Inspection on 27/05/08 for Deansgrove Residential Care Home

This inspection was carried out on 27th May 2008.

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

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 02/04/07

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Deansgrove Residential Care Home 38 Bluebell Lane Huyton Knowsley Merseyside L36 7XZ Lead Inspector Daniel Hamilton Key Unannounced Inspection 27th May 2008 09:30 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.V363364.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.V363364.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 deansgrove@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) 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.V363364.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. 2nd April 2007 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. Deansgrove 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. Deansgrove has 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 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 £357.00 to £377.00 per week. Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced ‘key’ inspection was carried out over one day and lasted approximately 9 hours. 26 people 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 viewed and the Registered Provider, Registered Manager, care staff, residents and visitors were spoken with during the visit. Survey forms were also distributed to a number of staff, residents and / or their relatives prior to the inspection to obtain additional feedback about the home. All the key standards were assessed and progress / action taken in response to the previous requirements and recommendations from the last key inspection in April 2007 was reviewed. Full feedback was given to the manager on conclusion of this inspection. What the service does well: Residents and visitors spoken with during the inspection were complimentary of the staff team and the care provided at Deansgrove. Comments included: “The girls [staff] are smashing. They are caring individuals”; “The staff are always pleasant and respectful” and “I have no concerns about the care in this home.” Deansgrove was generally well maintained and the Registered Provider (Owner) had continued to invest in the environment. The decoration, fabric and furnishings were in good condition and areas viewed were clean and hygienic. Residents were observed to receive visits from family, friends and personal representatives during the day. The routines in the home were flexible and residents spoken with confirmed they were able to exercise choice and control over their daily lives. Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 6 Systems had been established to ensure an appropriate response to complaints and suspicion / evidence of abuse and records confirmed that complaints and safeguarding issues had been appropriately investigated and acted upon. Staff had been correctly recruited to protect the welfare of the people using the service and residents were supported by appropriate numbers of staff. Staff were observed to spend time with residents throughout the day and appeared attentive to the needs of the people living in the home. Comments received from residents included; “So far the staff have been fine. It’s the first time I’ve been in a care home. Everyone is friendly and the staff are available to help when needed” and “I could not fault the care provided by staff. They [staff] understand the things I need help with and are there when needed.” What has improved since the last inspection? Since the last visit Care Plans had been updated to include information on the religious and cultural needs of residents and how the needs of residents were to be met. This helps to ensure the people living in the home receive the care they need. The training matrix had been updated to include the dates when staff had last completed training and a review date. Further progress had also been made in supporting a number of staff to complete Safe Working Practice and other training that was relevant to their role. This helps to ensure the people using the service are supported by trained and competent staff. A system had been developed to enable the manager to review the competency of staff responsible for medication. This framework enables the manager to monitor the learning needs and practice of staff who administer medication. The menus had been reviewed in consultation with the people using the service and feedback on the standard of catering was generally good. Comments included; “The food is lovely and I get plenty to eat”, “We get two choices for each meal and the food is of good quality” and “I have no complaints about the standard of catering.” Three resident meetings had been coordinated since the last visit to ensure residents were consulted on matters relating to daily life within Deansgrove. Minutes of meetings and discussion with residents revealed that the meetings had been used to discuss the day-to-day operation of the home and the planning of menus. Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 7 Visual inspections of the fire extinguishers had been undertaken on a monthly basis and the building risk assessment had been updated to address the risks associated with legionella. This action safeguards the health, welfare and safety of the people using the service, staff and visitors. The environment had continued to receive further refurbishment / investment to ensure it was fit for purpose and homely. The kitchen had been fitted with new kitchen appliances and a replacement floor covering, wall and ceiling panels, cupboards and shelving. Furthermore, two bedrooms had been fitted with bay windows and the downstairs bathrooms had been refurbished. What they could do better: The new contact details of the Commission for Social Care Inspection should be included in the Statement of Purpose and Service User Guide to ensure people have access to up-to-date information. Equality and diversity issues and past medical history should be taken into consideration as part of the pre-admission assessment process, to ensure a holistic assessment of needs. Care plans should be updated to include information on health care promotion and the outcome of all health care appointments should be recorded to improve record keeping. Furthermore, risk assessments should be kept under review and specify the preventative measures to safeguard the health and safety of residents. Medication must always be administered in accordance with the prescribed instructions and adequate stocks maintained to safeguard the health and welfare of individual residents. Arrangements should also be made to ensure the date, quantity and initials of the person receiving medication into Deansgrove is recorded on all Medication Administration Records, to provide a clear audit trail. Yellow Warfarin books should be available in Deansgrove to enable staff responsible for administering medication to check that they are the administering the correct dosage. A programme of activities should be developed in consultation with residents and the range and frequency of activities both within and outside the home should be further improved. The training programme should be further extended to include training in the conditions associated with old age and Equality and Diversity. This will help to develop staff awareness of the diverse needs of older people accessing social care services. Furthermore, all outstanding staff should complete Safe Working Practice training as a matter of priority to ensure they understand how to work safely and in accordance with best practice. Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 8 The home should 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. Furthermore, arrangements should be made to ensure Regulation 26 reports are completed by the Registered Provider, to ensure compliance with Regulation 26 of the Care Home Regulations 2001. The fire risk assessment should be dated and kept under regular review and day and night staff should receive fire refresher training at the recommended intervals to safeguard health and safety. 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.V363364.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents are assessed prior to admission, to ensure the service is appropriate. EVIDENCE: The Annual Quality Assurance Assessment for the Service detailed that a ‘Referral and Admissions Policy’ was in place for staff to reference as previously noted. The manager confirmed that prospective residents would not be admitted to the home until an assessment of need had been undertaken and this was confirmed in discussion with a social worker and relative. The files of three residents were randomly selected to view 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 3 years. Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 11 Each file viewed contained an assessment of needs and a contract. Copies of assessments and care plans completed by social workers had also been obtained for reference. Records confirmed that two of the assessments completed by the home had been completed on the day of admission. The manager reported that this was because the residents had been admitted at short notice. Assessments viewed were generally clear and concise however assessments completed by Deansgrove staff lacked information on equality and diversity issues and past medical history as previously noted. Likewise, the information recorded in one of the assessments viewed was not consistent with the information contained within the social work assessment. For example; the assessment completed by the home detailed; “X’s [Resident’s name] mental state is good. Short and long term memory good.” Conversely, the assessment completed by the social worker indicated that the resident had been diagnosed with multi-infarct dementia and had short-term memory loss. The manager agreed to review assessments to ensure the information was accurate. 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. 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. The manager agreed to update the documentation with the new contact details of the Commission for Social Care Inspection. Examination of records and / or feedback received from residents and their representatives via discussion 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.V363364.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of Health and Medication records is in need of review to fully safeguard the health and welfare of residents. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) for the service detailed that a policy on ‘Individual Planning and Review’ and ‘The Control, Storage, Disposal, Recording and Administration of Medicines’ had been developed for staff to reference. The files of three residents were randomly selected to view during the visit. Each file contained a care plan that was based upon the initial assessment of needs for individual residents. Care Plans viewed had generally been completed to a satisfactory standard and outlined the needs of residents, support required from staff and the aims and objectives of the plan. The manager was advised to include more information on how the service promotes the individual health care needs of residents and to specify the frequency of routine appointments e.g. dentist and optician appointments etc. Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 13 Furthermore, the manager was advised to develop the care plan review system and to ensure residents or their relatives sign each page of the care plan or a summary sheet, to confirm they are in agreement with the entire plan - as only the first page had been signed. 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 had been completed subject to individual need. Some risk assessments had not been kept under review and one did not contain information on the preventative measures/control mechanisms. The manager was advised to address these issues. Medical appointment records showed that residents had access to a range of health care professionals subject to individual need. Some medical appointment forms did not include information on the reason for and / or the outcome of appointments and this information had not always been recorded in individual daily report sheets. This issue should be addressed to ensure a clear audit trail. 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. A record of staff responsible for the administration of medication, together with sample signatures had been developed and a resident identification system was in place. Since the last visit the manager had introduced a system to monitor the competency of staff responsible for medication. At the time of the inspection none of the residents self-administered medication. Declaration of wishes /consent forms for the administration of medication had been completed by each resident and / or their representative. Deansgrove used a blister pack system that was dispensed by a local pharmacist. Medication was appropriately stored in medication cabinets, which were secured to the wall. A controlled drugs cabinet and register was also in place. A number of Medication Administration Records (MAR) were viewed during the visit. It was noted two MAR did not have a clear audit trail, as details of the date, quantity and initials of the person receiving medication into the care home had not been recorded. Furthermore, a MAR and controlled drugs register showed that a Schedule 2 Controlled Drug used for pain relief had not been administered in accordance with the prescribed instructions and had run out on one occasion. Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 14 The manager was also advised to ensure a yellow Warfarin book belonging to a resident was obtained from the hospital for staff to reference, to enable staff to verify that they were administering the correct dosage of Warfarin at all times. Previous inspection records detailed that the home had developed a policy on the values of Privacy and Dignity. Staff spoken with during the visit demonstrated an awareness of the value base of social care and their duty of care. Residents spoken with were complimentary of the care they received and staff were observed to interact with residents and appeared attentive to their needs throughout the day. Comments received from residents included; “The girls [staff] are smashing. They are caring individuals”; “The staff are always pleasant and respectful” and “I have no concerns about the care in this home.” Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Social activities should be further promoted and developed to improve daily life and satisfy the recreational needs, expectations and preferences of residents. EVIDENCE: Previous inspection records detailed that home had developed a ‘Policy on Therapeutic Activities’. A programme of activities based upon the recreational needs and interests of residents had not been developed as previously recommended and details of the daily activities on offer had not been recorded on the white board in the dining room. Since the last the manager had established an activities book which contained details of the activities coordinated and the participants. The manager reported that residents were offered a choice of activities each day. Some residents spoken with were of the opinion that there was still potential to further improve the range of activities provided and were unclear about the range of activities on offer. For example, feedback included; “There are some activities in the home but not many. I am not sure what is provided as they don’t have any information” and “They provide a few activities but there is not much variation. They are all based in the home and there is little variation”. Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 16 The Annual Quality Assurance Assessment (AQAA) for the service detailed that art and craft material and a Nintendo computer game had been purchased since the last visit. Records showed that residents had participated in a range of activities including; listening to music, sing-a-longs, cards, exercises, boards games, play your cards right, bingo and nail manicure. No evidence of regular community based activities was recorded in the activities diary or files case tracked. An outside entertainer continued to visit the home on a monthly basis and representatives from the local Church of England and Roman Catholic churches continued to visit residents periodically, subject to their individual religious beliefs and preferences. The AQAA for Deansgrove detailed that policies and procedures concerning contact with and visits by family and friends had been developed. Likewise, the Statement of Purpose detailed that; “Visitors are welcome at any time.” Residents were observed to receive visits from family, friends and personal representatives during the day and visitors spoken with confirmed that they were able to visit people living in the home at any reasonable time, subject to the agreement of individual residents. Feedback received from the people living in the home confirmed the routines in Deansgrove were flexible and that they were able to exercise choice and control over their daily lives. Policies and procedures had been developed regarding food safety and nutrition and previous records confirmed a copy of the ‘Food Standards Agency Guidelines’ had been obtained. A four-week rolling menu had been developed which provided a choice of meals for breakfast, dinner and tea. The manager reported that the menu plan had been updated since the last visit and was reviewed every 8 weeks. Minutes of residents meetings viewed during the inspection confirmed the menus had been discussed with the people living in the home. Since the last visit, the choice of evening meals had been improved in order to offer more variety. It was noted that there was still some repetition for week four of the menu plan i.e. the alternative choice of sandwiches or soup and the manager agreed to address this. Mealtimes were considered to be a social occasion and food was served in the home’s dining room at set times. Some residents preferred to eat their meals in their bedrooms and this choice was respected. Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 17 The dining room was pleasantly decorated and furnished and tables were set with table mats, paper napkins, flowers and condiments. Drinks were served throughout the day and a water cooler was available at the entrance to the dining room. Feedback on the meals provided was generally good. Comments included: “The food is lovely and I get plenty to eat”, “We get two choices for each meal and the food is of good quality” and “I have no complaints about the standard of catering.” 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. Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 18 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 good. This judgement has been made using available evidence including a visit to this service. Systems had been established to ensure an appropriate response to complaints and suspicion or evidence of abuse. This ensures that the views of people using the service are listened to and acted upon and that people are offered protection from abuse. EVIDENCE: A complaints procedure had been developed for Deansgrove, a copy of which was included in the ‘Service User Guide’ and the home’s ‘Statement of Purpose’. The manager reported that each resident had been provided with a copy of the Service User Guide and this was confirmed in discussion with the people using the service. The manager was advised to update the complaints procedures within each ‘Service User Guide’ as the contact details of the Commission for Social Care Inspection had changed since the last visit. Furthermore, the manager was recommended to clearly display a copy of the procedure in the reception area for residents and visitors to view. The Annual Quality Assurance Assessment for the service detailed that two complaints had been received by the manager since the last visit. Both the Complaints were anonymous and had been referred to the Registered Provider for investigation by the Commission for Social Care Inspection. Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 19 The nature of the complaints were as follows. The first complaint concerned the administration of medication by non-qualified staff, infection control, hygiene, meals and personal care. No elements of the complaint were substantiated. Likewise, the second complaint concerned the range of activities within and outside the home, staff interaction, the use of money for a residents’ fund and the conduct of care staff towards residents. Again records confirm that no aspects of the complaint were upheld. Residents spoken with during the inspection confirmed that they were generally happy living in Deansgrove and that the care provided was good. Likewise, residents spoken with confirmed that they felt safe and secure within their home. The Annual Quality Assurance Assessment for the service confirmed that policies and procedures were in place within the home to ensure an appropriate response to suspicion or evidence of abuse. Records showed that the policies had been kept under review and covered the disclosure of abuse and bad practice (Whistleblowing), physical intervention and safeguarding adults and abuse. A copy of the local authority adult protection procedures was also available for reference. Records showed that the manager of Deansgrove had made one safeguarding adult protection referral since the last visit. The outcome of the investigation was not known at the time of the visit. Training records showed that all staff except two had completed training in the Protection of Vulnerable Adults and the manager reported that training had been booked for the outstanding staff to complete. The manager demonstrated a good understanding of her role and responsibilities concerning adult protection. Some staff spoken with demonstrated different levels of awareness regarding the various types of abuse and / or reporting procedures and the manager agreed to monitor and address this issue. Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is 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. The manager reported that she continued to monitor the condition of the environment with the maintenance worker for Deansgove. The manager was recommended to establish a health and safety checklist to provide evidence of the scope and frequency of the health and safety / maintenance checks. Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 21 Since the last visit the environment had continued to receive further refurbishment/investment. The kitchen had been fitted with new kitchen appliances and a replacement floor covering, wall and ceiling panels, cupboards and shelving. Furthermore, two bedrooms had been fitted with bay windows and the downstairs bathrooms had been refurbished. 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. The Annual Quality Assurance Assessment for the service confirmed policies and procedures were in place for preventing infection and managing infection control. Training records also confirmed that 18 staff (including the manager) had completed infection control training. Two part-time domestic staff continued to work in the home and areas viewed during the visit appeared well maintained, clean and hygienic. Residents confirmed the home was kept clean and fresh and no offensive odours were noted. Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 22 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 good. This judgement has been made using available evidence including a visit to this service. Residents are supported by staff who are correctly recruited, inducted and have access to training and development opportunities. This safeguards the welfare of the people using the service. EVIDENCE: The manager reported that staffing levels had not changed since the last inspection. Rotas viewed confirmed four care staff were on duty each day from 8.00 am to 10.00 pm and during the night three waking night staff were on duty. The manager was supernumerary. At the time of the visit the rotas did not specify the capacity of each employee and the manager was advised to include these details as previously recommended. Ancillary staff including a cook, two part-time domestics, and a full time handyman were also employed. Residents spoken with during the visit confirmed that help and assistance was available from staff when needed and that they felt well cared for. Comments included; “So far the staff have been fine. It’s the first time I’ve been in a care home. Everyone is friendly and the staff are available to help when needed” and “I could not fault the care provided by staff. They understand the things I need help with and are there when needed.” Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 23 The Annual Quality Assurance Assessment (AQAA) for the service detailed that home had policies and procedures in place for the recruitment of staff and equal opportunities, diversity and anti-oppressive practice. The manager reported that two staff had commenced employment at the home since the last inspection. The two files for the new employees were examined during the inspection and both were found to contain the necessary records required under the Care Home Regulations 2001. The manager was advised to update the reference request form to enable referees to detail their designation. At the time of the visit the home employed 22 care staff (including the deputy manager). Records showed that 14 (63.63 ) staff had completed a National Vocational Qualification at Level 2 in Care or equivalent. A further one employee (4.54 ) staff had completed the award and was waiting to receive certificates and three staff (20.66 ) 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 18 (81.81 ) Staff spoken with confirmed they had received an induction from the manager upon commencing employment at Deansgrove. Progress logs and certificates of completion were available on files to confirm new staff had successfully completed the Skills for Care Induction course and were competent / ‘Safe to Leave’. Discussion with staff and examination of records also confirmed that staff received formal supervision from their manager periodically. Since the last visit the manager had updated the training matrix to include the dates that staff had completed various training courses and the approximate dates when staff were next due to complete refresher training. The manager was advised to also record the capacity of each employee for reference. Examination of training records and discussion with staff confirmed staff had access to induction, safe working practice, National Vocational Qualification and Medication Training. The manager was advised to explore opportunities for staff to complete equality and diversity training as some staff spoken with did not fully understand this area of their work. Furthermore, the home should expand the range of training offered to staff to include training on the conditions associated with old age etc. Records showed that progress had been made in supporting staff to access safe working practice training however some staff had still not completed all the necessary training. The AQAA for the service detailed that ongoing training was a priority for improvement in the next 12 months and this was confirmed in discussion with the manager. Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 24 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 system requires further development to demonstrate the home is appropriately managed and run in the best interest of residents. EVIDENCE: Mrs Amanda Byrne was registered with the Commission for Social Care Inspection as the manager of the home and had been in post since January 2006. Training records confirmed that the manager had completed the level 4 National Vocational Qualification (NVQ) Registered Managers Award and a certificate of completion was in place to verify this. The manager reported that she had also completed the level 4 National Vocational Qualification (NVQ) in Care and was waiting for her work to be verified by an external verifier. Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 25 Certificates were on file to confirm the manager had completed Medicines Management, Risk assessment and fire safety training since the last visit. Training records showed that the manger had also completed First Aid, Basic Food hygiene, Infection Control, COSHH and Care Planning training. At the time of the visit records showed that the manager still needed to complete H & Safety training. Prior to the inspection the manager completed a document known as an Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service and provides some numerical information about the service. The information in the document was brief but sufficient to inform the inspection process. The Registered Provider did not commission an external organisation to undertake a quality assurance assessment of Deansgrove as previously noted. Copies of Regulation 26 reports were available for reference, which had been completed by the manager and signed by the Registered Provider. The manager was informed that Regulation 26 reports must be completed by the Registered Provider or an employee who is not directly concerned with the conduct of the care home. Discussion with the manager and residents and examination of minutes confirmed that three resident meetings had been coordinated since the last visit. The manager also reported that questionnaires had been sent to residents and / or their representatives during February 2008. The survey had not been updated as previously recommended and the findings were not being displayed and could not be located for prospective and current residents to view. Furthermore, a development plan was not in place and the quality audit system previously purchased by the Registered Provider had not been completed. 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. At the time of the visit the owner and manager did not act as an appointee for any of the people living in the home. The home looked after the personal spending money for three residents. Individual records had been established to record transactions and receipts were available for expenditure. Two residents had also deposited money in a service user account and records were available to account for transactions. The Annual Quality Assurance Assessment (AQAA) detailed that equipment and services within the home had received regular maintenance / safety checks. Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 26 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 and fire extinguishers had been recorded. No records were available to confirm that day and night staff had received fire instruction refresher training at the appropriate intervals as previously recommended. Certificates were available to confirm public liability insurance cover was in place and that the fire alarm system and extinguishers had been appropriately serviced. A fire and building risk assessment had been completed. The manager was advised to date the fire risk assessment and to ensure the assessment was kept under review. Further progress had been made in supporting staff to compete safe working practice training however some gaps were noted for each topic. This issue is addressed in Standard 30. Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 27 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 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.V363364.R01.S.doc Version 5.2 Page 28 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 OP9 Regulation 13(2) Requirement Medication must be administered in accordance with the prescribed instructions to safeguard the health and welfare of individual residents. Timescale for action 27/06/08 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 OP1 Good Practice Recommendations The new contact details of the Commission for Social Care Inspection should be included in the Statement of Purpose and Service User Guide to ensure people have access to up-to-date information. Equality and diversity issues and past medical history should be taken into consideration as part of the preadmission assessment process to ensure a holistic assessment of needs. Risk assessments should be kept under review and specify the preventative measures to safeguard the health and safety of residents. 2. OP3 3. OP7 Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 29 4 5 OP7 OP9 6 7. OP9 OP12 8. OP16 9 OP30 10. 11. OP30 OP33 12. 13. 14. OP33 OP38 OP38 Care plans should be updated to include information on health care promotion and the outcome of appointments to improve record keeping. Details of the date, quantity and initials of the person receiving medication into Deansgrove should always be recorded on all Medication Administration Records, to provide a clear audit trail. Staff should have access to Yellow Warfarin books so that that can verify that they are administering the correct dosage of Warfarin at all times. A programme of activities should be developed in consultation with residents and the range and frequency of activities both within and outside the home should be further improved. The complaints procedure should be updated to include the new contact details of the Commission for Social Care Inspection and displayed in a prominent position so that it is visible for residents and their representatives to view. The training programme should be further extended to include training in the conditions associated with old age and Equality and Diversity. This will help to develop staff awareness of the diverse needs of older people accessing social care services. All staff should complete Safe Working Practice training as a matter of priority to ensure they understand how to work safely and in accordance with best practice. The home should 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. Regulation 26 reports should be completed by the Registered Provider to ensure compliance with Regulation 26 of the Care Home Regulations 2001. The fire risk assessment should be dated and kept under review to ensure best practice. Night staff should receive fire refresher training every three months and day staff every six months and records maintained. Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection North West Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 Deansgrove Residential Care Home DS0000021481.V363364.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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