Inspection on 19/05/08 for Headingley Park

This inspection was carried out on 19th May 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 11/12/08

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 19th May 2008 09:20 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.V364350.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.V364350.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.V364350.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 cagtegory: Dementia - Code DE 2. The maximum number of service users who can be accommodated is: 40 22nd November 2007 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.V364350.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. This was an unannounced visit, which took place on the 19th May 2008. The visit commenced at 09:20 and finished at 17:50. Three inspectors attended the home to carry out the visit. The link inspector for the home, an inspector from the Commission’s regional enforcement team to look specifically at outstanding requirements to determine if these had been addressed and a pharmacy inspector who attended to look at medication. Feedback was given during the visit to the area support manager and the deputy manager. A random inspection visit had taken place on 4th February 2008. This visit was to determine the progress the home had made with the requirements from the previous key inspection in November 2007. An immediate requirement had been issued at this random visit regarding people’s needs not being met with the number of staff on duty. This inspection visit included talking with people living at the home, a number of professionals, the deputy manager, the area support manager and eleven staff. During the visit we also walked round the building to gain an overview of the facilities. We also checked a number of records. The manager completed an annual quality assurance assessment (AQAA) and returned this prior to the visit this focuses on how well outcomes are being met for the people using the service. It also gives us some numerical information about the service. Some survey forms were sent to people who live at the home and their relatives. At the time of this visit two of these had been returned to the Commission. The home has had a large number of adult safeguarding referrals since September 2007 and Doncaster Council placed an admissions embargo on the home. This was to prevent further admissions and safeguard the people living at Edlington Park. Doncaster Council’s contracts department have also made a number of visits to the home and have identified similar shortfalls to what we have identified. Following this visit and the findings that required improvements have not been addressed the Commission is taking enforcement action against this service, to ensure the outcomes for people living there are improved. Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 6 THE OUTSTANDING REQUIREMENTS RELATING TO REGULATION 13 MEDICATIONS ARRANGEMENTS AND REGULATION 18 STAFF TRAINING ARE NOW SUBJECT TO FUTHER ENFORCEMENT ACTION AND ARE NOT INCLUDED IN THE REQUIREMENTS SECTION AT THE END OF THIS REPORT. What the service does well: What has improved since the last inspection? What they could do better: There were a large number of improvements required and these are covered throughout the report, and the requirements and recommendations are detailed at the end of the report. The outcome area requiring substantial improvements are health and personal care, daily life and social activities, complaints and protection, staffing and management. Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 7 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.V364350.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.V364350.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): 1 & 3. Standard 6 does not apply. 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 statement of purpose and service user guide contained all the required information. Assessments were incomplete and it was not possible to determine if all people’s needs had been identified. EVIDENCE: The manager had updated the statement of purpose and service user guide with information people need to make an informed choice about where to live. People’s assessments in plans of care were incomplete and it was not possible from the information they contained to determine if people’s needs could be met. No health and social services assessments were in peoples plans of care so it was not clear what peoples needs were and if they could be met. Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 10 It is however acknowledged that there has been a suspension of new placements at the home and so there hasn’t been the opportunity to carry out any new assessments. The company have stated they are unable to gather information from other agencies i.e. Local Authority or Primary Care Trust. The manager had said he was going to review all people’s assessments so that needs were clearly identified to enable plans of care to be drawn up. The manager has provided the Pre Admission Assessment policy, Pre Admission Assessment form and Residents choices proformas. Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. 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, putting people at risk. There remains a lack of a robust system within the care home for the accurate administration of medicines. This puts people at risk of not receiving medication as prescribed and their health and wellbeing may be at risk of harm. EVIDENCE: We case tracked three people during the visit, this means we looked at their plans of care and the care they received in detail, to determine if peoples needs were being met. The manager was reviewing all people’s plans of care. One plan looked at in detail had been rewritten by the acting manager in March 2008 and had needs identified. However it had not been reviewed or amended since then by the key worker. When we looked in detail at that person’s needs, they had Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 12 changed, many issues had not been addressed. The persons weight had decreased and their swallowing had deteriorated yet this had not been followed up with professionals as required, putting the person at risk of harm. During the case tracking process a number of areas of concerns requiring improvement were identified some examples of these concerns are detailed below. One other person case tracked was at a high risk of poor nutritional intake due to their lack of appetite. The manager had put the person on a food and fluid chart, these were not completed correctly, were not reviewed or any action taken to reduce the risk or seek professional advice. The charts were also found in various places on the unit, they were not filed in the person’s plan of care. These actions put the person at risk. Another person case tracked was on a pressure-relieving mattress, however it was not identified in the plan of care. The person was not at risk of developing pressure sores and therefore did not require this specialist equipment. When the deputy manager was asked she said, “I didn’t know she was on a pressure mattress”. The mattress was also set for someone weighing 80 kilo grams the person weighed less than 40 kilo grams, it could therefore be putting her at risk of harm. The company have stated the mattress was ‘prescribed by a district nurse’. The three people case tracked did not have all their needs identified and not all their health care needs were addressed or met putting them at risk. When we spoke to staff regarding reviewing care plans they said, “We do not always have time to sit and review the plans, a lot of the time there is only two staff on duty and it tends to be least priority as we want to ensure the people are looked after”. The company have stated that when they carry out their monitoring visits they speak to staff and staff have not expressed this view to them. Some staff also told us, “I have not really received any training on how to complete the plans I have been told I will get this”. The company have stated feedback on care plan audits, identifying corrective actions and how these need to be addressed is covered at frequent supervisions. Also that one to one support has also been provided. People’s privacy and dignity was maintained on most occasions during the visit. The district nurse told us they have to treat people in the lounge on occasions as there is not the staff to take them to their bedrooms or there was not the time. The nurse told us “We have asked if the home could provide a treatment room, this would help and we would be able to treat people in private”. The company have stated they also find varying practice from the District nurses in relation to treating people in private or not. Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 13 It was also noted that many ladies did not have any stockings on and a number of gentlemen did not have any socks on. It was noted in the lounge on Daffodil unit two men did not have socks on and five ladies did not have any stockings on. It was not clear if this was their choice or lack of time to put these on, staff spoken to were not really sure why they weren’t used it was just what they did every day. The pharmacy inspector covered standard 9 medications and her findings are included below. The current and previous months’ Medication Administration Records (MARs) were looked at. The recording of medicine administration has improved. There were few gaps and the records of medication administration matched the dose on the MAR. An audit system is now in place to check that accurate records of administration are maintained. One person has eye drops with a dose prescribed as one drop as directed. Advice has been taken from the pharmacist on how often to administer. This is good practice as it helps to make sure that the person is getting their medication correctly. There remain a number of MAR recording that no medication had been given because no stock was available. For example one MAR for furosemide 20mg tablets had out of stock written for 9 days. It is important to make sure that the quantity of medication is regularly checked so that a prescription can be ordered in plenty of time to prevent the person being without. The code ‘O’ is still being used on the MAR without an explanation. However there was no definition on the chart to explain why the person had not received their medication. It is important that a clear reason is given so there is accurate information on how a person is taking their medication. The prescriber, who may wish to review the medication, may also use this information. The quantity of medication that is used from one monthly cycle is not always recorded on the MAR. This means it is difficult to check how much medication has been administered and to know how much stock there is. The recording of the administration of antibiotics for one person recently discharged from hospital did not evidence that the prescribed dose had been given. The number of signatures recording administration was less than the quantity supplied when course complete was written. Antibiotics must be accurately given to make sure the infection they were prescribed for is treated properly. An audit of current stock and records showed that some medication had been signed for but not given. For example one person had 30 tablets supplied. Thirty records of administration had been made but 3 tablets were left. This Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 14 means people are not getting their medication as prescribed, which may effect how their condition responds. The room for storing medication remains warm and there is no ventilation. A thermometer has been put in place to record the room temperature. Most manufacturers recommend that medication is not stored above 25 degrees Celsius, this helps to keep the medicines safe to use. The date of opening was recorded on the packaging of medications with limited use once opened such as eye drops. This is good practice as it helps to reduce the risk of medication being used beyond the time recommended by the manufacturer and keeps them safe to use. Medication to be returned to the pharmacy for disposal is now separated from medicines in use. This reduces the risk of these medicines being incorrectly used. The deputy manager had developed good working relationships with the pharmacy supplier and the local GP practices. A review of people’s medication had been requested. The deputy manager had identified that some people taking medication that can cause drowsiness, were sleeping a lot during the day. To resolve this she had asked if the dose of medication could be given later. This is an example of good practice and has positive outcomes for people for example if they are no longer as drowsy during the day they can take part in activities. There is a good system for the ordering of monthly prescriptions. The prescriptions are sent to the home before going to the pharmacy. This is an example of good practice as it is an opportunity to check if any new medicines or dose changes are included and any problems with prescriptions can be addressed at this point rather than after the supply has been made. The checking of prescriptions is an important part of the management of medication. Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 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 was maintained. The meals were not always wholesome, appealing or balanced. EVIDENCE: An activities co-ordinator is employed sixteen hours each week, group activities and 1 to 1 sessions were organised depending on the people’s needs and choices. Activities were varied and changed depending on the choices of the people who attended on the day. More activity hours had been approved but the area support manager said, “The additional hours available for activity will be recruited into as the numbers of residents increase or their needs change”. People spoken to spoke highly of the activities person but all said they wished there was more activities, as it could be boring at times with nothing to do but watch television. Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 16 One person seen during the visit was continuously trying to go outside, for her safety this was not possible, however staff could have taken her out but this was not offered once during our visit. On the day of the visit we observed people sat in the lounge looking uninterested and bored, there was no interaction seen by care staff with the people. The people and their relatives we spoke to all said that contact with family, friends and the local community was encouraged by the staff and relatives were always made welcome. A church service was held in the home each month this was well liked by the people we spoke to, but they said; “it would be nice if the church service was more often”. The activities person had taken people in the past but there were not always staff available to take the people to the church of their choice. We interviewed the cook on duty she has obtained intermediate food hygiene in 2002 however she advised that she had no qualifications in elderly nutrition or catering for people with dementia. The home does have a ‘diet requisition and special needs’ sheet but the cook advised that she had no current instructions from the care team about anyone who needed any additional nutritional support. She was aware of the use of full fat milk into rice puddings to provide extra calories for one person who had specific needs. However butter and whole milk is not used routinely. Cook confirmed that around ten people at the home require blended diets but that a structured/ rotational soft diet menu is not available and blended meals are provided on an ad hoc basis to coincide with the normal menus. She advised that packet soup was often provided as the soft diet particularly at teatime when the lighter meal is provided. She did acknowledge that these packets mixes are low in calorie and fat content and therefore will provide minimal nutritional content to people who are at high risk of malnutrition. Also as seen on the day of the visit vegetables are not always included in the blended diets. The inspectors observed that the meat and potato content was mixed up together into an unappetising brown mixture in a bowl. This means that people are not receiving the nutritional content of vegetables in their diet and are being offered food that doesn’t resemble a normal meal where the components are served separately on the plate. The four-week rotational menus were examined and found to be lacking in detail, variation or choice. On closer examination after the visit we found that these are actually two week menus that are entirely repeated despite being headed weeks 1 – 4. The repetition in these 2 weeks was significant for example an apple dessert on three teatimes in one week. Also a large number of ice cream or angel delight/ mousse based convenience desserts at dinnertime. Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 17 Out of the three people we case tracked and looked at in detail, two were underweight and at high risk of not receiving enough nutritional intake. From looking at diet sheets it was evident a large number of people were on a soft diet, it was not clear if this was required to meet people needs. Records of the breakfast, mid-morning, mid-afternoon and supper menus, choices and what is provided are not available for either normal or soft meals. Cook said that fruit was sometimes provided between meals but not on the day of our visit. Also, that the care staff made the supper meal from items left in the fridge. The ‘two veg’ on offer are not described or recorded and cook had no knowledge of what vegetables had actually been provided on her days off. Sandwich contents are not described or recorded. Furthermore records of the actual food provided are not kept even when the daily menus are not followed which was found to be the case on several recent occasions. Cook advised that she had returned from leave to find that several items were out of stock and this had led to menu changes. These findings demonstrate that people living at the home are not receiving a varied, wholesome, appealing and balanced diet which is suited to their individual assessed and recorded requirements. Edlington Park Care Home DS0000070011.V364350.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 complains procedure. People were aware of how to make a complaint if they required and relatives also knew how to make a complaint. However complaint records were insufficient it was not clear what the outcomes were or if the complainant had been satisfied. It was not clear therefore if complaints were acted upon to ensure people were listened to. The adult safeguarding process still continued and the home still had an admissions embargo in place by Doncaster Council. An investigation was still ongoing by the police and adult safeguarding. The adult safeguarding investigator had found during there investigation, that a number of incidents that had occurred in the home, which had been recorded in care plans were adult safeguarding incidents and should have been referred. However no referrals were ever received. This puts people at risk of potential harm. One safeguarding referral was received this was as a result of the staff not managing a person’s behaviour. This was investigated by Doncaster Council Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 19 and measures have been but in place by the company to protect the affected people. Care staff had still not received training in adult safeguarding and many when asked where not fully aware of policies and procedures to follow to protect people. The Commission for Social Care Inspection are part of the adult safeguarding meetings and have given feedback regarding the evidence from this inspection at these meetings. Edlington Park Care Home DS0000070011.V364350.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 adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment was not well maintained. The cleanliness was good. EVIDENCE: We looked around the building the foyer had been redecorated and the company state some bedrooms have been redecorated, however the following environmental standards still required attention. Floor coverings in bathrooms, toilets, bedrooms and corridors were badly stained and marked. Some chairs, tables and bedroom furniture were damaged and marked. Wall plaster in some bedrooms was still damaged and in a poor state of repair. The environment was not well maintained for the people who lived there. Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 21 There was a slight odour on both units however this was due to the state of the floor carpets and not the lack of cleaning. The standard of cleanliness throughout was to a good standard. The inner courtyard had been improved with the floor surface being removed, which meant it could now be used safely. However the access was still via a step so was not accessible to all people. Access improvements to the courtyard had been required on previous visits by the Commission and Doncaster Council and had still not been provided. The shower had been repaired so that both units had an accessible shower for the people, which met their needs. The company have assured that ‘ the programme of refurbishment continues to improve the environment for our residents’. Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. 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. Skill mix of staff does not always meet the needs of people in the home and training was not up to date. Recruitment procedures did not always protect people. EVIDENCE: The number and skill mix of staff on duty did not meet people’s needs. We made a detailed assessment of staffing levels throughout the twenty-four hour period. Information was based on the staff duty rota for all designations of staff, the clocking in sheets that were explained by the homes administrator and discussions with the deputy manager who was in charge of the home. Our findings were: • • • • The manager’s hours and input are not included on the staff duty rotas. Staff surnames are not included on the care staff duty rotas. The weekly rota and staff clocking in sheets didn’t always tally. Also we found that the actual staff on duty did not correspond with the names on the rota. For example on the day of the visit the domestic had actually moved to care duties and her replacement of three weeks, whose name was not on the rota, was working the shift. A carer was on early duty but was scheduled as a day off. DS0000070011.V364350.R01.S.doc Version 5.2 Page 23 Edlington Park Care Home • • • • There is no identified staff handover period with shifts ending and starting at the same time, for example 2.15 pm. This means that staff may not be given time to communicate verbally with each other or they may be working overtime that they are not being paid for. The dedicated maintenance and activities input is not recorded on the staff rotas. Domestic, catering and laundry hours are not detailed on the duty rotas. Some staff work in more than one area. For example care and kitchen work. These varying roles were not clearly apparent from the training summary or duty rotas. We found that the numbers of care staff scheduled for duty varied between four and six throughout the day and that usually three staff were on duty at night. We found that a senior carer had been on duty every night apart from 12/05/2008 in the last two weeks. We were concerned to find from the previous and current weekly rota that one carer regularly works between sixty and sixty-six hours per week and that this includes a combined late and night shift and five other night shifts. Four care staff were on duty for twenty-four people at the start of the visit. This included the deputy manager who was in charge of the home overall. People were living in two separate units and have dementia. We identified that 2 of these people were bed bound and required input from two staff to meet their care needs. Care plans were not reviewed monthly or when changes occurred. People’s needs were not identified; records kept for food and fluid intake were not reviewed or acted on to ensure people’s needs were met. The ancillary support team appeared adequate in numbers but actual shift times were not recorded on the duty rotas but would be available on the clocking in sheets. A selection of staff files was seen these did not contain all the required information to protect people. One person was started on a Protection of vulnerable adults initial check but no Criminal Record check. This is permitted as long as formal supervision arrangements were in place this was not being done. Two other files seen did not have the last employer reference and only contained one character reference. There were also no records of induction found in two files. This did not protect the people living at Edlington Park. We found that neither the deputy manager nor the area support Manager were able to produce any up to date staff training records or evidence of recent training provision. The new acting manager was contacted and reported that as yet there were no individual staff-training folders available and that he had collated the existing information from the training certificates available in the home. Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 24 After some delay a loose-leaf folder of these training certificates was located as was a staff training summary. These showed that while some staff had received recent update in areas such as basic food hygiene, basic medications awareness and manual handling the majority of staff were not up to date with appropriate training and unable to meet people’s needs. The following information was found on the staff-training summary sheet where thirty-four staff of varying designations was listed. Where possible details were confirmed with the deputy manager and the staff on duty. • No inductions were listed for fourteen staff, eight of which had commenced since January 2008. • Only three staff had received moving and handling update and examples were seen and confirmed where care and ancillary staff had either not received any training or update since 2001. • Five staff were listed as having received training in dementia, seventeen in adult protection, ten in infection control and fifteen in fire safety awareness. • The inspector found that details on available training certificates did not always correspond with the summary. For example a certificate of manual handling was dated November 2004 but was detailed on the summary as May 2006. • Some staff had received training in abuse prevention from an operations director in 2007 but management could not confirm whether this person was an accredited trainer in this subject. • One person, who was reported as having a shoulder injury, last received manual handling training in June 2004. An external training company has had some recent input but records indicated poor attendance at sessions in manual handling and basic food hygiene awareness. We interviewed a number of staff of varying designations as part of the inspection. A domestic employed in March 2008 said that colleagues had provided their induction, including the fire safety procedure. This person had received no introduction or training in manual handling, infection control or the use of hazardous substances. They had not received any guidance in dealing with people with dementia although they came across them on a daily basis. Another new domestic had also been shown by colleagues but had been given advice on adult protection by the manager. An experienced carer of seven years confirmed that their last attendance at manual handling training was May 2001, fire safety awareness October 2002, first aid November 2002 and pressure area care in March 2001. They described dementia care training in June 2007 as very basic and advised that they had had no training in infection control. Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 25 One of the cooks told us they had not received any training in elderly nutrition or catering for people who have dementia. Training information indicated that seven of the twenty people in the care team hold NVQ’s. Only one carer currently holds NVQ level 3. One new carer did say that they had commenced key skills training in advance of enrolling for NVQ. Also several staff, including the cook told the inspector that they were about to commence a sixteen-week distance-learning programme of dementia care training with Sheffield College. We saw evidence of this. The deputy manager told the inspector that she thought she had undertaken training in manual handling, medications and adult protection last year. However she couldn’t recall any detail and no records were available. We found no evidence that staff had received specific training in the particular needs of the people living at the home for example conditions of the elderly, terminal illness or continence promotion. The attempts made by the manager to complete training information are acknowledged. However it was apparent that the majority of staff, particularly those most recently employed, are working without having received induction and training in key areas relevant to their work. This places the safety of people living at the home and the staff at significant risk and could lead to health and welfare needs not being met. Edlington Park Care Home DS0000070011.V364350.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, 34, 35 & 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. There is a manager who is experienced and qualified to run the home. The home is not run in the best interests of the people, and people’s health and welfare is not always protected. We acknowledge the hard work by the manager, however overall performances of the site and the company were not ensuring outcomes for people were met, putting people at potential risk of harm. Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 27 EVIDENCE: The provider appointed a new manager in February 2008; he has applied to the Commission to become the registered manager. That application is being processed. The manager had worked very hard since his appointment. There was a high staff turnover at the time of his appointment so he had to recruit senior carers and carers. He therefore has a very inexperienced staff team that are still be to trained, to ensure they are competent in their roles. Resident’s satisfaction surveys were sent out in January 2008, a large number had been returned but it was not clear what had been done with the information and it was not available to the people living at the home or their relatives. It was not clear if their views were listened to and the home run in their best interests. The administrator looks after people’s finances and these have been checked on previous visits, they were not checked on this occasion. However, the administrator told us they are kept up to date and regular checks carried out to ensure people’s financial interests are safeguarded. While reviewing staff training records we looked for attendance at fire drills and practises. During this process it was identified that weekly testing of the home’s fire alarm system had not been carried out. There were gaps from 4 August 2007 to 13 May 2008, when only one of seven zones was tested. We were told that this had been due to the absence of a dedicated maintenance person at the home. Weekly fire extinguisher checks had not been recorded between 7 December and 11 May 2008. This put people at risk of potential harm. Monthly checks of the emergency lighting had not been carried out between December 2007 and May 2008. When checked on 11 May 2008 it was found that most of the exterior lights were out of order and there was no record of what action had been taken. The home’s written fire risk assessment was dated August 2006 with a suggested review date of August 2007. This had not been completed. The emergency contingency plan was in place at time of the visit. The home’s nominated responsible fire person no longer works at the home. People were not protected by the homes polices and procedures. This matter was brought to the attention of the area support manager and these findings have been shared with the Fire Authority. A fire officer had carried out a visit on 28th May 2008 and agreed an action plan with the home’s acting manager. Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 28 The only records of fire drills available to the inspector were dated 9 May 2007. However staff did tell us that they had recently attended a drill. The deputy manager, who could not provide any attendance records, confirmed this. The deputy manager talked about an extensive list of her key responsibilities. These included medications arrangements, care planning, duty rotas, audit, staff supervisions and standards of care delivery. She often works as part of the hands on care team and was clearly struggling to achieve her workload demands. She and several of the staff felt hopeful that the newly appointed manager, who they described as approachable, would help relieve the work pressures and improve things overall. We did not see all the maintenance records the area support manager assured us all maintenance of equipment was up to date, the five-year electrical certificate expired in March 2008 and it was not clear if this had been renewed to ensure people’s safety. The Commission has considered overall performance, lack of improvements and poor outcomes for people throughout this report. The Commission is therefore, in this instance, requiring that the provider supplies information for the purpose of considering the financial viability if the care home. Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 1 X X X X X X 3 STAFFING Standard No Score 27 1 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 1 3 X X 1 Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 30 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 stained and marked floor coverings that were causing an offensive odour, throughout the home must be thoroughly cleaned or replaced. This will make sure 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) Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 31 Timescale for action 01/10/08 2. OP7 15 01/08/08 3. OP8 12 01/08/08 4. OP18 13 Staff must receive training to understand all aspects of abuse and the need to report any incident immediately. This should make sure that issues of abuse are dealt with appropriately. (Revised requirement outstanding from 01/02/08) The numbers of staff on duty and their competence must be reviewed to ensure that the needs of people are met. (Revised requirement outstanding from 01/01/08) A ramp must be provided to the inner courtyard to make it accessible for everyone. (Revised requirement outstanding from 01/03/08) People must be consulted on their preferred mode of dress and grooming to ensure their dignity is upheld. 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. People must be given choice and control over their lives to ensure their needs are met. A wholesome, varied and balanced diet must be provided for people to ensure their nutritional needs are met. Records of concerns and complaints must include full details of any investigation, the actions taken and outcomes to ensure they are acted on. Staff must only be employed when all checks are completed DS0000070011.V364350.R01.S.doc 01/08/08 5. OP27 18 01/08/08 6. OP19 23 01/09/08 7 OP10 12 01/08/08 8. OP12 16 01/08/08 9. 10. OP14 OP15 12 16 01/08/08 01/08/08 11. OP16 22 01/08/08 12. OP29 19 01/08/08 Page 32 Edlington Park Care Home Version 5.2 13. 14. OP3 OP34 14 25 15. OP33 24 16. OP38 23 and suitable references have been obtained. Peoples assessment of needs must be completed and in the plans of care of each person. You must provide the Commission with the following information and documents: • The annual accounts of the home certified by an accountant; • A reference from a bank expressing an opinion about the provider’s financial standing • Information about to the financing and financial resources of the home • Information about associated companies and • A certificate of insurance for the provider in respect of liability, which may be incurred by them in relation to the home. Quality monitoring systems must be maintained to ensure the home is run in the best interests of the people. The requirements from the fire authority must be addressed. 01/08/08 31/07/08 01/08/08 01/08/08 Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 33 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP12 OP13 OP28 Good Practice Recommendations The additional ten hours for an activity co-ordinator should be filled to ensure all people’s needs are met. Links with the local community should be encouraged and people should be given choices to access the community. NVQ training for staff should continue to ensure 50 of care staff achieve NVQ level 2 or above. Edlington Park Care Home DS0000070011.V364350.R01.S.doc Version 5.2 Page 34 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.V364350.R01.S.doc Version 5.2 Page 35 - 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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