated to 43°C. Please contact the provider for advice of actions taken in response to this Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 Page 8 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 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 Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Assessments had been completed, to enable the home to identify the needs of residents however residents were not provided with the necessary information, to make an informed choice about living in the home. EVIDENCE: Three files were viewed. One was for a resident who had moved into the home since the last key inspection and two were for residents who had been living in the home for over six months. Since the last key inspection, the manager had introduced new assessment documentation for each resident. Assessments viewed were well structured and generally contained appropriate information on the needs of residents. Information regarding the religious and cultural needs of residents had not been recorded on assessments viewed. The manager added this information to the assessments during the visit. Assessments completed by social workers were also available on some files. None of the files viewed contained a copy of a written contract / statement of terms and conditions with the home, however a new Statement of Purpose and Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 Page 11 a Service User Guide had been developed that included information on terms and conditions. Copies of the documents were displayed in the reception area of the home however some residents were unaware of the documents and unsure if they had received a copy. For example one resident said; “I don’t think I have received a Service User’s Guide or terms and conditions of residency” and another stated; “I can’t remember being given a copy.” The home had a ‘Referral and Admissions Policy’ in place and the manager and her deputy demonstrated a good understanding of the home’s admission process. Feedback from a survey form confirmed that the home had offered a new resident the opportunity to have a trial visit. Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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. Care plans had been developed which outlined how the care needs of residents were to be met. Some medication records were not being appropriately completed. This practice has the potential to place the health and welfare of residents at risk. Care was provided in accordance with the needs, expectations and rights of the people living in the home. EVIDENCE: The care files of three residents were viewed as part of the inspection process. Each file contained a care plan that was based upon the initial assessment of needs for individual residents. A ‘Policy on Service Users’ Plans of Care’ had been developed by the home for staff to reference. Since the last key inspection, the manager had introduced a new care plan system and overall, the quality of the home’s care plans had significantly improved. Staff spoken to during the visit had a good awareness of the home’s care plan system. One member of staff reported that; “The Care Plans are much better now and set out more clearly.” Likewise a resident said; “The staff understand how to care for me.” Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 Page 13 Information regarding the religious and cultural needs of residents had not been included on some care plans viewed and the manager addressed this during the visit. Care plans viewed had been signed by residents or their representatives and kept under monthly review. Supporting documentation including: daily report sheets, health care and weight records, dietary preferences and a range of risk assessments to address: individual risks; falling; nutritional intake; pressure areas and the absence of radiators in some parts of the home were also in place. The manager reported that plans were in place to develop / improve the night shift report records, to ensure more information was recorded. Since the last visit, the manager had established individual records of health care intervention. Health care records viewed showed that residents had accessed health care professionals subject to need. These included: dentists, doctors, hospital based services, district nurses, physiotherapists and opticians. Residents spoken with confirmed their health care needs were met by the home. Comments from three residents included; “I have a lovely doctor and the staff arrange appointments with other professionals when you need them”; “I have access to health staff if I want them” and “The staff would not hesitate to call my doctor if I was unwell.” The home had a ‘Policy on medication’, a ‘Covert Medication Policy’ and a ‘NonCompliance with Medication Policy’ in place. A copy of the Royal Pharmaceutical Guidelines; ‘The Administration and Control of Medicines in Care Homes and Children Services’ was not available for reference. Records showed that one resident self-administered her medication and a risk assessment had been completed. A disclaimer was not in place for any of the residents. An example copy was given to the manager for reference / use. The manager reported that only senior staff were responsible for administering medication. Certificates were viewed which confirmed that staff had completed training from an external provider. A resident identification system was in place however, at the time of the visit, a record of staff authorised to administer medication together with sample signatures could not be located. Furthermore, there was no system in place to review the competency of staff responsible for medication. Medication was stored in a locked medication cabinet. The cabinet was not secured to a wall when not in use. Overall, Medication Administration Records (MAR) viewed had been correctly completed however two issues were noted. Firstly, there was no audit trail, as the date that medication had been received into the home had not been recorded on any of the medication administration records checked. Furthermore, one MAR and blister pack showed that a resident had not received prescribed medication and there was no explanation code used to explain why. Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 Page 14 At the time of the visit there was no controlled medication in the home. The home did not have a controlled drugs register to record any controlled medication prescribed to residents and advice was given on how to obtain a copy. The home had developed a policy on Privacy and Dignity to provide guidance to staff. Staff were observed throughout the day and were seen to support and engage with residents in an appropriate manner. This included spending time with residents chatting in the conservatory and lounge areas. Staff spoken with were able to demonstrate a good awareness of how they promote and treat the people living in the home with dignity and respect. Likewise residents complimented the care provided by staff. Comments included; “The staff have asked me about my preferences and the care I need”; “The staff are very considerate and always knock on my door before entering” and “The staff are very sensitive and caring when assisting me.” Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 and frequency of activities both within and outside the home was limited and did not satisfy the recreational needs and preferences of some residents. Visiting times were flexible and residents retained control of their daily lives in order to maintain their relationships and preferred lifestyles. Residents received a choice of meals, which were appealing and wholesome. EVIDENCE: The home had developed a ‘Policy on Therapeutic Activities’ however a programme / information about the range of activities for residents had not been established as recommended at the last visit. The manager had developed and circulated a brief questionnaire on activities for residents to indicate their preferred activities and reported that residents had requested more external activities / trips. The new management team indicated that they were planning to improve the range of activities available to residents. Examination of the home’s diary for the last month showed that some residents had participated in a limited range of recreational activities. These included; watching Television and Videos, participating in sing-a-longs and exercises, listening to music, attending hairdressing appointments and playing dominoes. A lay preacher from the local Roman Catholic Church also visited the home to provide communion on a Sunday. Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 Page 16 Residents spoken with expressed different views regarding the range of activities provided. Comments from four residents included; “I don’t think there is enough to do”; “I’d love the home to organise quizzes, bingo and trips”; “I have no restrictions placed on my life but I would like to go out more” and; “There are enough activities for me”. The home had developed a ‘Policy on Visiting and Visitors’ and the home’s Statement of Purpose stated that: “Visitors are welcome at any time.” The visitors book in reception showed evidence of relatives and friends visiting residents and visitors were observed to visit residents during the inspection. One visitor spoken with said; “I think this is a lovely home. I am always made to feel welcome whenever I visit.” Likewise, residents spoken with confirmed visitors were welcome at any reasonable time. One resident said; “This home is ideal for me. My family and friends can visit whenever I want.” Residents interviewed confirmed that they retained control of their day-to-day lives in accordance with the home’s policies on ‘Rights’ and ‘Autonomy’. Overall, the routines in the home were observed as being based around the needs and wishes of the residents and residents confirmed this. Feedback from three residents included; “I choose my own routines and noone interferes with my wishes”; “More or less I do as I please” and “I can make decisions and choose what I want.” Residents were able to bring personal possessions into the home and rooms viewed had been personalised with pictures, ornaments and personal belongings. Meals were served in the home’s conservatory, which 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 home had a range of policies and procedures in place for; ‘Food Safety and Nutrition’, ‘Food Hygiene and Safety’ and ‘Meals and Mealtimes. The manager had also obtained a copy of the new ‘Food Standards Agency Guidelines’, to ensure the home worked in accordance with best practice guidelines. Since the last inspection, the home had stopped using a two-week menu and introduced a four-week rolling menu to offer more variety and less repetition for residents. The manager reported that residents were due to be consulted about their preferences and a new menu was to be constructed shortly. Menus viewed offered a choice of meals and a record of daily choices was recorded and stored on file. Overall residents were satisfied with the meals provided. Feedback from three residents included; “The meals have improved. We now have a four week menu and our preferences catered for”; “The food is OK. I’m not complaining” and “Mike [Chef] caters for our needs and preferences and gives us a choice.” Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. 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. A complaints procedure was in place and residents were confident that the home would listen and act upon any concerns. A copy of the local authority adult protection procedures could not be located and some staff lacked awareness of how to protect the people living in the home from abuse. EVIDENCE: The home had a complaints procedure in place. A copy of the procedure was included in the Service User Guide and the Statement of Purpose, which were displayed in the reception area of the home. The home’s complaint record was viewed. This showed that two complaints had been received from residents since the last inspection. Both complaints concerned the presence of a stranger on the premises. Records showed that action had been taken by the previous manager in order to address the issues raised. All residents spoken with during the visit had no complaints regarding the service and were confident that any concerns would be listened to and acted upon. One resident said; “I would speak to Mandy [Manager] or the person in charge if I had a complaint.” Likewise, another resident stated; “Mandy and Jackie [Deputy Manager] are great. I’m sure they would listen to me if I reported a problem.” The home had developed a “Policy on the Protection of Service Users” and a “Policy on Whistleblowing”. A copy of a “Practical Guide for the Protection of Vulnerable Adults Scheme” was also in place. At the time of the visit, a copy of Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 Page 18 the Local Authority’s Adult Protection Procedures could not be located. The manager made arrangements to order another copy during the inspection. Records showed that eleven of the home’s twenty-two staff (including the manager and deputy manager) had completed training in the protection of Vulnerable Adults. Staff interviewed demonstrated different levels of understanding regarding adult protection. Staff who had completed training in adult protection were able to demonstrate a better awareness of the different types of abuse, their duty of care to protect residents and reporting procedures. Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was benefiting from ongoing investment however some parts were in need of repair / redecoration, to ensure the environment was safe, clean and comfortable for all residents. EVIDENCE: Since the last inspection, the side of the premises had been redeveloped, to provide an additional 12 bedrooms with ensuite facilities. Furthermore, all rooms had been fitted with new furniture, beds, curtains and nets. Overall, the physical appearance of the home was improving and refurbishment work was ongoing. This was observed during the visit as one room was in the process of being re-plastered / refurbished. The home employed a full time maintenance person who was responsible for maintaining the home and grounds and a maintenance book was in place to record jobs requiring attention. The manager reported that the home received ongoing maintenance and investment as required. Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 Page 20 Some parts of the existing home which had been affected by the building work were still in need of repair / redecoration. The owner reported that these issues would be addressed soon, given that the extension work had been completed. Furthermore, some vinyl / carpet floor coverings were in need of repair / replacement as they were worn and presented a trip hazard. Likewise, some of the communal areas were in need of redecoration. These matters were brought to the attention of the manager and owner during the visit. The home had a copy of the ‘Guidelines on the Prevention and Control of Infection in Residential and Nursing Homes’ and a ‘Policy on Clinical Waste’ in place. Furthermore, policies and data sheets were available for the Control of Substances Hazardous to Health (COSHH). Domestic staff were observed to be on duty and overall, areas viewed were clean and hygienic. One bedroom required attention as it had an offensive smell at the time of the visit. Residents spoken with considered their home to be clean and hygienic. One resident said; “The home is always clean and tidy” and another reported “The staff keep my room spotless.” Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 the service. Sufficient staff were deployed to meet the needs of residents. Although some recruitment records were not in place for existing staff, pre-employment checks had been completed for new employees. This provided safeguards for the people living in the home. Some staff had 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 not changed since the last inspection. Three staff were on duty through the day with two waking night staff during the night. The deputy manager was included in the daytime staffing however the manager was supernumerary. Residents spoken to during the visit confirmed there were sufficient staff on duty to meet their needs. One resident said; “The staff work very hard and are always there to help you.” Likewise a visitor said; “Staff are attentive to the needs of the residents and always available to assist them.” The home had a ‘Policy on Recruitment,’ which included equal opportunities. Four new staff had commenced employment at the home since the last inspection. The four files were looked at and all contained application forms and evidence that the home had obtained Criminal Record Bureau (CRB) checks, two references and proof of identity. Records showed that Protection of Vulnerable Adult (POVA) checks had also been completed for two staff that had commenced employment before a CRB had been received. Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 Page 22 At the time of the visit, the manager reported that she was still in the process of trying to obtain outstanding references for three staff that had been employed by the previous manager without the necessary records. Staff records showed that good progress had been made by the manager and owner in obtaining outstanding CRB / POVA checks for staff. The manager reported that the home employed eighteen care staff (including the deputy manager). Records showed that 12 of the care staff (66.6 ) had a National Vocational Qualification (NVQ) at level 2 or above in Care. A further 5 staff had completed a NVQ at level 2 or above in Care and were awaiting a certificate. Once certificates have been received, this will bring the total number of qualified staff to 17 (94.4 ). Induction checklist records (not dated) were available for only two of the four new staff that had commenced employment since the last inspection. The manager reported that she was due to hold a meeting with a training provider on 1/05/06, to organise for staff to complete additional induction training, as the home’s induction programme did not meet the specification of the National Training Organisation. The home did not have a training matrix however each member of staff had an up-to-date record of training completed. Discussion with staff and examination of training records showed that a number of staff had not completed all safe working practice training or were in need of refresher training. Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Further work was needed to develop the home’s quality assurance system and residents’ financial records in order to demonstrate that the home is run in the best interests of residents. Staff had not received supervision and some important health and safety checks / training had not been completed. This has the potential to place the health and safety of residents at risk. EVIDENCE: Since the last inspection, a new manager (Amanda Byrne) had been appointed by the owner to manage the home. The manager had been in post since January 2006 and had started to make noticeable improvements in key areas. At the time of the inspection, the Commission for Social Care Inspection (CSCI) was waiting to receive an application from the manager for registration. Residents and staff interviewed spoke highly of the new manager. One staff member said; “I like Mandy. She is very approachable and keeps the staff updated on everyday things concerning staff and residents. She gives 100 to Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 Page 24 the residents.” Likewise, a resident said; “This home is ideal for me. The management team is brilliant.” The manager reported that she had enrolled on the National Vocational Qualification (NVQ) level 4 Registered Managers Award with Knowsley Community College. Training records showed that the manager had completed a range of training that was relevant to her role however some safe working practice training had not been completed / refreshed. The Commission had not received Regulation 26 reports for approximately two months as the provider / owner had been visiting the home on a regular basis due to building work and supporting the new manager to settle in. The owner agreed to recommence completing and sending a copy of the report to the Commission each month. No resident meetings had been coordinated since March 2004 and one resident reported; “We’ve not had a residents meeting for while. I think they would be useful to express views and share information.” The manager reported that she planned to introduce monthly meetings shortly. A brief ‘Service Users Questionnaire’ had been developed which was circulated to 15 residents during February 2006. At the time of the visit, no report had been produced / published to identify the outcomes. The home had established a system for fees to be paid directly into a business account. The majority of residents looked after their financial affairs with support from family members / appointed representatives. The registered provider reported that he was in the process of being registered as an appointee for one resident. The Registered Provider had opened a non-interest paying ‘Deansgrove Residents Account’ approximately six weeks ago. This was to ensure residents’ monies were kept separate to the home’s business account. No statements had been received to date however a copy of the cheque book was viewed. The home looked after the personal money of four people. Individual records had been established to record transactions and receipts were obtained for expenditure. The cash balances could not be checked as the home had only recorded the bank balance. Advice was given on how to improve the record keeping. Records belonging to a resident who received money from a relative were checked as the home had a record of the cash balance. Details of expenditure and the cash balance were found to be correct. Discussion with the manager and staff and inspection of staff records confirmed that none of the staff had received a supervision session since the last inspection. The manager advised that she had met with all the night staff for an informal chat however no records had been written up to date. The Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 Page 25 manager highlighted that she was planning to introduce supervisions within the next four weeks. The pre-inspection records showed that equipment within the home received regular maintenance. Fire records were inspected. A new fire alarm system had been fitted during December 2005 and a commissioning certificate for the fire alarm system and emergency lighting was available. The fire extinguishers had been serviced during January 2006. Records showed that the fire alarm system had not been tested since 10th December 2005. Furthermore, records to monitor the hot water temperature at each outlet were not in place. The manager reported that the temperature of water was tested before residents entered a bath. Records showed that some staff had not completed all the necessary safe working practice training. This issue is addressed in Standard 30. Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 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 1 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 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 2 X 2 X 2 2 X 2 Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 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 2 Standard OP9 OP9 Regulation 13 (2) 13 (2) Requirement Residents must receive their medication in accordance with the prescribed instructions. The date that all medication is received into the care home must be recorded on the Medication Administration Record. The bedrooms requiring repair following building work must be redecorated. The floor coverings identified to the manager as presenting a trip hazard must be repaired / replaced. The room identified to the manager as having an offensive smell must be kept clean and hygienic. The Registered Manager must ensure that all staff receive induction training in accordance with TOPSS specification. [Previous timescale of 4/06/05 not met]. A system must be established to review the quality of care provided at the home and to ensure consultation with DS0000021481.V290825.R01.S.doc Timescale for action 24/05/06 24/05/06 3 4 OP19 OP19 23 (2) 23 (2) 01/06/06 01/06/06 5 OP19 16 (2) K 24/05/06 6 OP30 18 (1) C 24/05/06 7 OP33 24 24/06/06 Deansgrove Residential Care Home Version 5.1 Page 28 8 9 OP36 OP38 18 (2) 18 (1) a 10 OP38 23 (4) C residents and their representatives. Staff must receive supervision at least six times a year The Registered Manager must ensure that safe practice training is completed by all staff and refresher training must be completed periodically. [Previous timescale of 12/12/05 not met]. The fire alarm system must be tested on a weekly basis and records maintained. 24/05/06 24/06/06 24/04/06 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. 2 3 4 5 6 7 Refer to Standard OP2 OP9 OP9 OP9 OP9 OP9 OP9 Good Practice Recommendations A written contract / statement of terms and conditions and a copy of the new Service User Guide should be given to all residents or their representatives. Medication Disclaimers should be completed by residents or their representatives. A record of staff responsible for the administration of medication, together with sample signatures should be placed in the medication file. The competency of individual staff responsible for the administration of medication should be reviewed by the manager on a regular basis and records maintained The medication cabinet should be secured to a wall when not in use. A controlled drugs register should be in place at the home. A copy of ‘The Administration and Control of Medicines in Care Homes and Children Services (Issued by The Royal Pharmaceutical Society of Great Britain) should be obtained for reference). A programme of activities should be developed in consultation with residents and the range and frequency of activities provided should be improved. All staff should complete training in the Protection of Vulnerable Adults from Abuse. DS0000021481.V290825.R01.S.doc Version 5.1 Page 29 8. 9 OP12 OP18 Deansgrove Residential Care Home 10 11 12 13 OP30 OP31 OP35 OP38 A training matrix should be developed to assist the home in identifying the outstanding training needs of staff. The manager should ensure that she completes an award equivalent to NVQ level 4 in Management and Care. Each resident’s financial records should be updated to include a cash balance and record all transactions from the bank. Arrangements should be made to test, on a monthly basis, the temperature at each hot water outlet used by residents, to ensure the temperatures are regulated to 43°C Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 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 Deansgrove Residential Care Home DS0000021481.V290825.R01.S.doc Version 5.1 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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