Inspection on 04/05/05 for Deansgrove Residential Care Home

This inspection was carried out on 4th May 2005.

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 24/04/06

Deansgrove Residential Care Home 12/10/05

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 4/05/05 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 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 F53 F03 S21481 Deansgrove R.H V224864 040505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Deansgrove Residential Care Home Address 38 Bluebell Lane Huyton Knowsley Merseyside L36 7XZ 0151 489 1356 Telephone number Fax number Email 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 Ms Susan Cormell Care Home 17 Category(ies) of Old age 17 registration, with number of places Deansgrove Residential Care Home F53 F03 S21481 Deansgrove R.H V224864 040505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Service users to include up to 17 Old age and up to 17 Physical Disability Date of last inspection 12th July 2004 Brief Description of the Service: Deansgrove is a small residential care home which is registered to provide personal care and support for up to 17 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 is not purpose-built but has been adapted from existing properties. It is situated on two floors and has access to upper floors via a passenger lift 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 back garden to the home, which can be accessed via the conservatory. Building work is currently in progress, to expand the side of the premises to accommodate a further 12 bedrooms with ensuite facilities. This work is scheduled to be completed by August 2005. Deansgrove Residential Care Home F53 F03 S21481 Deansgrove R.H V224864 040505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 8 hours. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The manager, three staff on duty and seven of the seventeen residents were spoken to during the visit. Leaflets were also left in the home to enable residents and others to comment on the service provided. What the service does well: What has improved since the last inspection? What they could do better: A full assessment of need must be undertaken for new residents, before they are admitted to the home. Likewise, each resident must have a care plan that details their individual needs and the support required by care staff. The practice for administering controlled drugs, completion of medication records and supporting residents to self-administer medication without an assessment was not safe and must stop. Residents expressed a range of views about the activities available in the home. One resident said, “the only activities are on a Wednesday afternoon”. This should be reviewed as some residents felt there were limited activities available. Although the majority of residents spoke highly of the food, many residents expressed concern about the lack of choice available at dinner time. This must be addressed. In order to ensure a proper response to suspicion or evidence of abuse, the home should obtain a copy of the local adult protection procedure, review the abuse policy and ensure staff receive training on adult protection. An action plan must be developed, to ensure the areas in the home requiring redecoration / repairs are addressed. Although there were sufficient staff on duty to meet the needs of residents, the managers supernumerary hours should be reviewed, to enable her to complete Deansgrove Residential Care Home F53 F03 S21481 Deansgrove R.H V224864 040505 Stage 4.doc Version 1.30 Page 6 urgent administrative work. For example, recruitment practice was poor. Preemployment checks, certificates and references were not in place for a large number of staff working in the home. Staff must be recruited correctly, so that people living in the home are protected. Furthermore, all staff must receive induction and safe practice training, to ensure competency in their roles. Service certificates were not available for the fire extinguishers, passenger lift, stair lift, hoists and electrical wiring. These must be produced. Furthermore, the fire alarm system must be tested on a weekly basis and staff should receive fire instruction training at the intervals recommended by the fire department. The absence of radiator and thermostatic water valves must also be risk assessed, to safeguard the health, safety and welfare of residents. 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. Deansgrove Residential Care Home F53 F03 S21481 Deansgrove R.H V224864 040505 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Deansgrove Residential Care Home F53 F03 S21481 Deansgrove R.H V224864 040505 Stage 4.doc Version 1.30 Page 8 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 standard(s) 3 Assessment information completed by the home was incomplete. Unless a full assessment of needs is undertaken before admission, there is no assurance that care needs will be met. EVIDENCE: Two assessments were viewed. One was for a resident who had recently been admitted to the home and the other was for a resident who had been living in the home for over a year. Assessment information completed by the home for one resident was only partly completed and there was no care management assessment on file. Furthermore, the resident was able to provide significant information about her medical history, some aspects of which had not been recorded. Deansgrove Residential Care Home F53 F03 S21481 Deansgrove R.H V224864 040505 Stage 4.doc Version 1.30 Page 9 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 standard(s) 7, 9 and10 Care plans were not in place and did not detail the needs of residents. Likewise, medication practice was still unsatisfactory. These shortfalls have the potential to place residents at risk. Residents appreciated the care practice in the home and felt their rights were valued and respected. EVIDENCE: Two files were viewed. Care plans had not been completed to ensure that all aspects of residents’ health, personal and social care needs were identified and planned for. A care plan for ‘handling and lifting a dependent resident’ was available for one resident only. None of the residents spoken during the visit had any knowledge of the existence of an individual care plan. This situation was also noted at the last inspection, when a requirement was made to improve practice. There was no evidence that any action had been taken. Monthly reviews were being recorded for one resident, but the process was not clear, as there was no direct link to a plan of care. A resident was self-administering medication without a risk assessment. The administration of a controlled drug was not being administered or recorded correctly. Medication Administration Records had not always been signed to record administration of medicines and the date on some medication records did not correspond with the date medication was administered. There were still no records of medication being counted upon entering the home. Deansgrove Residential Care Home F53 F03 S21481 Deansgrove R.H V224864 040505 Stage 4.doc Version 1.30 Page 10 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 standard(s) 12 and 15 Some residents felt that activities were limited and did not provide daily variation and interest. Choices for dinner time meals were not available, but meals were varied and balanced, to ensure residents received a nutritious diet. EVIDENCE: Residents expressed mixed views about the range of activities provided within the home. A resident said; “there are plenty of activities” and others reported that they preferred not to participate. Some residents felt there were insufficient activities. Comments included; “the only activities are on a Wednesday afternoon for an hour” and “I would like to see more activities.” No progress had been made on providing external trips out for residents, in particular for those who used wheelchairs, despite a recommendation at the last inspection. There was no programme of activities or a record of activities provided for residents. A number of residents were spoken to regarding the meals. Overall, the majority of residents spoke highly of the food. Comments included “the food is very good” and “the food is homely, it’s lovely.” Some residents expressed concern about a lack of choice available at dinner time. Comments included “there is no choice for dinner time meals” and “you have whatever comes for dinner.” The menus were viewed and found to be balanced and interesting although there was no alternative choice for dinner. This situation was also found at the last inspection visit, when a requirement was issued to ensure that residents were offered appropriate choices on meals. Deansgrove Residential Care Home F53 F03 S21481 Deansgrove R.H V224864 040505 Stage 4.doc Version 1.30 Page 11 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 standard(s) 16 and 18 Although there had been no complaints since the last inspection, residents were confident that their concerns would be listened to and acted upon. There had been no progress on obtaining a copy of the local adult protection procedures, to ensure a proper response to any suspicion or evidence of abuse. EVIDENCE: The home had a complaints procedure and maintained a record of complaints. The complaints procedure did not contain the contact details of the Commission for Social Care Inspection or an assurance that complaints would be responded to within 28 days. The complaint record showed that no complaints had been received since the last inspection. Residents were confident that any concerns raised would be acted upon and all expressed confidence in approaching the manager with any complaints. The home had a brief abuse procedure but this did not contain guidance on the action to be taken in response to suspicion or evidence of abuse. A copy of the local adult protection procedures had not been obtained following a recommendation at the last inspection visit. Staff spoken to had only a limited knowledge of the different types of abuse and had not received training in this area. Deansgrove Residential Care Home F53 F03 S21481 Deansgrove R.H V224864 040505 Stage 4.doc Version 1.30 Page 12 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 standard(s) 19 and 26 Some parts of the home were in need of repair / redecoration, to ensure residents benefit from safe, comfortable surroundings. EVIDENCE: A major building programme was in operation, to develop the side of the building in order to increase the bed capacity of the home by a further 12 beds. Some areas of the home had been affected by the building work and were in need of repair / redecoration. Despite a requirement at the last inspection, two rooms had still not been redecorated. On the day of the visit, the home presented as being clean, tidy and hygienic. Deansgrove Residential Care Home F53 F03 S21481 Deansgrove R.H V224864 040505 Stage 4.doc Version 1.30 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Sufficient numbers of staff were deployed, to meet the needs of residents. The procedures for the recruitment of staff remained extremely poor and did not safeguard the people living in the home. Some staff had not received the necessary training, to ensure competency in their role. EVIDENCE: Inspection of rotas and direct observation confirmed that three staff were on duty through the day with two waking night staff during the night. The manager was included in these numbers and was expected to provide direct care. This resulted in the manager having limited time to address key management and administrative duties. At the time of the visit, the home was in the process of recruiting one waking night staff. Four new staff had commenced employment at the home since the last inspection. None of the staff had a valid Criminal Record Bureau certificate or Protection of Vulnerable Adult check. Only one file contained two written references and one file contained none. All of the files lacked key information required under the Care Home Regulations. This situation was also noted at the previous inspection when a requirement was made for action to be taken to obtain Criminal Record Bureau checks. No action had been taken. A further nine staff were still awaiting Criminal Record Bureau checks. There were no induction records available for any of the newly appointed staff members. The home’s induction programme did not meet the Training Organisation for Personal Social Services specification. Records showed that only two of the four new night staff had completed fire training. No other training had been completed by staff appointed since the last inspection. Deansgrove Residential Care Home F53 F03 S21481 Deansgrove R.H V224864 040505 Stage 4.doc Version 1.30 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Some important records were not available, to safeguard the health, safety and welfare of residents. EVIDENCE: Service certificates were not available for the fire extinguishers, passenger lift, stair lift, hoists and electrical wiring. A requirement had been issued at the last inspection to forward a copy of the electrical testing certificate to the Commission for Social Care Inspection. No action had been taken. Records indicated that the fire alarm was not being tested on a weekly basis and that staff were not receiving fire instruction training at the recommended intervals. A building risk assessment was available, however the absence of radiator and thermostatic water valves had not been risk assessed. Some staff had not received mandatory training in safe practice areas. Deansgrove Residential Care Home F53 F03 S21481 Deansgrove R.H V224864 040505 Stage 4.doc Version 1.30 Page 15 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x x x x 2 Deansgrove Residential Care Home F53 F03 S21481 Deansgrove R.H V224864 040505 Stage 4.doc Version 1.30 Page 16 yes Are there any outstanding requirements from the last inspection? 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 3 Regulation 14 Requirement The Registered Manager must ensure that all service users have a full assessment of their needs by a suitably trained person. No service user must move into the home until their needs have been fully assessed. The Registered Manager must ensure that each service user has a care plan that identifies their individual needs (as detailed in the assessment) and the action required by care staff to ensure that identified needs are met. The Registered Manager must ensure that service users who self medicate have risk assessments in place. (Previous timescale of 30/08/2004 not met). The Registered Manager must ensure that all medications are signed in and counted when they enter the home. (Previous timescale of 30/08/2004 not met). The Registered Manager must ensure that Medication Administration Records are signed by staff following Timescale for action 4/06/05 2. 7 15 (1) 4/06/05 3. 9 13 (4) 4/06/05 4. 9 13 (2) 4/06/05 5. 9 13 (2) 4/06/05 Deansgrove Residential Care Home F53 F03 S21481 Deansgrove R.H V224864 040505 Stage 4.doc Version 1.30 Page 17 6. 9 13 (2) 7. 15 16 (1) 8. 19 23(2)(b) 9. 29 19 (1) 10. 29 19 (4) 11. 29 19 (4) 12. 30 18 13. 30 18(1)c 14. 38 13 (4) administration and that the relevant codes are used when applicable. The Registered Manager must ensure that the administration of controlled drugs is correctly recorded in a register and is witnessed by another designated, appropriately trained member of staff. The Registered Manager must ensure that service users are offered appropriate choices on meals. (Previous timescale of 30/08/2004 not met). The Registered Manager must produce an action plan, with timescales, for the areas identified during the inspection as requiring redecoration / repair and a copy forwarded to the Commission. The Registered Manager must ensure that all staff have a CRB check completed. (Previous timescale of 31/10/2004 not met). The Registered Manager must obtain a CRB and POVA check for all staff employed since the 26th July 2004. The Registered Manager must ensure that all staff files are brought up-to-date to include the documentation outlined in schedule 2 of the Care Homes Regulations. The Registered Manager must ensure that all staff receive induction training in accordance with TOPSS specification.. The Registered Manager must ensure that all staff receive a minimum of three paid training days per year. (Previous timescale of 31/10/04 not met). The Registered Manager must ensure that the absence of any 4/06/05 4/06/05 4/07/05 4/07/05 4/07/05 4/07/05 4/06/05 4/08/05 4/06/05 Page 18 Deansgrove Residential Care Home F53 F03 S21481 Deansgrove R.H V224864 040505 Stage 4.doc Version 1.30 15. 38 18(1)a 16. 38 23(2)b 17. 38 23(2)c 18. 38 23(4)c radiator covers and thermostatic valves is risk assessed for each service user. Planned installation work must be prioritised according to the level of risk identified. The Registered Manager must ensure that all staff have received appropriate training in mandatory subjects. (Previous timescale of 30/11/04 not met). The Registered Manager must ensure a copy of the electrical testing certificate is forwarded to the Commission for Social Care Inspection. (Previous timescale of 30/11/04 not met). The Registered Manager must ensure a copy of the service certificates for the extinguishers, passenger lift, stair lift and hoists is obtained and forwarded to te Commission for Social Care Inspection. The fire alarm system must be tested on a weekly basis. 4/08/05 4/06/05 4/06/05 4/06/05 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. Refer to Standard 12 16 Good Practice Recommendations A range of activities including external trips out for service users, should be provided. The complaints procedure should include the contact details for the Commission for Social Care Inspection and an assurance that complaints will be responded to within 28 days.. The home should obtain a copy of the local adult protection procedures and update the abuse policy to include reporting procedures.. Staff should receive training on the protection of vulnerable adults from abuse. The Registered Manager should be given sufficient F53 F03 S21481 Deansgrove R.H V224864 040505 Stage 4.doc Version 1.30 Page 19 3. 4. 5. 18 18 27 Deansgrove Residential Care Home 6. 38 supernumerary hours to complete management and administration duties. Night staff should receive fire instruction training every three months and day staff every six months Deansgrove Residential Care Home F53 F03 S21481 Deansgrove R.H V224864 040505 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Burlington House South Wing, 2nd Floor Crosby Road North, Waterloo 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. 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