Inspection on 11/12/08 for Headingley Park

This inspection was carried out on 11th December 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Headingley Park 10/06/09

Headingley Park 19/05/08

Similar services:

Elmleigh Convent

Eastfield Farm Residential Home Limited

Cranwell Court Care Home

Fairview

Cottingham Hall

Cranmer Scheme

Fairburn Mews

Claremont House

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Edlington Park Care Home Headingley Way Edlington Doncaster DN12 1SB Lead Inspector Sarah Powell Key Unannounced Inspection 11th December 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Edlington Park Care Home DS0000070011.V373576.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. Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Edlington Park Care Home Address Headingley Way Edlington Doncaster DN12 1SB 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) 01709 862542 01709 869200 edlington@mimosahealthcare.com None Mimosa Healthcare (No4) Limited Post Vacant Care Home 40 Category(ies) of Dementia (40) registration, with number of places Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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 category: Dementia - Code DE The maximum number of service users who can be accommodated is: 40 19 may 2008 2. Date of last inspection Brief Description of the Service: Edlington Park is a care home for older people consisting of two units; both units provide care for people with dementia. The home is in Edlington village close to local shops and amenities. All the bedrooms are single with 30 of the rooms having en-suite facilities. There are adequate communal baths and shower facilities. There are dining rooms and lounge areas on each unit. The home also has a large conservatory. There are gardens accessible to all people. The fees at Edlington Park at the time of the inspection were £395 to £410. These fee charges only applied at the time of inspection, more up to date information may be obtained from the home. Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means that the people who use this service experience poor quality outcomes. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. This was an unannounced visit, which took place on the 11 and 16 December 2008. On the first day the visit commenced at 09:30 and finished at 15:30. Two inspectors attended the home on the 11 December. One was the link inspector for the home and the other an inspector from the Commission’s regional enforcement team. In addition to the key inspection the inspectors were checking compliance with outstanding requirements and a second Statutory Requirement Notice on staff training issued on 7 November 2008. The second visit commenced at 11.45 and finished at 18.30. Full feedback was given to the acting manager during both visits. Three random inspection visits have taken place since the last key inspection. On 20 August 2008 a pharmacy inspector visited to check compliance with a Statutory Requirement Notice on medication arrangements. Partial compliance was found and a one-month timescale extension for full compliance was given. On 10 October 2008 the inspectors identified non-compliance with the Statutory Requirement Notice on medication arrangements. In addition noncompliance with a Statutory Requirement Notice on staff training issued in May 2008 was confirmed. On 24 October 2008 a further Statutory Requirement Notice was issued in respect of medication arrangements and on 7 November 2008 a further Statutory Requirement Notice was issued in respect of staff training. On 11 November 2008 the pharmacy inspector identified that the requirements of the Statutory Requirement Notice on medication arrangements had not been met. Further enforcement action and investigation is now in progress. This inspection visit included talking with people living at the home, a number of professionals, the acting manager and eleven staff. During the visit we also Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 6 walked round the building to gain an overview of the facilities. We also checked a number of records. The registered manager had completed and returned an annual quality assurance assessment (AQAA) on 3 November 2008. This document focuses on how well outcomes are being met for the people using the service. It also gives us some numerical information about the service. The registered manager resigned and left the home in November 2008 since which time the deputy, Jackie Gaunt, has been acting manager, The home has had a significant number of adult safeguarding referrals since September 2007 and Doncaster Council had previously placed an admissions embargo on the home. This was to prevent further admissions and safeguard the people living at Edlington Park. This embargo was lifted on 13 August 2008 following improvements made by the registered manager. However during November 2008 officers from Doncaster Council identified further concerns about care delivery and another four adult safeguarding referrals were made. Following subsequent investigations Doncaster Council have placed a further admissions embargo on the home with effect from 4 December 2008. The outstanding requirements relating to Regulation 13 Medications are now subject to further enforcement action and the deadline requirement dates are not included in the requirements section at the end of this report. THE OUTSTANDING REQUIREMENTS RELATING TO REGULATIONS 12 HEALTH AND WELFARE OF SURVICE USERS, & 16 FACILITIES AND SERVICES ARE SUBJECT TO ENFORCEMENT ACTION. What the service does well: What has improved since the last inspection? The staff training statutory requirement notice was complied with all staff had attended the required mandatory training. All staff had also successfully completed the induction training. Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 7 Some areas of the environment had also been improved one unit had been partially redecorated and new carpets laid, the windows had all been repaired and we were told by the providers that a refurbishment programme had been implemented. The medication room had been enlarged and work was continuing at the time of our visit to improve this room to meet requirements. What they could do better: A large number of improvements are required to improve the safety and quality of life for people living at the home. These are covered throughout this report and the Commission’s requirements and recommendations are detailed at the end of the report. To do this, improvements must be made in: • • • • • • • Care planning and delivery People’s health care needs identified and met. Making sure people receive the nutrition they need to promote and maintain their health and well-being. Keeping people safe from harm and abuse Making sure the environment is clean and safe. Skill mix of staff to ensure peoples needs are met. Effective management of the home. Management processes need to be put in place to make sure that people living at the home receive the care they need and are safe. 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. Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 8 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 Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 9 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): 3. Standard 6 does not apply People who use the service experience poor outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Assessments of need were incomplete and it was not possible to determine if all people’s needs had been identified. EVIDENCE: One new person had moved into Edlington Park since our last visit. We looked at their assessment in detail and found it was incomplete with very little information regarding the person’s needs. It was therefore not possible to determine if their needs could be met by the home. No health and social services assessment was available; when we asked the acting manager for this she was unable to find the assessment and told us she had never seen one. Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 10 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, & 10. Standard 9 was looked at during the random visit on 10th November 2008, and we are now following our enforcement pathways. People who use the service experience poor outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s heath and personal care needs were not met. Care plans did not clearly identify peoples needs or have measures in place to determine how needs could be met. Peoples changing needs were not reviewed and instructions given by professionals had not been followed therefore putting people at potential risk of neglect or harm EVIDENCE: We case tracked four people during the visit, this means we looked at their plans of care and the care they received in detail, to determine if their needs were being met. A care plan written on 8 July 2008 gave details that the person was self-caring with eating their food and just required prompting. An evaluation on 28 July Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 11 2008 stated the person was now in bed and needed full assistance. The care plan had not been rewritten to include these changes. Another eating and drinking care plan stated that the person liked their meals in the dining room with other residents. However the evaluation stated that this person liked their meals in their room. The care plan had not been changed to reflect this preference. Another person’s plan for pressure area care stated that the district nurses treated their pressure sores. However this plan had only been reviewed twice in a 4-month period. No information was detailed as to what actions staff must take to meet this persons needs. Another person’s care plan on their challenging behaviour did not give instructions to staff as to how to deal with any aggressive behaviour. The only instruction stated to record any aggression and contact the Community Psychiatric Nurse (CPN) if required. A district nurse told the inspectors that she had advised the staff to apply barrier cream to a person after they had been washed. However this instruction had not been documented on the persons care plan. When questioned the staff were unaware that this cream was to be applied. One person’s plan on pressure area care had been reviewed on 24 August 2008 and 3 November 2008. No reviews were recorded for September or October 2008 and there had been no further review since the beginning of November. The risk assessment carried out by the home’s staff scored this person as ‘very high risk of developing pressure sores’ yet the inspector’s findings indicated that this persons skin care needs were not being met, as reviews had not been carried out to determine change and ensure needs were met. People have access to health care professionals who visit the home regularly to ensure people’s needs are met. A number of health care professionals we spoke to told us they had given instructions and advice to staff to ensure people’s needs were met. They also told us, on a number of occasions, staff had failed to record this guidance in plans of care and in some instances important care instructions had not been followed. One health care professional told us, “I gave instructions regarding a person’s pressure area care and staff did not follow instructions, this led to the person’s pressure areas deteriorating”. Another health care professional told us, “Staff do not know how do deal with peoples challenging behaviour and due to this are putting people at risk, one person had to be moved, as staff were unable to manage their behaviour which has caused extreme distress to their family”. This had been subject to an adult Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 12 safeguarding referral the evidence and outcomes of the investigation were shared with us at a strategy meeting. During the visit we saw that staff maintained peoples’ privacy and dignity at most times. However on 16 December 2008 the inspector found that some people, approximately five were ready for bed at 17.30. These people were then sat in the lounge in nightclothes from 17.30 pm until they went to bed. Care staff told us some would not go to bed until the night staff came on duty. Care staff said, “We were told to get them ready for bed as there are more staff on days than nights, so a staff member is in the lounge while we get them ready and they are not left unattended”. That evening the Salvation Army were visiting to entertain, it would have been nice to see people dressed for this rather than put in nightclothes When we asked if the people requested to get ready for bed the care staff told us, “Not usually”. Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 13 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 & 15. People who use the service experience poor outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Activities were good but more could be provided to meet peoples’ needs. Contact with family and friends were maintained. The meals were not wholesome, appealing or balanced and people did not receive the nutrition they needed to promote and maintain their health and well-being. EVIDENCE: An activities co-ordinator is employed sixteen hours each week. Group activities and 1 to 1 sessions were organised depending on people’s needs and choices. A number of Christmas activities were organised, which included a Christmas party, carol singers from the local school and a visit from the Salvation Army. Activities were varied and changed depending on the choice of people who attended on the day. However these were mostly group activities such as dominos or board games. An increase in the activities provision had been approved by the providers in January 2008 but had still not come into effect. Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 14 The acting manager told us this was still planned for but only when occupancy levels increased. People continue to speak highly of the activities person but everyone said they wished there was more activities, as it could be boring at times with nothing to do but watch television. People and their relatives told us that contact with family, friends and the local community was encouraged by the staff and relatives were always made welcome. On 11 December 2008 we observed the lunchtime meal. The menu on the day was sausage with onion gravy, mashed potatoes, cabbage and mixed vegetables. The cabbage was cooked from fresh and the mixed vegetables from frozen. The dessert was mousse with no other choice available. The senior carer on duty told us that there was only mousse dessert at lunchtime as it was the Christmas party that evening, when more choices would be available. Two care assistants were asked whether they thought the meal was suitable for people who required a soft diet. They both said that the sausages were very soft and could therefore be mashed. We saw this and observed that there was, none or very little substance to the sausages also that there was fat floating on the top of the gravy. A senior carer, who was cooking the meal, told us that she was not following the menu set for the week commencing 8 December 2008. She thought the meal should have been corned beef hash but had been unable to find the corned beef. She knew that people liked sausages so had decided to make sausages with onion gravy instead. The carer who was cooking told us that the evening meal on 10 December 2008 had been jacket potato with a choice of cheese or tuna. When asked what would be offered to people who required a soft diet the carer told us that she had liquidised the potato with cheese. We asked what this carer knew about people who had been identified as being at high risk of having a poor nutritional intake and if she knew who they were. She said she knew of two people who were receiving supplements. She also said, “They are on high fat yogurts and full fat milk”. We were told there was no list in the kitchen to inform catering staff which people had specialist nutritional needs. We asked the kitchen assistant, the same question about people who had been identified as being at high risk of having a poor nutritional intake. She told us, “I don’t know, I am only a kitchen assistant”. Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 15 When asked the carer who was cooking she confirmed that whole milk, butter and cream were used. However, when we looked for evidence of this there was no butter or cream available in the kitchen. We also found there were only five pints of whole milk and that the remaining milk supply was semiskimmed. The acting manager and the carer told us that people were given yoghurts with a high fat content as a food supplement. However, when we looked for evidence of this in the main kitchen fridge and the storeroom fridge we only found yoghurts with a low fat content of 1.5g per small pot. When asked, the carer told us there was no specific menu for people who required a soft diet and that their food was ‘just liquidised.’ She added that it was usually the meat, which was liquidised and then served with the mashed potato and vegetables. After the mid day meal we noted that there was a lot of waste and that two people in the dining room did not eat their meal. A carer who had been in the lounge serving and giving assistance with meals told us that the two people we had seen not eating had been given assistance, one person took a long time to eat their meals but did eventually eat it, however the other person did not always eat their meals. The carer told us that the person who didn’t eat their meal had only just got out of bed before lunch and that was why they had not eaten their meal. When asked if an alternative would be offered to this person the carer said no. She went on to say that the person would be offered a sandwich with afternoon tea at 14.15pm. We asked if the person had been offered breakfast when they got up. The carer said no as it was lunchtime and they had not been given breakfast in bed because they had been asleep. This meant that this person had no food or drink from supper the night before at approximately 19.00 until 14.15 the following day, a period of over 19 hours. On 16 December 2008 we observed the teatime meal and spoke to the cook and kitchen assistant. The kitchen is manned until 15.00 every day and the kitchen staff prepare the teatime meal, which is served by the carers at 16.00. We were also told that the care staff prepare and serve supper at approximately 19.00. The staff told us that the lunchtime meal on 16 December 2008 had consisted of gammon, peas and chips. Fish cakes, mashed potato and peas were available for people who needed a soft diet. There was no choice of vegetables and the inspectors had previously been told that at least one person is known to not like peas. So as there was no alternative to peas this Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 16 person would not have had any vegetables with this meal. The staff told us that the choice of dessert was either ‘arctic roll’ or yoghurt. There was confusion about which menu staff were supposed to be following. The menus run in sequence from week one to week four. However we found that there was very little variation in each week, such as five days of week one were repeated on week three. The staff told us they were following week three however this was the same as staff had apparently been following the previous week. The kitchen staff were preparing chicken soup for the teatime meal on 16 December 2008. Staff showed us the dried packet mix of soup, which would be mixed with water prior to heating. When asked if they would add any milk or cream the staff replied ‘no that they followed the instructions on the packet by adding water only.’ We asked the staff about the provision of cream, butter or full fat yoghurts for those people who need extra nutritional content. Staff said one person had butter because it was their choice but that no one else had butter. Staff also said there was no double cream and that whipping cream was used for trifles. We found yoghurts in the fridge with a fat content of 4.4g per pot. The staff said these had been delivered the previous day. This indicated that there had been no high fat content yoghurts available for at least four days. We could find no records in the kitchen to tell staff which people required supplements. In addition no records were being kept of the food that was actually being served. Staff confirmed that kitchen staff did not keep or have any such records. Staff said they thought communication between the care staff and the kitchen staff could be improved so that the kitchen staff knew which people required food supplements and what those should be. Staff told us that supper would consist of sandwiches or cheese and biscuits and that care assistants would have to prepare any suppers. On 16 December 2008 we saw the teatime meal at 4.30 pm. This consisted of a selection of sandwiches. Half were made up of jam and the other half tuna or ham. The sandwiches were of sliced white bread. Chicken soup was also available. For dessert there were yoghurts or chocolate sponge and custard. The bread roll served with the soup was a ‘hot dog’ roll and was not buttered. During our observation of the meal staff did not ask if people wanted butter on their roll. Very little supervision was given to assist people. One person poured soup over their roll on the plate; another person was eating a serviette Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 17 as they thought it was a bread roll. When we told the person the bread roll was on their plate, they were able to pick it up and eat it. Two people who both required a soft diet were given a beaker of soup and a high fat yoghurt. Neither of them were given a choice or offered anything else to eat. Since our visits we have been informed, the acting manager and providers have taken advice from a dietician. Following this a revised menu has been implemented following her advice, although on the whole she had been satisfied with the menu in place. The dietician had recommended that oily fish be added to the menu each week and all snacks and extras provided also be added to the menu. We will determine at out next visit if this is followed, if so the people would be receiving a wholesome, varied, nutritious diet. It was good to see that following our feedback at the end of our visits that the providers had taken action by contacting the dietician to improve the meals and ensure people needs were met. Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. People who use the service experience poor outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s concerns are listened to but not always resolved and people are not always protected from abuse in the home. EVIDENCE: There was a clear and accessible complaints procedure. People were aware of how to make a complaint if they required and relatives also knew how to make a complaint. However records of complaints received since the last key inspection could not be found. The acting manager told us, “I have been unable to find the records that the last manager kept”. The acting manager assured us that all further concerns or complaints would be documented and records kept of outcomes to ensure people were listened to and issues resolved. Adult safeguarding processes are still underway and the home has another admissions embargo in place. Four adult safeguarding referrals have been made recently as a result of concerns from health care professionals and Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 19 council officers that peoples needs were not being met and people were not safeguarded. Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. People who use the service experience poor outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment had improved but areas were still not well maintained. Cleaning was not always carried out due to staff shortages. EVIDENCE: We looked around the building and found that some improvements had been made. Some areas on Daffodil unit had been redecorated and new carpets laid. Bedroom doors had been painted, however many were badly finished and required repainting. Many environmental standards still required attention. Floor coverings in bathrooms, toilets, and some bedrooms and corridors were badly stained and marked. Some chairs, tables and bedroom furniture remained damaged and Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 21 required repairing or replacing. The environment was still not well maintained for the people who lived there. The acting manager told us that the maintenance person would repair the damaged furniture if possible or it would be replaced. Cleanliness in some areas was found to be very poor particularly during the second visit on 16 December 2008. Some bathrooms and toilets had obviously not been cleaned; the toilet pans were stained and marked, baths had not been washed out after use and some floors were littered with debris. The acting manager told us, “I don’t have a designated cleaner at present so staff are covering, one member of staff is currently at college so will do some hours for me on cleaning when she finishes.” This person was subsequently called in to ensure some areas were cleaned. The inner courtyard had been improved at the last visit. The floor surface had been removed and this area could now be used safely. However access was still via a step so was not accessible to all people. Both the Commission and Doncaster Council had previously required access improvements to the courtyard. The acting manager told us, “It is in the process of being done by the handyman and will be completed in two weeks”. We have been informed by Doncaster contracts that the ramp has now been provided. During this visit we observed that the existing medication room had been enlarged and was scheduled for refurbishment It was encouraging to see that action was being taken to resolve the problems with the medication room. The room had previously been very small, too warm and without hand wash facilities. However the acting manager was unable to show us a plan of the proposed changes. She did advise that the home’s handyman, who was not working on the day of the visit, was carrying out this work. We raised concern over the amount of time this work appeared to be taking when the room was still in operational use. In particular we found high levels of dust within the area and a visiting District Nurse raised concern over conditions in the room during the inspection. We advised the acting manager that all wound dressings and any medical sundries should be removed from the area and stored securely possibly in an empty bedroom. Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 22 The acting manager informed us that she was currently storing oral medications such as analgesics within a bedroom area. We advised that these must be returned to the medications room and stored either in the locked medicine trolleys or the metal wall cabinets. The acting manager also told us ‘ the programme of refurbishment will continue to improve the environment for the residents’. Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 23 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 & 30. People who use the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The numbers and skill mix of staff did not always meet the needs of people in the home. Staff had not received specific training on conditions associated with old age; some examples are diabetes, tissue viability and nutritional requirements. However all mandatory training had now been completed. Recruitment procedures protected people. EVIDENCE: The acting manager told us that one senior carer and three other carers were on duty. Another senior carer was covering kitchen duties with a kitchen assistant. One member of laundry staff and one cleaner were also on duty. Duty rotas detailed several recent night shifts where only two staff were rostered for duty. This included Monday 8 – Friday 12 December 2008. The following week only two staff were rostered for night duty on Monday 15 December 2008. Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 24 We spoke with the acting manager about the night shift cover. She confirmed that only 2 staff had been on duty as stated on the rotas due to either staff sickness or leave. She told us that agency cover was not sought and was vague as to whether her employer knew about the reduced staff levels at night. The night shift runs from 21.15 – 07.15 am and the acting manager told us that staff are expected to launder bedding and towels, set the dining tables, vacuum, wipe settees and chairs in addition to their care duties. Two carers who worked nights told us that they had carried out laundry of bedding, set dining tables, cleaning duties such as washing down settees, hovering and emptying bins and getting people up for breakfast while only 2 night staff on duty. Duty rosters were very muddled and did not reflect the staff on duty or the fact that care staff were undertaking ancillary staff duties. For example nothing was documented on the roster to say who had cooked, laundered or cleaned on 6 December 2008. No regular kitchen assistants were rostered during the first week of the inspection The senior carer who was cooking at our first visit told us that the kitchen assistant was on leave although she was rostered for duty. Also the activities coordinator who was not rostered was reported as working evening shifts in the kitchen. Overall the findings showed that the duty rosters for the ancillary staff in particular did not correspond with the staff on duty. Another example of this was the previous day when no laundry staff were rostered for duty. However we met with the laundry person who told us she worked the shift and confirmed this by showing us her clocking in card. We found that the care staff could say who had done what and support this with entries on the clocking in sheets. However the acting manager was vague about how the staff were organising themselves and who had worked on which shifts. Informal interviews were carried out with staff on duty to check compliance with the statutory requirement notice for staff induction and training. We found that all of the requirements within the notice had been met. Staff were able to give a good account of the training they had received, which had also included dementia care. Staff said they had enjoyed the training and found it beneficial to their work with people living at the home. The new cook told us she was due to undertake food hygiene training but as yet the date was to be arranged. When we asked the kitchen staff during our visit on 16 December regarding specific training, staff told us that they had not received any training regarding Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 25 the nutritional needs of older people. They said they would like to be trained so that they could understand people’s nutritional needs. We looked at selection and recruitment records where minimal information was assessed as very little recruitment had taken place. We looked at two files and saw that all the required documentation including references, protection of vulnerable adults (POVA) and criminal record bureau (CRB) checks were in place. Individual files were untidy but information was accessible. We found original CRB’s still retained in files, the CRB advice regarding data protection was not followed. Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 26 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, 37 & 38. People who use the service experience poor outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is not run in the best interests of the people and people’s health and welfare is not always protected. Overall management and record keeping at the home was not ensuring outcomes for people were met, putting people at potential risk of harm. EVIDENCE: The previous deputy manager has been promoted to acting manager since the departure of the registered manager in November 2008. However the inspectors remain concerned that this person although of good integrity, honesty and of good character does not have the required experience and Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 27 management ability to take charge of the home particularly when so many urgent improvements are required. The home’s administrator looks after people’s finances and these were not checked on this occasion. The administrator told us that individual finances are kept up to date and regular checks carried out to ensure that people’s financial interests are safeguarded. Maintenance records were not available again at this visit. The acting manager told us that she did not know where they were kept but that she was certain they were up to date. Many records referred to in the regulations under schedule 3, records to be kept in a care home in respect of each service user and schedule 4, other records to be kept in a care home, were not all maintained or kept up to date. This did not demonstrate people were protected or that the home was run effectively or efficiently. At our visit on 19 May 2008 we identified that the five-year electrical installation safety certificate had expired in March 2008. The acting manager was unable to tell us whether this had now been renewed. The ongoing lack of maintenance records and certificates raises concerns over the safety of the premises for both staff and people living at the home. It also demonstrates the lack of overall management and organisation of the home. We had raised concerns over fire safety issues at our last key inspection on 19 May 2008. The previous manager had provided the Commission with fire safety information and confirmation that fire drills and checks had been carried out. This matter was shared with the local Fire Safety Officer who has continued to monitor the situation at the home. Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 x 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 X X X X X X 1 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X 1 1 Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 29 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 OP19 Regulation 16 Requirement The redecoration programme must continue to that people are provided with a well-maintained environment. (Revised requirement outstanding from 01/03/08) All people must have a plan of care that clearly identifies their needs. It must be kept under review and be implemented to make sure peoples needs are met. (Revised requirement outstanding from 01/03/08) Proper provision must be provided for people’s health and welfare and you must seek the advice of health care and other professionals and follow any instructions from them to make sure peoples needs are met. (Revised requirement outstanding from 01/03/08) The numbers of staff on duty and their competence must be reviewed to ensure that the DS0000070011.V373576.R01.S.doc Timescale for action 01/04/09 2. OP7 15 31/03/09 3. OP8 12 31/03/09 4. OP27 18 31/03/09 Edlington Park Care Home Version 5.2 Page 30 needs of people are met. (Revised requirement outstanding from 01/01/08) Consult people about a programme of activities and provide facilities for recreation taking into account the needs of the people and prevent the people from being bored. (Revised requirement outstanding from 25/11/08) People must be given choice and control over their lives to ensure their needs are met. (Revised requirement outstanding from 25/11/09) A wholesome, varied and balanced diet must be provided for people to ensure their nutritional needs are met. (Revised requirement outstanding from 25/11/08) Records of concerns and complaints must include full details of any investigation, the actions taken and outcomes to ensure they are acted on. (Revised requirement outstanding from 25/11/08) Peoples assessment of needs must be completed and in their plans of care. (Revised requirement outstanding from 25/11/08) Quality monitoring systems must be maintained to ensure the home is run in the best interests of the people. (Revised requirement outstanding from 25/11/08) Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 31 5. OP12 16 01/04/09 6. OP14 12 01/04/09 7. OP15 16 31/03/09 8. OP16 22 01/04/09 9. OP3 14 01/04/09 10. OP33 24 01/04/09 11. OP9 13 All people must have in place 31/03/09 effective arrangements to ensure that all medication is administered to people as prescribed. (Outstanding requirement from 01/11/07) Provide senior staff with appropriate training in the conditions and diseases associated with old age. Ensure that staff collectively have the skills to deliver the care, which the home offers to provide. People’s dignity and choice must be respected at all times. People must be dressed appropriately for the time of day and where possible in accordance with their wishes. People must be protected from abuse in accordance with the home’s and local written policies. The premises must be kept clean, hygienic and systems must be place to control the spread of infection. Someone who is competent and experienced in order to meet its stated purpose, aims and objectives must manage the home. All records must be kept up to date. All maintenance records must be available at the home. The outcome of the five-year electrical installation checks must be forward to the Commission. 12. OP30 18 01/04/09 13. OP10 12 01/04/09 14. 15. OP18 OP26 13 23 01/03/09 01/03/09 16. OP31 9 01/04/09 17. 18. OP37 OP38 17 13 31/03/09 01/03/09 Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 32 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP12 OP9 Good Practice Recommendations The additional ten hours for an activity co-ordinator should be filled to ensure all people’s needs are met. Ensure that medicines are stored at the correct temperatures in accordance with the manufacturers instructions. Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Edlington Park Care Home DS0000070011.V373576.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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