Inspection on 29/10/08 for East Clune Care Home

This inspection was carried out on 29th October 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

East Clune Care Home 09/11/06

East Clune Care Home 24/02/06

East Clune Care Home 13/09/05

East Clune Care Home 23/03/05

East Clune Care Home 09/11/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 29/01/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: East Clune Care Home West Street Clowne Chesterfield Derbyshire S43 4NW     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jill Wells     Date: 2 9 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 33 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 33 Information about the care home Name of care home: Address: East Clune Care Home West Street Clowne Chesterfield Derbyshire S43 4NW 01629537080 Telephone number: Fax number: Email address: Provider web address: amanda.cooper@derbyshire.gov.uk Name of registered provider(s): Name of registered manager (if applicable) Derbyshire County Council Type of registration: Number of places registered: care home 30 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 30 The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Oldage, not falling within any other category - Code OP Date of last inspection Brief description of the care home East Clune provides personal care for up to 30 older people. It is located within the village of Clowne, which lies to the north east of Chesterfield. Accommodation is arranged over two floors and there is a choice of lounge and dining space. There are 22 single and 4 double bedrooms, with one of the single room having an en suite. There are 3 bathrooms and a shower room and toilet facilities, which are suitably equipped. There is a central kitchen and laundry. Access to outside garden areas is Care Homes for Older People Page 4 of 33 Over 65 30 0 Brief description of the care home level and provides seating. The Manager has the support of a team of deputies, care and hotel services staff and also external management arrangements of Derbyshire County Council. One of the communal rooms is accessed by a small group of older persons for the purpose of day care. Service users who live in the home are able to access activities there if they so choose. The home provides both short term respite and long term care provision. Fees charged are Short-term care 102.90 to 336.42 per week dependant on a persons savings. Long term care 0.00 to £392.18 per week, dependant on income, savings and property they have. Additional charges are made for hairdressing, private chiropody, newspapers and toiletries. Care Homes for Older People Page 5 of 33 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for the service is one star. This means the people who use the service experience adequate quality outcomes. The inspection visit was unannounced and took place over 7 hours. There were 20 people living at the home on the day of the inspection and 5 people staying for respite. 7 residents, 3 staff, 2 visitors, the manager and service manager were spoken with during the visit. We also looked at all the information that we have received, or asked for, since the last key inspection on the 9th November 2006. This included Care Homes for Older People Page 6 of 33 The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. The previous key inspection report. Completed surveys from people living at the home, staff, relatives and professionals that visit. Records were examined, including care records, staff records, maintenance, and health and safety records. A tour of the building was carried out. What the care home does well: What has improved since the last inspection? What they could do better: The managers need to ensure that people are not admitted without a full needs assessment and up-to-date care plan from the Social Services care manager. A personal service plan should be completed for everyone at the home detailing the action that needs to be taken by care staff to meet all aspects of each persons health, personal and social care needs. Staff should be aware of the content of these plans. Information about the service called a service user guide should be up to date and staff should ensure that people living at the home and new people receive this information. There should be a falls prevention strategy in place for anyone that is at risk of falls and relevant equipment to help minimise the risk. There needs to be more activities available for people living at the home to ensure that they have the opportunity for stimulation. Several residents commented about the lack of activities. One relative wrote in our survey, there seems to be an overall lack of recreational activities to keep residents occupied which we have seen at all the care homes. Care Homes for Older People Page 8 of 33 Maintenance, redecoration and refurbishment is needed in some areas, particularly toilet areas. The manager has been in post since May 2008 and has not yet registered with CSCI. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 33 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 33 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Inadequate written information was provided about the service to prospective or new people to help them make an informed decision about where to live. Not everyone received a full written assessment before being admitted to the home so that the staff knew about their needs and how they should be met. Evidence: The annual quality assurance assessment completed by the manager said that all prospective residents have a comprehensive assessment of their needs. During the inspection visit a statement of purpose and service user guide were made available. These had been reviewed but had some out of date information including the manager that has since left and the incorrect address and telephone number of CSCI. There was no evidence that the service user guides had been made available to people. One person spoken with who was admitted three days previously had not Care Homes for Older People Page 11 of 33 Evidence: received this guide, and several other people spoken with had not seen it. However most people had stayed at the home at least once before deciding to live at the home. Three peoples files were seen. Only one person had a completed needs assessment in place. The manager explained that the care manager from Social Services usually completed these. One person had been at the home for several months but there was no assessment in their file. The manager was aware that the person should not be admitted to the home without a full needs assessment other than in an emergency. The statement of purpose confirmed that people were invited to visit the home and to move in on a trial basis before they made decision to stay. Several people spoken with confirmed that they came to the home for respite care before deciding to stay. Intermediate care was not provided at the home. Care Homes for Older People Page 12 of 33 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples records did not support staff to meet their health and personal care needs, however the principles of privacy and dignity were being put into practice. Evidence: The annual quality assurance assessment completed by the manager said that there were signed personal service plans in place in residents files and residents are viewed as individuals and receive person centred care. They are encouraged at all times to maintain their independence and to support each other. Three files were seen during the inspection visit. Each one had a written care plan completed by a Social Services care manager. These varied in quality, some were very detailed whilst others provided very little information. One care plan had been written several months prior to the person been admitted to the home and has clearly been written for the purposes of receiving home care services. Staff member had written in our survey, people we get in have very little information about them. You find out about these people by getting on caring for them and asking them about what they Care Homes for Older People Page 13 of 33 Evidence: can and cant do. another staff member said, care managers dont always provide deputy managers with all the information about service users. None of the three files that were seen had a fully completed personal service plan written by staff at the home. One had a partially completed plan that was very task focused and not specific for example needs help with personal care. On discussion with the staff and manager this person was admitted to the home 7 months previously and had a significant level of memory loss. This was not reflected anywhere within the persons file. One person had been admitted to the home for the first time three days previously. There was no photograph in the file or medical records. The inspector was informed that a photograph was taken on the day of the inspection. The daily logs did not show any evidence of how staff had settled this person in. On the persons second day at the home the daily log said, went to bed after breakfast and dinner, got up at 4:15 p.m.. There was no record of checks made or discussions held with this person about why they had spent the day in bed and whether they were settling in. The manager had started a new recording system, however significant work was needed for these records to be working documents. The ones that had been completed were not written in a person centred way. Significant information about each person had been archived in a separate file that would have been necessary for staff to have readily available for example health professional contacts. This was however available, but not in the working file. People spoken with confirmed that they had easy access to relevant health professionals when necessary. One person had a very poor appetite and was losing weight. Staff were monitoring the persons food intake, although their weight had not been recorded for a month. There was not an up to date nutritional risk assessment in place. One person spoken with was at risk of falls, and had fallen twice recently. They had been told to call staff if they needed assistance to the toilet, however where they were sat they did not have access to a call bell. There was no risk assessment or falls prevention strategy in this persons file. There were no up to date risk assessments in place in any of the files that were seen. A new end of life plan had been introduced, and had started to be completed for each individual. The medication systems were inspected. Medication was safely stored, however the fridge storing medication had a lock, but this was not working. Not everyone had a Care Homes for Older People Page 14 of 33 Evidence: photograph attached to their medication records. There was a medication risk assessment attached to each record. Some had been completed and included issues concerning self medication and ability to take medicines independently once administered. Others were still to be completed. Handwritten medication administration records had not been signed and checked by a second person. Several records that were seen had pharmacy instructions amended by hand. There was nothing within the homes recording systems to evidence why the instructions had changed and who had authorised this change. The controlled drugs storage and register was in good order. There was a monthly stock check taking place. There was a good system for receipt and returns of medication. There was a record of the district nurse signing to say that they had observed each manager giving insulin and they were safe to do so. Resident spoken with said that they felt that staff respected their privacy. A survey was returned from a GP that visits the service. They said that staff respect dignity and individualism and steps are made to find appropriate venues to examine people, and this is not done in front of others. Care Homes for Older People Page 15 of 33 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was not sufficient evidence that activities were provided to meet the needs and wishes of people living at the home. Food provided was varied and appealing. Evidence: The annual quality assurance assessment completed by the manager said that residents choose how they wish to spend their time, including use of their rooms. The home has allocated hours for an activities coordinator. This is linked to the day service, with additional activities for residents. During the inspection visit the activity records were seen. There had been no record of activities for 11 days. The last record was playing noughts and crosses with one service user. The record before this was an outside entertainer 12 days before. Records did however show that an outside entertainer was booked on a monthly basis. Resident spoken with enjoyed this entertainment. There was a weekly activities rota displayed at the home. This showed daily activity including dominos, darts, bingo, skittles and noughts and crosses. On the day of the inspection visit no activities were seen taking place, however the inspector was informed that a staff member had played noughts and crosses with one person that day. There was a notice displayed Care Homes for Older People Page 16 of 33 Evidence: saying that movement to music was held on a weekly basis. The manager said that this was not taking place. The manager explained that there were 15 care staff hours for activities, but most of these hours were being used to provide care. This was planned to change in the New Year with the appointment of an activities co ordinator. Older people come from the community and use one of the rooms at the home for activities, supported by additional staff. The manager said that residents could take part in these activities, but did not often choose to do so. There was no evidence that people were encouraged to take part and several people spoken with said that they did not realise that they could do so. A church service was held at the home on a monthly basis. Several people living at the home were asked about activities. One person said, I do nothing all day, staff used to ask about dominoes but not now. Another person said, there is not much going on but I am happy to just sit and rest. There was no evidence in the working files of peoples interest being recorded. The inspector was informed after the inspection visit that work had been done with families to record peoples interests. Several people commented in our surveys about activities. A relative said, there seems to be an overall lack of recreational facilities to keep residents occupied which we have seen at all other care homes. A service user commented that there were only activities arranged sometimes. Mealtimes were at set times although staff said that there was some flexibility for example one person occasionally asked to stay in bed late and then had a late breakfast. People could choose where they wished to sit, and several people chose to spend time in their rooms watching TV or resting. Several visitors came to the home during the inspection visit. People could receive their visitors in private if they wished to do so. A visitor confirmed that they could visit at any reasonable time and felt welcomed by staff. Residents spoken with were very pleased with the food provided. One person said, the food is very good. Another person said, there is not normally a choice but staff would get you something else if you didnt like what was on the menu. The manager explained that she was looking into providing a choice at every meal time. Sample menus had been devised and she had requested input from a specialist to further develop the menus. The cook was spoken with. She said that all food was home-made for example pies and cakes. Additional Kitchen staff were to be recruited to provide more flexibility at tea time. They had sought guidance from the diabetic nurse concerning food for diabetics. Care Homes for Older People Page 17 of 33 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints and concerns were being responded to but were not been recorded to show that people were being listened to and their concerns were dealt with appropriately. Evidence: The Information in the Annual Quality Assurance Assessment Completed by the Manager said that all comments and informal complaints are investigated promptly and resolved as soon as possible. As a result the home has received no formal complaints since the last inspection. A staff member wrote in our survey that if someone makes a complaint they know to pass it onto the office staff for them to deal with. They also commented that, complaints never seemed to be sorted out though, although it was not evident what this was in relation to. There was a complaint procedure displayed at the home. This had not been amended to reflect the new address and telephone number of CSCI in case people needed to contact us. The complaints file showed that there had been no complaints since 2004. This was discussed with the manager and service manager. They confirmed that there had been concerns expressed by someones family that had been responded to appropriately by letter, but had not been recorded in the complaints record. There was not a system for recording informal complaints, however on discussion with staff and Care Homes for Older People Page 18 of 33 Evidence: residents it was evident that complaints had been made and dealt with, but had not been recorded. Earlier this year there had been an unfortunate situation concerning a resident who left the building unnoticed, and was later found in the grounds having fallen. This person died in hospital. The situation was very distressing for family and staff. As a result of this incident Derbyshire County Council instructed a thorough investigation by their lead health and safety officer. The Health and Safety Executive and Coroner were also involved. The Coroners verdict made no criticism of the care provided by staff at the home. Derbyshire County Council have treated the matter very seriously and the assistant director has commissioned a learning review from a senior manager. The purpose of this was to assess what could be learnt from this unfortunate situation and consider whether any changes needed to be made at this home and other homes run by Derbyshire County Council to ensure that this does not occur again. The service had also put some changes into immediate effect. Seven staff training records were seen. Although Social Services policy is that staff should have safeguarding adults training every two years, the record that were seen showed that there was only one out of the seven staff members who had attended this training. New staff received this training as part of their induction. A staff member spoken with was not aware of the whistle blowing policy, although on further discussion they were aware of the importance of reporting any concerns regarding staff practice. Care Homes for Older People Page 19 of 33 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe, adequately maintained and comfortable environment, which encourages independence. Evidence: The information in the annual quality assurance assessment completed by the manager was that the home provides a homely, clean, safe and comfortable environment, which is well equipped and maintained. All residents personalise their rooms as they choose. The toilet and bathrooms are clean, tidy and well decorated. A resident spoken with were very satisfied with the level of cleanliness. One person said, the home is always lovely and clean. Several relatives spoken with also commented on the cleanliness. A tour of the building took place during the inspection visit. The home was clean and comfortable. There are 22 single rooms and four double rooms. The home is on two floors, with a passenger lift. There are 3 bathrooms and a shower room, with equipment to assist people with mobility difficulties. There are 3 lounge areas and a large dining room. There is also a hairdressing room. There is a well-sized garden area. Care Homes for Older People Page 20 of 33 Evidence: There were areas around the home that needed attention for example damaged mirrors in toilets, dirty grouting in toilet areas, a broken light cord, a bathroom ceiling badly stained, patching on toilet wall not re-decorated, a loose toilet seat, a first floor toilet was very cold as the radiator did not seem to be working. Some toilet areas needed refurbishment as toilets were very old and some sink areas were damaged. A storage room near to the kitchen did not have fire detection equipment. The manager explained that she was in the process of doing an audit of the environment and highlighting all the issues that needed to be dealt with. She would then pass these on to the relevant people for action. Care Homes for Older People Page 21 of 33 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The recruitment practices and staff training programme were generally good and ensured that people were protected by competent, well-trained staff. There were sufficient numbers of staff to support the people who use the service. Evidence: Information received in the annual quality assurance assessment completed by the manager was that the home is a stable staff team who know the residents and their needs well. Additional staffing is authorised if required. Mandatory training is up-todate and 90 of care staff hold NVQ 2 Care. A comprehensive induction and training programme is provided for all staff. There is a robust recruitment and selection procedure. All staff receive criminal record bureau checks and these are updated every three years. During the inspection visit we looked at staff rotas. These showed that there was always a minimum of two care staff on duty at all times of the day and night. There was an additional care worker in the mornings, usually 7 a.m.-11 a.m. to help at this busy time. We received several comments about staffing from surveys that were returned to us. These included comments from a relative, need more staff so that they can spend more time to talk to residents and, from staff, we have a lot of people with high needs and there have been many times when two staff have found it Care Homes for Older People Page 22 of 33 Evidence: very difficult getting everything done that we need to do, and the workload can be very hard for staff. Dependency levels can be quite high and staff can struggle. The manager was spoken with about this. She explained that recently the dependency levels of people living at the home was quite high, but due to changes in residents, this has now changed and they have no residents with high dependency needs which means that pressure on staff has reduced. Some additional staffing was provided when peoples needs were higher.The service manager present during the inspection visit also explained that additional staff hours was to be made available for laundry and clerical duties which would free up care staff to spend additional time with people living at the home. Additional care hours are also planned. A GP commented in our survey, the skill level of staff is usually very high and we often comment that it is higher than in some local private nursing homes. Although staff files were centrally held, the manager was keeping records of relevant documents to evidence that safe recruitment practices were taking place. Seven staff members training records were seen. Record showed that most staff had attended regular fire safety training and moving and handling training and updates. Some staff had undertaken additional training for example an introduction to equalities and diversity, confidentiality in recording/sharing information and awareness of tissue viability and infection control. None of the training records showed that staff had undertaken dementia awareness and as previously mentioned many staff had not received update training in safeguarding adults. The manager confirmed that dementia training had not been organised for staff although several people living at the home had some level of confusion. There were some gaps where people had not had the required mandatory training as frequently as Derbyshire County Council guidelines stated. Staff spoken with knew residents well and enjoyed their job. One care assistant said, we help new people to settle and make a fuss of them, another person said, its hard work but very satisfying. Several positive comments about staff came from residents. These included, if you need any help it is there, staff are very good. Another person said you couldnt get better. One person said that no matter how busy staff are they never pull a face or act too busy to help. Care Homes for Older People Page 23 of 33 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The acting manager ensures that people are listened to and the home continues to develop and improve. Evidence: The existing registered manager retired in January 2008. CSCI were informed of this. The new manager started in May 2008. As yet they have not applied to CSCI to be registered, therefore their fitness to be the registered manager has not yet been assessed. The manager explained that this was partly due to a delay in receiving a criminal record bureau check. Information in the annual quality assurance assessment completed by the manager said that she is qualified and experienced. It states that staff seek to implement all policies and procedures and the manager intends to implement a clear action plan each year. Systems are in place to safeguard and manage residents money and possessions and residents have full access to their personal records. Risk assessments Care Homes for Older People Page 24 of 33 Evidence: are undertaken in relation to residents and the home environment. The manager discussed during the inspection visit that the management team has not been stable due to new deputy managers, some sickness absence and needing to use relief managers. This has meant that the changes that she has been implementing have been slower to put into place than the manager had hoped. The manager hopes that the management team will soon be a more stable group. There are clear lines of accountability within the home and the service manager responsible for the service visits regularly to support the manager. Monthly reports had been completed evidencing unannounced visits from a service manager, although recent reports were not available. It was explained that an acting service manager had been given this role. There was however ample evidence to show that the manager of the home was well supported. Staff and residents spoken with said that the manager had started to make changes, and had done this in a planned way, involving everyone. Some people commented that they would like to see the manager spending more time with residents, but it was evident that she had been working hard to improve systems and records. Regular staff and residents meetings were being held. Minutes of these meeting showed that people were involved and consulted concerning changes. An external quality assurance manager undertakes the quality assurance review. Although this was on display and dated January 2008 the manager explained that it had only recently arrived at the home. The manager had not yet completed an action plan in response to the findings. Fire records were checked. There was a fire risk assessment although this was dated August 2006 and had not been reviewed. The head office had completed a fire audit in September 08. Some but not all fire checks had been done. Fire alarm tests had been completed weekly and fire extinguishers were regularly maintained. Fire drills were not being undertaken on a six monthly basis and the full date of the drill was not recorded. Servicing of gas and electrical appliances were taking place and a sample of these were checked. Accidents were being recorded including any action taken to prevent a re-occurrence. Care Homes for Older People Page 25 of 33 Evidence: The manager had set up a system for staff supervision, although these dates were not always being met due to deputy managers being off sick. Safe working practices were observed including safe storage and preparation of food and safe practices to prevent spread of infection. Key alarms have been fitted to the external doors around the building to ensure the added safety of residents. New moving and handling hoist has been purchased. The service manager contacted CSCI the day after the inspection visit explaining improvements that will be made as a result of the feedback given immediately after the inspection visit. This demonstrates that the service manager and manager are quick to respond to the outcome of inspections. Care Homes for Older People Page 26 of 33 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 27 of 33 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 New people being admitted 30/12/2008 to the home must have a full written assessment undertaken by people trained to do so, and to which the person and relatives if appropriate are involved. This is to ensure that staff are made aware of their needs and the service can assess in advance that these needs can be met. 2 7 15 Each person must have a 16/01/2009 service user plan, drawn up with involvement from the person and setting out in detail the action which needs to be taken by staff to ensure that all aspects of their health, personal and social care needs are met. These should be completed in a person centred way. Care Homes for Older People Page 28 of 33 This is to support staff to meet the needs of each individual. 3 8 12 There must be adequate 30/12/2008 strategies in place for minimising the persons risk of falls. This should include a risk assessment and falls prevention strategy, taking into account any additional equipment that they may need. This is to minimise individuals risk of falls. 4 12 16 Activities must be made available that are flexible and varied to suit peoples expectations, preferences and capacities. So that people are offered the opportunity for stimulation through leisure and recreational activities. 5 16 22 All complaints must be recorded and include the response to the complaint, any investigation, and the outcome. To evidence that all complaints are taken seriously and responded to appropriately. 6 18 13 All staff must receive training in safeguarding adults including update training. 28/02/2009 30/12/2008 30/12/2008 Care Homes for Older People Page 29 of 33 So that staff have the knowledge to prevent people from being harmed or suffering abuse. 7 30 12 All staff must receive the required mandatory training as well as regular updates. This is to ensure that all staff are well trained to undertake their job. 8 31 8 The manager must place an application with CSCI to become the registered manager. To meet the Care Standards Act and Care Home Regulations so that CSCI can assess the managers fitness to be registered. 30/12/2008 30/03/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 2 1 1 The statement of purpose and service user guide should be reviewed to ensure that it is up to date. The service user guide should be made available to each person staying at the home in a relevant format so that they have the information they need to make an informed choice about where to live. The working file for each person must have all relevant information in place. Archived information should only be information that is unlikely to be needed on a regular basis in order to provide a good quality of care for the individual The manager should ensure that care plans completed by Social Services care managers are up to date and relevant so that they assist staff to complete their own personal service plan. Daily logs should have sufficient detail to reflect the care 3 7 4 7 5 7 Care Homes for Older People Page 30 of 33 and support provided to each individual, particularly new people, so that this is a useful record to monitor a persons care and support needs. 6 8 Each person should have relevant risk assessments in place that are regularly reviewed. These should include moving and handling, nutrition, risk of falls and administration of medication to assess each persons risk and to minimise that risk with a relevant plan of care. Handwritten medication administration records should be checked and countersigned by a second person to ensure that these are accurate. The fridge for storing medication should be lockable to ensure that all medication is kept secure. Any written changes to the pharmacy instructions on the medication records should also have an explanation of the reason for this change and who has authorised this to ensure a safe medication system. There should be a photograph in place for each person attached to their medication records, including new people to ensure a safe medication administration procedure. Each persons interests should be recorded in their individual files to assist staff to try to meet individual needs. There should be a record of activities taking place including individual records stating what each person has been offered and taken part in, to evidence that staff are meeting peoples social needs. An accurate record of activities taking place each day should be available for people living at the home to help them choose if they wish to take part. The complaints procedure displayed at the home should be revised to include the new address and telephone number of CSCI and the name of the new manager so that people have correct information and can contact us if they wish to do so. The manager should continue the audit of routine maintenance and refurbishment and ensure that the work is completed in a timely way to ensure that people live in a comfortable environment. Care staff should undertake training in dementia awareness to improve their knowledge when caring for people with dementia. An action plan should be completed as a result of the quality assurance report to measure the success in meeting 7 9 8 9 9 9 10 9 11 12 12 12 13 12 14 16 15 19 16 30 17 33 Care Homes for Older People Page 31 of 33 the aims and objectives of the home and to ensure continuous development and improvement. 18 19 36 38 Staff should receive formal supervision at least six times a year to ensure that their work is appropriately supervised. The written fire risk assessment must be reviewed to ensure that it remains up to date and that people remain safe. Care Homes for Older People Page 32 of 33 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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