CARE HOMES FOR OLDER PEOPLE
Eagles Rest 10 Church Street Southport Merseyside PR9 0QT Lead Inspector
Daniel Hamilton Key Unannounced Inspection 9th August 2007 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 Eagles Rest DS0000067109.V345790.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. Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Eagles Rest Address 10 Church Street Southport Merseyside PR9 0QT 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) 01204 364652 Eagles Rest Limited Vacant Post Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users to include up to 16 Older Persons The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 13th October 2006 Date of last inspection Brief Description of the Service: Eagles Rest is a privately owned care home that is registered to provide personal care and support for up to 16 older people. The home is situated close to Southport town centre and shops and public transport are easily accessible. The home is a large, double fronted, detached property that has a lounge with a conservatory attached and a separate dining room. There are 14 single and 1 double bedrooms. Four of the rooms are fitted with en-suite facilities and bathing and toilet facilities are located throughout. A passenger lift is installed and a call bell system is available in all bedroom and communal areas. Off-road parking is available at the front of the premises and there is a large garden to the rear, which is accessible via the side of the property. Care Home Fees range from £295.00 to £450.00 per week. Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day and lasted approximately 9 hours. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The inspector met with the Owner, staff and residents during the visit. An Expert-By-Experience also assisted in the inspection process. An Expert-byExperience is a person who, because of their shared experience of using services and / or ways of communicating visits a service with an inspector to help get a picture of what it is like to live in or use the service. Care Home Survey forms were also distributed to a number of residents and / or their relatives prior to the inspection, to obtain additional feedback about the home. All the key standards were assessed and action taken in response to the previous requirements and recommendations from the last key inspection in October 2006 were reviewed. What the service does well:
Feedback received from the people living in the home was generally positive about the service provided at Eagles Rest. Comments received from two residents included; “I am very relaxed with the staff at the home I am in. I feel I can talk to the staff. They make themselves very approachable” and “We’re well looked after.” Staff spoken with demonstrated an awareness of the daily living needs of the people living in the home and interaction between staff and residents was positive. Feedback from three relatives included; “The service looks after my husband very well”; “The staff are always helpful and caring” and “I am very pleased with the home. They do all they can to help.” Health Care records showed that residents had accessed a range of health care professionals including; general practitioners, chiropodists, district nurse, and optician appointments, subject to individual needs. Residents spoken with were generally satisfied with their lifestyle and the activities and meals provided. The general atmosphere in the home was warm and friendly and residents spoken with confirmed they were able to follow their preferred routines and receive visits from family and friends at any reasonable time.
Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 Page 6 A monthly programme of in-house activities had been developed and outside entertainers visited the home. Some residents also reported that the Owner had recently supported a small group of residents to visit a motor rally, aerodrome and a trip to Ormskirk market. Comments received from residents included; “I have lived in four care homes and this is the best one I have lived in”; “The food is very good. We get a good variety” and “The cook will always do an alternative if it is something we don’t like.” A Complaints procedure had been developed for Eagles Rest, which was displayed around the home for residents and their representatives to view. Residents spoken with confirmed they felt listened to, were aware of who to speak to if they had any concerns and how to make a complaint. One resident stated; “The manager is always available to speak to if we need to discuss anything.” The Owner Commissioned an external consultant to undertake an annual quality assurance assessment of the service to ensure the views of residents and their representatives were obtained on the service. The home had continued to receive ongoing investment from the Owner and overall, areas viewed appeared clean and hygienic. What has improved since the last inspection?
Since the last visit, arrangements had been made to ensure residents and / or their representatives had signed their care plans, to confirm they were in agreement with the content. A Controlled Drugs Register had been obtained to record the receipt, balance and administration of any prescribed Controlled Medication. The Owner had purchased an induction-training package for new staff, which met the requirements of the ‘Skills for Care’ Common Induction Standards. Residents had been consulted regarding their dietary preferences via a Residents Association Meeting, to ensure they were consulted and in agreement with any proposed changes to the menu. Details of all the shifts and sleep-in duties worked on the rota by the Owner had been included on the staffing rota. The home had continued to receive ongoing investment in order to improve the environment for residents. Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 Page 7 What they could do better:
Some residents reported via Care Home Surveys that they had not received information on the service and / or a Contract to date. Other residents reported that they could not remember whether they had received information on the service due to the length of time they had lived in the home. The Owner was advised to request residents and / or their representatives to sign a record, to confirm they have received information on the service and to retain a signed copy of the Contract on each resident’s file. Assessment and Care Plans viewed lacked information on the diverse needs of residents and the support required by staff. This information must be included in assessments and / or care plans, to ensure the needs of residents are appropriately identified and planned for. Medication Administration Records had not always been signed to confirm medication had been administered in accordance with the prescribed instructions. This practice must be addressed to confirm the health and personal care of residents is safeguarded. Furthermore, the competence of staff responsible for handling medication should be kept under review and a risk assessment should be completed for residents who self administer medication, to identify and control potential risks. Records showed that staff had commenced employment at the home without two up-to-date satisfactory references. Likewise, written confirmation on the outcome of Protection of Vulnerable Adult (POVA) and / or Criminal Record Bureau (CRB) checks had not been received from the Umbrella Body responsible for undertaking the checks. Staff must be correctly recruited to protect the welfare of vulnerable adults and key information relating to the employment of staff must be available for inspection. A training matrix was not available for the staff team and some staff did not have a record of induction and / or training completed. Furthermore, documentary evidence was not available for all training completed e.g. National Vocational Qualifications. This information must be maintained to provide evidence that staff have completed the necessary training for their role. Staff should also receive formal supervision at appropriate intervals and records maintained. The home’s menu was not adequately displayed and did not include an alternative choice of meal. One resident reported; “We don’t’ always know what we are eating but it tastes good.” These issues should be addressed in consultation with residents. The Owner reported that staff had completed training in the Protection of Vulnerable Adults since the last visit however some staff spoken with lacked awareness of the different types of abuse and / or reporting procedures. This
Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 Page 8 training need should be reviewed to ensure staff fully understand how to respond to suspicion or evidence of abuse. The home had continued to receive investment since the last visit but some key areas of the environment remained in need of maintenance / refurbishment. A new maintenance and refurbishment schedule should be completed to address outstanding issues and priority should be given to the installation of an entrance ramp to the front entrance (as requested by some residents) and the replacement of the carpets in the lounge and dining room. Records showed that the fire alarm system had not been routinely tested each week and the emergency lighting and fire extinguishers had not been visually tested on a monthly basis. Furthermore, day staff had not received fire instruction refresher training every six months and night staff every three months. No records of health and safety audits had been maintained. Action should be taken to address these points to protect the health and safety of residents, staff and visitors. 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. Eagles Rest DS0000067109.V345790.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 Eagles Rest DS0000067109.V345790.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. Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Assessments undertaken by the service were not complete. Unless a full assessment of need is undertaken before admission, there is no assurance that the care needs of residents will be met. EVIDENCE: A Statement of Purpose / Service User Guide had been developed to provide residents and / or their representatives with key information on the service. Contracts had also been produced to outline residents’ rights and responsibilities. Some people reported via Care Home Surveys that they had not received information on the service and / or a Contract to date. Other residents reported that they could not remember whether they had received any information due to the length of time they had lived in the home. The Owner reported that copies of the Statement of Purpose / Service User Guide were given to residents or their relatives prior to admission and that Contracts were issued following a 28-day trial period. The Owner was advised
Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 Page 11 to request residents and / or their representatives to sign a record, to confirm the documents had been given and to retain a signed copy of the Contract on each resident’s file. The home’s Annual Quality Assurance Assessment detailed that the home had developed policies and procedures for referral and admission and equal opportunities, diversity and anti-oppressive practice for staff to reference. The files of three residents were viewed during the visit. Two were for residents who had recently moved into the home and one was for a resident who had lived in the home for over 12 months. Records showed that the Owner had introduced a new assessment and care planning system since the last visit. Each file contained a ‘Pre-admission Assessment’ and a ‘Service User’s Long Term Need Assessment’. Pre-admission assessments viewed had not been dated and had not been fully completed. Likewise, ‘Service User’s Long Term Need Assessment’ forms were vague, lacked information on the needs of residents and some sections had not been completed. For example, one form had no information on history / risk of falls, daily routines and cultural and spiritual needs. Two of the residents had been funded by the local Social Services Department. Only one file contained an assessment completed by a Social Worker. Advice was given to the Owner on how the assessment process could be further developed in order to ensure a holistic assessment of needs. Eagles Rest DS0000067109.V345790.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 home manages the personal care needs of residents satisfactorily, but care plans and medication records are in need of attention, to fully safeguard the health and welfare of the people using the service. EVIDENCE: The Owner reported that she had introduced a new Care Planning system since the last visit. The files of three residents were examined. Each file contained a Care Plan which outlined the ‘Need Area’, ‘Care Instructions’ and ‘Evaluation / Outcome.’ Staff spoken with were able to demonstrate an awareness of the daily living needs of the people living in the home however Care Plans viewed were vague and lacked detail of the support required by staff to ensure the needs of residents were met. For example, one resident was a diet controlled diabetic and the care plan lacked information on the procedure for the testing of blood sugar levels. Other examples were discussed with the Owner during the visit.
Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 Page 13 A system had been established to ensure care plans were kept under monthly review and plans had been signed by residents and / or their representatives. It was noted that some identified needs had not been kept under review as part of the monthly care plan review process. Feedback received from service users and their representatives via Care Home Survey forms and through discussion confirmed the people living in the home received support to access medical services as required. One resident was supported to attend an appointment at their doctor’s surgery during the visit. Health Care Records viewed detailed that residents had accessed a range of health care professionals including; general practitioners, chiropodists, district nurse and optician appointments, subject to individual needs. The home had developed a brief ‘Procedures for Administration of Medication’ policy. A copy of guidelines issued by the Royal Pharmaceutical Society of Great Britain was also available for staff to reference. The Owner reported that all staff had completed in-house and external medication training via the dispensing pharmacist. Advice was given on how to further develop the medication policy. A record of staff authorised to administer medication and a system to check the identity of residents prior to administering medication had been established. One resident was responsible for self-administering medication at the time of the visit. A risk assessment had not been completed to assess and control potential risks. The home used a blister pack system and medication was stored in a medication cabinet and lockable cupboard. Separate storage and recording facilities were available for controlled medication. Medication Administration Records (MAR) were checked for a number of residents. MAR viewed showed that staff had not always signed to confirm the administration of medication. Furthermore, one MAR had been handwritten. The dose of medication had not been recorded for three types of medication and the record had not been checked / witnessed by another staff member. Details of medication received had not been recorded on the medication administration records, as a separate record had been established for this purpose. Since the last visit the home had obtained a Controlled Drugs Register. No progress had been made in reviewing the competency of staff responsible for the administration of medication. Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 Page 14 Staff spoken with during the visit demonstrated a satisfactory understanding of the principles of care and were observed to be attentive, caring and sensitive to the needs of the people living in the home. Feedback received from residents and their representatives via Care Home Surveys and discussion confirmed they were generally satisfied with the care provided by staff and treated with privacy, dignity and respect. Interaction between residents and staff appeared positive. One resident reported; “I am very relaxed with the staff at the home I am in. I feel I can talk to the staff. They make themselves very approachable.” Likewise another reported; “We’re well looked after.” Comments received from relatives included; “The service looks after my husband very well”; “The staff are always helpful and caring” and “I am very pleased with the home. They do all they can to help.” Eagles Rest DS0000067109.V345790.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 good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to maintain their independence and exercise choice in relation to most aspects of their daily life and social activities. This enables the people living in the home to lead a lifestyle that satisfies their needs and expectations. EVIDENCE: A monthly programme of activities had been developed, which was displayed in the dining room for residents to view. The Owner confirmed that the programme had been based upon the recreational needs and interests of the people living in the home. Records of each resident’s participation in activities had been maintained as part of the care plan system and showed different levels of interest / engagement in activities. Feedback received from residents via care home surveys and through discussion confirmed that activities were arranged by the Owner and staff and that the people using the service were encouraged to attend. Examples of activities organised for July included; card games, bingo, dominoes, hair and beauty and cooking. Outside entertainers had also visited the home and the Owner had supported a small group of residents to visit a motor rally and Woodvale aerodrome. A number of residents also reported that
Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 Page 16 they had recently enjoyed a trip to Ormskirk market. Photographs had been taken of the activities for residents to view. None of the residents received input from local churches / ministers of religion at the time of the visit however two residents attended a local church and regularly accessed their local community. One resident spoken with reported that they would like a minister of religion to visit the home. The general atmosphere in the home was warm and friendly and residents spoken with confirmed they were able to follow their preferred routines and receive visits from family and friends at any reasonable time. Residents reported that they could meet with visitors in the communal parts of the home or in the privacy of their own bedrooms. Rooms viewed had been personalised by residents and contained personal possessions including pictures and ornaments. Eagles Rest had a four-week rolling menu in place. The menu was not adequately displayed for residents to view at the time of the visit and it had not been updated to offer a choice of meal for each sitting as recommended at the last visit. This was highlighted by one resident who reported; “We don’t’ always know what we are eating but it tastes good.” Residents spoken with confirmed they could have an alternative meal upon request. Examination of the menus and discussion with residents confirmed that a range of wholesome meals was provided. Additional drinks were offered throughout the day. Residents spoken with confirmed they had been consulted regarding their dietary preferences and the current menu via a Residents Association Meeting. Meals were generally served in the home’s dining room at set times although two residents preferred to eat their meals in their bedrooms. Residents confirmed that arrangements for mealtimes were flexible and that alternative arrangements could be accommodated upon request. Special diets were provided for two residents and the Owner reported that the dietary needs of residents were kept under review as part of the assessment / care planning process. Tables viewed were equipped with condiments and tablemats. Some residents reported concerns that there were “Still no serviettes” and this was brought to the attention of the Owner. Residents spoke well of the quality of the food and praised the chef. Comments included; “The food is very good. We get a good variety” and “The cook will always do an alternative if it is something we don’t like.” Mealtimes were unhurried and staff were observed to be available during mealtimes to offer help and support as required.
Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 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. 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. Residents and / or their representatives were able to express their concerns via a complaints procedure so that their rights were upheld and their concerns acted upon. Some staff required refresher training in abuse awareness, to ensure an appropriate response to suspicion or evidence of abuse. EVIDENCE: A Complaints procedure had been developed for Eagles Rest. A copy of the procedure was displayed in the reception area of the home and copies were available in each resident’s room, within ‘Keyworker’ files. The Annual Quality Assurance Assessment for the home and the record of Complaints for the home detailed that one complaint had been received by the home since the last visit. The complaint was made by a resident and concerned a personal issue regarding another resident. Action had been taken by the Owner in response to the Complaint. A number of concerns had also been brought to the attention of the Commission for Social Care Inspection since the last visit. These related to the management / organisation of the home. The majority of the issues were investigated during a random inspection of the 19th January 2007. Some recommendations were made following the visit, to improve future practice. Residents confirmed via care home surveys and through discussion that they felt listened to, were aware of who to speak to if they had any concerns and how to make a complaint. One resident stated; “The manager is always
Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 Page 18 available to speak to if we need to discuss anything.” No complaints were brought to the attention of the inspector during the visit. Policies and procedures were in place to protect the people living in the home from abuse. A copy of the local authority adult protection procedures for the City of Liverpool and Borough of Sefton was also available for reference. The Owner reported that all the staff had completed training in the protection of vulnerable adults from abuse since the last visit. This was not possible to verify, as some training records were not-up-to date. Some staff spoken with lacked awareness of how to recognise and respond to suspicion or evidence of abuse. Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 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. 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 had continued to receive ongoing investment but some parts environment remained in need of maintenance and refurbishment, to ensure the home was comfortable for residents and fit for purpose. EVIDENCE: The Owner undertook day-to-day minor maintenance work, including the upkeep of the garden areas, as the home did not employ a handyperson. Contractors were hired as and when necessary. The Owner reported that she undertook weekly audits to review the physical environment of the home, but no records were maintained. Since the last visit, the home had continued to receive ongoing investment in order to improve the environment for residents. For example, the hall, stairs and landing had been redecorated; a ramp had been fitted to the rear of the premises; four bedrooms had been furnished with new carpet, curtains and / or bedding and a new laundry system had been installed to improve infection
Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 Page 20 control standards. Additional maintenance work had been completed on the roof, drainage and hot and cold water system. The main entrance of Eagles Rest had not been fitted with a ramp to improve access as recommended in the home’s ‘Assessment of the Premises and Facilities’ (2004) report and as scheduled in the home’s maintenance schedule for 2006 / 2007. Some residents spoken with during the visit considered this to be a priority need. It was also noted that the worn carpet in the dining room, hallway and the staircase had not been replaced. The Owner reported that new carpet had been purchased for the entrance hallway, back hall and staircase and that this was scheduled to be fitted on the 28th and 29th August 2007. Overall, other areas viewed during the visit appeared to be maintained to a reasonable standard. The Owner was advised to risk assess the layout of the furniture in the lounge, the position and height of the rotary clothes line in the back garden and to remove a tall step ladder that was leaning against the wall on one of the landings - as they presented a potential risk to residents when mobilising. The external grounds were generally tidy however comments were received regarding the need to remove the dead leaves in the front garden. An overall risk assessment had been completed to address the absence of radiator guards, thermostatic valves and window restrictors in some areas of the home. The Owner was advised to undertake individualised risk assessments. The annual quality assurance assessment for the service detailed that policies and procedures were in place for Communicable Diseases, Infection Control and the Control of Substances Hazardous to Health. Training records showed that some staff required infection control training. The home continued to employ one housekeeper and areas viewed were generally clean, fresh and hygienic. The laundry was appropriately equipped to meet the needs of the people living in the home. Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff recruitment practice was poor and did not fully protect the welfare of the people using the service. EVIDENCE: Examination of rotas, direct observation and discussion with the Owner and staff confirmed two care staff were on duty from 8.00 am to 10.00 pm. An additional care assistant worked from 9.00 am to 1.00 pm each day. During the night, two staff were on duty. One staff member worked a waking night and the Owner provided a sleep in service. Ancillary staff were employed for working in the kitchen and cleaning duties. Feedback received from residents via care home surveys and through discussion confirmed that staff were available when needed and that they received the care and support they required. One resident stated; “I have lived in four care homes and this is the best one I have lived in.” Some changes had occurred with the staffing team since the departure of the previous manager. Residents reported that the team of carers had now stabilised and that they were generally pleased with the level of care provided. The Annual Quality Assurance Assessment for the service detailed that the home had a policy on staff recruitment. The Owner reported that six new care staff had commenced employment in the home since the last visit. Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 Page 22 The personnel files of the six new staff were viewed during the visit. Five of the six files did not contain references and there was no evidence to confirm that a Protection of Vulnerable Adult (POVA) check and / or a Criminal Record Bureau (CRB) certificate check had been completed for the four employees. The Owner reported that her Umbrella Body had undertaken POVA and CRB checks, but had failed to provide written confirmation of the outcome of the checks. Other issues were also noted. For example, one employee had four references on file but three of the references were over 12 months old. Start dates had not been recorded on personnel files. The Owner reported that the home employed 13 care staff. The Owner reported that 6 staff (46.15 ) had completed a National Vocational Qualification in Care at level 2 or above in Care however certificates were available for only 3 staff (23 ). A further 3 staff (23 ) were working towards the award at the time of the visit. Files viewed did not contain documentary evidence that staff had completed an induction programme that met the requirements of the ‘Skills for Care’ Common Induction Standards. Staff spoken with confirmed they had received an induction and the Owner was able to produce examples of documentation that were used to ensure staff were inducted in accordance with Skills for Care Induction Standards. Advice was also given to the Owner on where to obtain additional information. A training matrix for the staff team was not available for inspection at the time of the visit. Consequently, it was difficult to make an accurate assessment of the outstanding training needs of staff. Some personnel files viewed did not contain a record of training completed however all the files, except one, contained documentary evidence of some training completed. Records showed that the majority of staff had completed a range of training in their current / previous employment that was relevant to their roles. Some staff had not completed training in all Safe Working Practice topics e.g. infection control and fire safety. Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 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. 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 Management and Administration of the home is in need of ongoing development and review, to ensure the home operates safely and in the best interest of the residents. EVIDENCE: The home did not have a Manager who was registered with the Commission for Social Care Inspection. The Owner (Heather Jackson) was in day-to-day charge of the service and reported that she had sent an application pack to the Commission for Social Care Inspection, to apply for registration as the manager. No application had been received by the Commission at the time of the visit. The Owner reported that she was in the process of completing a National Vocation Qualification (NVQ) level 4 in Health and Social Care and had completed the (NVQ) level 4 Registered Managers Award during November
Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 Page 24 2006. This could not be verified, as a certificate had not been issued by the training provider, to confirm successful completion of the award. Feedback received from the residents and the staff confirmed the Owner was approachable and supportive. One resident stated; “She is warm and friendly and you can talk to her about anything.” Likewise, another reported “Everything is perfect for me.” Records showed that the Owner had commissioned an external consultant to undertake a quality assessment of the home and to review policies and procedures during October 2006. Residents’ satisfaction surveys had last been distributed to residents and / or their representatives during May 2006. The Owner advised that she would re-distribute surveys during September 2007, to obtain feedback from stakeholders on the service provided. A ‘Residents’ Association’ had been established and residents spoken with confirmed the meetings had taken place periodically to discuss a variety of issues concerning the operation of the service. The Owner was advised to produce formal minutes for residents to view. One resident said; “Heather [Owner] always keeps us up-to-date.” The Annual Quality Assurance Assessment (AQAA) for the service detailed that the home had a policy on the management of service users’ money. The owner reported that she did not act as an appointee for any of the residents and that the people using the service looked after their financial affairs independently or with support from family members or solicitors. Arrangements had been established for residents to pay their fees into the company’s bank account via standing order. Alternative arrangements had been established for two residents. The Owner looked after the personal spending money for seven residents. Personal monies were not pooled and electronic records and receipts were in place to account for expenditure. The owner was advised to maintain written records of financial transactions and to sign alongside all entries / transactions. Staff spoken with reported that they did not receive formal supervision and written records of supervision were not available on files viewed. The (AQAA) for the service detailed that Health and Safety related policies and procedures had been developed for staff to reference. The (AQAA) also confirmed that maintenance and associated service records were available for all key areas. Fire records were viewed during the visit. A certificate of testing was in place for the alarm, extinguishers and emergency lights. Records showed that the fire alarm system had not been tested on a weekly basis since 14/01/07 and there was no record of monthly testing of the emergency lighting or visual
Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 Page 25 inspection of the fire extinguishers. A fire risk assessment certificate was in place together with a fire equipment plan. No records of fire instruction training were available for day and night staff. Some staff had not completed all safe practice training as identified in Standard 30. Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 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 2 2 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X 2 X 2 Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 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 Standard OP3 Regulation 14 (1) (a) Requirement The needs of prospective residents must be fully assessed before people move into the home, to provide evidence that the home is able to meet the needs of new residents. Care Plans must contain information on all the care needs of residents and detail particular interventions in greater detail for staff to reference. Staff must sign Medication Administration Records to confirm medication has been administered to residents in accordance with the prescribed instructions. Staff must only be confirmed in post if full and satisfactory written information has been obtained via a Protection of Vulnerable Adult (POVA) check, a Criminal Record Bureau (CRB) has been applied for and two upto-date satisfactory written references have been received. [Previous requirement of 30/04/06 not met]. A record of all training
DS0000067109.V345790.R01.S.doc Timescale for action 09/09/07 2 OP7 15 (1) 09/10/07 3 OP9 13 (2) 09/09/07 4 OP29 19 09/09/07 5 OP30 17 (2) 09/10/07
Page 28 Eagles Rest Version 5.2 undertaken, including induction training must be kept in the Care Home and available for inspection, to provide evidence that staff have completed the necessary training. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP1 OP2 OP9 Good Practice Recommendations Residents and / or their residents should sign a record to acknowledge they have received a copy of the Statement of Purpose / Service User Guide. A signed copy of a Contract should be available on each residents file for reference. The Owner should review the competency of staff designated with responsibility for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home and maintain written records of competency assessments to ensure best practice. A risk assessment should be undertaken for residents before they are supported to self-administer medication, to ensure their health and welfare is protected. Handwritten Medication Administration Records should be checked and witnessed by another suitably trained member of staff to ensure the information recorded is correct and in accordance with the prescribed instructions. Residents should be consulted about whether they wish for ministers of religion to visit the home and appropriate action should be taken in accordance with their needs, preferences and expectations. The home’s menu should be updated to include an alternative choice of meal for each sitting and be displayed for residents and their representatives to view. Refresher training in ‘Abuse Awareness’ should be arranged as required, to ensure all staff understand how to recognise and respond to abuse. A new maintenance and refurbishment schedule should be developed for the home and priority should be given to the installation of a front entrance ramp and the replacement
DS0000067109.V345790.R01.S.doc Version 5.2 Page 29 4. 5. OP9 OP9 6. OP12 7. 8. 9. OP15 OP18 OP19 Eagles Rest 10. OP30 11. 12. 13. 14. 15. 16. OP33 OP36 OP38 OP38 OP38 OP38 of the threadbare / worn carpets in the lounge and dining room. A training matrix should be developed for the service and arrangements should be made to ensure all staff complete training in Safe Working Practice Areas, to provide evidence that staff are trained and competent to undertake their roles. Minutes of the Residents Association Meetings should be made available for residents to view. Staff should receive formal supervision at regular intervals and written records of the meetings should be maintained. Written records of health and safety audits should be maintained to ensure best practice. The emergency lighting and fire extinguishers should be visually inspected on a monthly basis and records maintained. The fire alarm system should be tested on a weekly basis and written records maintained, to ensure the system is operating effectively at all times. Day staff should receive fire instruction refresher training every six months and night staff every three months, to ensure they are fully aware of the correct procedures to follow in the event of a fire. Eagles Rest DS0000067109.V345790.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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
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