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Inspection on 17/02/06 for Ernehale Lodge Care Home

Also see our care home review for Ernehale Lodge Care Home for more information

This inspection was carried out on 17th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Service users have their needs assessed prior to moving to the home. Service users health care needs appear to be addressed by the home and where appropriate or necessary the home seek input from health care professionals. Service users appear to be treated with respect and dignity. The staff at the home supports their right to privacy. Medicines management is generally well organised. It was evident during the inspection that staff appeared to maintain privacy and dignity. When members of staff were showing the inspector around the home, they knocked before they entered service user bedrooms. Service users said staff knocked on their bedroom doors prior to entering. The Inspector observed members of staff with service users in the lounge; it was evident that the staff members had a good rapport with service users. Service users spoken to stated that staff are respectful and polite towards them and maintain their privacy. They also stated that staff are welcoming towards their visitors. The service users spoken to during the inspection confirmed they are happy with issues around privacy and dignity within the home. They have access to a pay phone, which is in the staff room. The home has a welcoming and friendly atmosphere, which was witnessed during the inspection. There was positive interaction between staff, service users and visitors. Throughout the inspection visitors were observed to come and go. Service users spoken to as part of the inspection were able to confirm that visiting times were flexible and there are no restrictions in place. The service users reported they are able to see their visitors in private should they wish to. One service user spoken to stated that she is able to have access to the local community i.e. she goes out with her friends and the home has arranged outside activities including a visit to the canal for those service users wishing to go. The inspector was shown around the home by a member of staff including service user bedrooms, which showed evidence that service users are encouraged to personalise their rooms. Around the home there are photographic displays showing both service user and staff participating in activities both organised within the home and outside including a visit to Trent Canal.

What has improved since the last inspection?

Ernehale is now keeping a record of any complaints made and the action taken to resolve them. Regular formal supervision is provided for all care staff. Window restrictors have been fitted to first floor windows. Picture hooks are now being used to hang pictures. Service users have been asked if they wish to have a lockable bedroom door and where this has been confirmed door -locks have been fitted. Improvement and development of care plans is underway.

What the care home could do better:

An application must be submitted urgently for the acting manager to be registered. The health and safety of service users is not fully promoted and protected and action is identified for the home to address some issues. Because of poor record keeping in relation to recruitment practices, because adult protection protocols were not up to date and that there was evidencethat current protocols had not been followed in one instance indeed followed, improvement is needed to ensure service users are fully protected from abuse and requirements are set in relation to this. There was not sufficient evidence to make the judgement that service users are protected by the home`s recruitment practices. The practice of overall record keeping and incident reporting does not meet the standards or regulations fully. Further work is recommended to consolidate and keep care plans up to date and fully evaluated and there are some areas of medicines management to address also.

CARE HOMES FOR OLDER PEOPLE Ernehale Lodge Care Home 82a Furlong Street Arnold Nottingham NG5 7BP Lead Inspector Jayne Hilton Unannounced Inspection 17th February 2006 10:00 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 Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 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. Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ernehale Lodge Care Home Address 82a Furlong Street Arnold Nottingham NG5 7BP 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) 0115 9670322 0115 8406763 Mr Keith Sidney Dobb Mr Gerald Hudson Care Home 30 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (30), of places Physical disability (2), Terminally ill (3) Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. There must be at least one dementia trained staff member on each shift 18th July 2005 Date of last inspection Brief Description of the Service: Ernehale Lodge is a purpose built home providing care for older people and also pallative care. In addition it has recently been registered to provide care for people with dementia. It is in a residential area of Arnold close to the local amenities and shops. The home is on two floors with a passenger lift between the two levels. On the ground floor there is a dining room and lounge. Leading from the lounge is a patio area with tubs and flower baskets. There are 10 single bedrooms and 10 double bedrooms split between the two floors. There are communal toilets; four on the ground floor and three on the first floor. In addition there are two bathrooms. The home provides 24 hour registered nurse cover and has a range of specialist equipment to meet complex nursing needs. The home has access to a minibus which it uses for service users who wish to have days out. [Please note access to Ernehale is by James St Arnold.] Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulation Inspectors Jayne Hilton and Rehana Rashid carried out the unannounced inspection on 17th February 2006 for duration of four hours. The focus of the inspection was to assess if compliance had been achieved for the requirements set at the previous inspection and to assess any remaining key standards not previously assessed in this inspection year. The methodology used was by sampling care plans of a selection of service users, and by speaking with service users, a relative and staff, examination of records and a part tour of the building. The care and development manager for the Provider was also in attendance for the inspection as she was undertaking a regulation 26 visit that day. Twenty-six service users were in residence on the day of the inspection. What the service does well: Service users have their needs assessed prior to moving to the home. Service users health care needs appear to be addressed by the home and where appropriate or necessary the home seek input from health care professionals. Service users appear to be treated with respect and dignity. The staff at the home supports their right to privacy. Medicines management is generally well organised. It was evident during the inspection that staff appeared to maintain privacy and dignity. When members of staff were showing the inspector around the home, they knocked before they entered service user bedrooms. Service users said staff knocked on their bedroom doors prior to entering. The Inspector observed members of staff with service users in the lounge; it was evident that the staff members had a good rapport with service users. Service users spoken to stated that staff are respectful and polite towards them and maintain their privacy. They also stated that staff are welcoming towards their visitors. The service users spoken to during the inspection confirmed they are happy with issues around privacy and dignity within the home. They have access to a pay phone, which is in the staff room. The home has a welcoming and friendly atmosphere, which was witnessed during the inspection. There was positive interaction between staff, service users and visitors. Throughout the inspection visitors were observed to come and go. Service users spoken to as part of the inspection were able to Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 6 confirm that visiting times were flexible and there are no restrictions in place. The service users reported they are able to see their visitors in private should they wish to. One service user spoken to stated that she is able to have access to the local community i.e. she goes out with her friends and the home has arranged outside activities including a visit to the canal for those service users wishing to go. The inspector was shown around the home by a member of staff including service user bedrooms, which showed evidence that service users are encouraged to personalise their rooms. Around the home there are photographic displays showing both service user and staff participating in activities both organised within the home and outside including a visit to Trent Canal. What has improved since the last inspection? What they could do better: An application must be submitted urgently for the acting manager to be registered. The health and safety of service users is not fully promoted and protected and action is identified for the home to address some issues. Because of poor record keeping in relation to recruitment practices, because adult protection protocols were not up to date and that there was evidence Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 7 that current protocols had not been followed in one instance indeed followed, improvement is needed to ensure service users are fully protected from abuse and requirements are set in relation to this. There was not sufficient evidence to make the judgement that service users are protected by the home’s recruitment practices. The practice of overall record keeping and incident reporting does not meet the standards or regulations fully. Further work is recommended to consolidate and keep care plans up to date and fully evaluated and there are some areas of medicines management to address also. 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. Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 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 Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Service users have their needs assessed prior to moving to the home. EVIDENCE: There is assessment documentation for each service user. Assessment plans now include details of each individuals ability to self medicate. The home is about to introduce a new format for assessments. This new documentation appeared to be comprehensive in their layout and it is planned that it will be used in future when new service users are admitted or reviews carried out. Service users and relatives are involved and signatures obtained. The home does not provide intermediate care. Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Service users health care needs appear to be addressed by the home and where appropriate or necessary the home seek input from health care professionals. Service users appear to be treated with respect and dignity. The staff at the home supports their right to privacy. Medicines management is generally well organised, some aspects require improvement to meet the requirements fully. EVIDENCE: Individual plans of care are in place. Each plan included a section that recorded the action that staff needed to take to meet the needs of the service user, however these were not specific to the identified need on every occasion and did not detail inform staff fully of how they would meet the specific need. The new care plan documentation should address this. Risk assessments were also seen, there was evidence however that both care plans and risk assessments were not being regularly reviewed. Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 11 During the inspection process the Inspector randomly examined the files of two service users, however the files did not contain information on whether or not they had received input from health care services including input from GP or District Nurse. At the time of the inspection this was discussed with the acting manager who advised that progress/communication sheets for each resident are all held in one central file. These communication sheets are dated and signed by the author. After looking at the sheets it was evident that the service users had been receiving input from health care services, which included GP, District Nurse and Dietician. The acting manager has agreed to look at service user files so that they incorporate daily communication sheets. The Acting Manager was further advised to keep a separate communication book or sheet, which provides details of visits, by all health care professionals, to ensure easy reference. The provider wishes it to be recorded that the new care plan documentation has these templates included. Currently this information is recorded on service user daily communication sheets. One service users currently presents challenging behaviour, and it is recommended that the individual care plan contains more detail as to the monitoring and evaluation of the behaviour, possible triggers and what works best in ways to manage the behaviour. The Care and Development manager reported that a procedure for dealing with challenging behaviour is intended. Personal Activity monitors are used in the home and the Care and development manager reported that the company overall has noted a reduction in the incidence of falls, since the implementation of these devices. Improved documentation is recommended regarding their use for individuals and that authorisation for these and the use of bedrails is signed by the relative or representative of the service user. It was evident during the inspection that staff appeared to maintain privacy and dignity. When members of staff were showing the inspector around the home, they knocked before they entered service user bedrooms. Service users said staff knocked on their bedroom doors prior to entering. However one service user stated when she first arrived at the home there had been an incident when a member of staff allegedly walked into her bedroom without knocking. However the service user stated she spoke with the member of staff and since then all staff knock on her bedroom door. The Inspector observed members of staff with service users in the lounge; it was evident that the staff members had a good rapport with service users. Service users spoken to stated that staff are respectful and polite towards them and maintain their privacy. They also stated that staff are welcoming towards their visitors. The service users spoken to during the inspection confirmed they are happy with issues around privacy and dignity within the home. They have access to a pay phone, which is in the staff room. However staff confirmed should the service users need to use the phone, staff leave the room. One service user spoken to stated that when her friend’s telephone she Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 12 is able to take the cordless handset in her room should she require privacy. This particular service user is waiting for a phone line to be installed in her bedroom, the deputy manager has confirmed she has made contact with the phone company several times. The same service user confirmed she receives her personal mail unopened. Members of staff stated some service users are not able to deal with their own correspondences so there is a notice board in the reception area, where messages are left for family members to collect mail on behalf of their relative. A service users relative was visiting whilst the inspection was being carried out, he confirmed he was able to maintain social contact and visit when he wanted to. He said he has a good rapport with the staff and if for any reason he is not happy about something he is able to speak with the manager. The systems in place for Medicines management and clinical waste arrangements were assessed and found to be generally satisfactory. New policies and procedures are being developed in conjunction with the Royal Pharmaceutical guidance for medicine administration in Care Homes. The following areas were identified that require implementation/improvement to meet the standard fully: Photographs should be used with the Medication Administration Record to assist with identification. The room storage temperatures are not being taken and this must be implemented as required by regulation. A sample of staff signatures should be place at the front of the records, of those staff authorised to administer medication. Keys for the treatment room and drugs trolleys are kept together with other office/home keys. It is recommended that keys for medication management are kept separate to other keys. The BNF [British National Formulary] seen in the home was dated 2003. The Care and Development Manager reported that new versions had been purchase recently by the company and would be distributed. A prescription of Paracetomol for one service user had not been signed as given. The matron reported that staff was asking the service users if the medication was required in relation to pain monitoring and therefore not administering the medication for this. The prescription did not state to be given as required and the medication sheet had no indication of refusal code or any other reason for non-administration. Action must be taken to ensure prescriptions are administered as required and referral and consultation made to GP where a change of prescription may be required and that medication record sheets are completed fully. Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 13 Where equipment such as suction machines are borrowed from other homes, the date of last service should be checked before use and kept with the equipment or on a separate record in the home that the equipment is in use. [No evidence was provided for this during the inspection] See also issues re accidents and incidents in Standard 38 of the report. Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14,15 Service users are able to maintain community contact with family, friends and their representatives. Service users are assisted to exercise choice and control over their lives and enjoy their meals. EVIDENCE: The home has a welcoming and friendly atmosphere, which was witnessed during the inspection. There was positive interaction between staff, service users and visitors. Throughout the inspection visitors were observed to come and go. Service users spoken to as part of the inspection were able to confirm that visiting times were flexible and there are no restrictions in place. The service users reported they are able to see their visitors in private should they wish to. One service user spoken to stated that she is able to have access to the local community i.e. she goes out with her friends and the home has arranged outside activities including a visit to the canal for those service users wishing to go. The inspector was shown around the home by a member of staff including service user bedrooms, which showed evidence that service users are encouraged to personalise their rooms. Around the home there are photographic displays showing both service user and staff participating in activities both organised within the home and outside including a visit to Trent Canal. Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 15 The home is going through a process where they have been giving the service users a choice for lockable storage and locks to bedroom doors. During the tour of the premises it was noted by the inspector that this process is taking place as some of the rooms have locks, also some service users have lockable storage in the form of a small box safe. Service users spoken to stated that they have had a choice as to whether or not they wished to have locks fitted to their bedroom doors and if they wanted a safe. Some service users have decided to have locks fitted to their doors. One service user stated she has a key to her room and the manager keeps the master key. Service users where observed during lunch, some staff members interacted more with service users compared to other staff. During lunch time the atmosphere was quiet, with no background entertainment such as a radio. [The provider wishes the inspector to record that the staff keep the dining area calm and quite during mealtimes to assist service users with dementia to remain calm and not harassed and that the issue has been discussed with service users and they have no wish at this time to have background entertainment during their lunch and will be reviewed at resident meetings] The menu examined as part of the inspection process showed during breakfast and teatime residents have a choice, however there appears to be no choice for lunchtime. This was raised with the Acting Manager at the inspection. Service users spoken to report they are able to have an alternative at lunchtime should they not like what’s on the menu. The Inspector had a discussion with the Cook Supervisor who demonstrated she ha good understanding of service user dietary needs. The home is currently catering for a selection of dietary needs including the following diets, diabetic, pureed and vegetarian. Service Users reported they enjoy their meals. Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Service users can be assured their complaints will be listened to and acted upon. The systems in place for recruitment and adult protection protocols need to be improved to ensure service users are fully protected from abuse and requirements are set in relation to this. EVIDENCE: The home has a complaints procedure, this is displayed and each service user and their family receive a copy as part of the admissions process. Records demonstrated that service users and staff were able to make complaints freely and eight complaints had been logged since the previous inspection. Through the examination of the complaints that were documented it was assessed that one complaint constituted a requirement top report under safeguarding adults procedures. Through discussion with the acting manager, it was agreed that the service users social worker be contacted promptly regarding the safeguarding adults issue and for the outcome to be communicated to CSCI. A regulation 37 notifications had not been completed for this particular incident either. Policies were in place for Adult Protection, whistle blowing, restraint and physical intervention. However the Adult protection policy requires some updating to current county reporting and referring procedural guidance and the Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 17 acting manager needs to attend training in relation to Safeguarding Adults Reporting and referral protocols. Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25,26 Service users live in a safe, clean and comfortable environment, which meets their needs. EVIDENCE: Communal areas were fitted with a variety of appropriate seating and furnishings and lighting appear to be in good order. The home has two bathrooms with hoists. In addition there are four communal toilets on the ground floor and three on the first floor. None of the bedrooms have ensuite facilities but have wash hand basins and modern discreet commodes. Service users rooms contain the necessary furnishings and are personalised with pictures and other belongings. The home is undergoing a cycle of re-decoration. Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 19 Radiators are covered and lighting is of a domestic style. Window restrictors are fitted to all first floor windows. One bedroom window was noted to have some damage, from recent incidents of vandalism and therefore requires replacing. The home was clean and free from any mal odours on the day of the inspection. Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29,30 There was not sufficient evidence that service users are protected by the home’s recruitment practices. Staff are trained and competent to do their jobs. EVIDENCE: Evidence was seen that all new members of staff receive induction training from a senior member of staff during their first three shifts. Evidence was also seen of a wide variety of training that was provided to staff including training on dementia care and visual impairment, deafness awareness, food supplements, peg feeding, tissue viability and falls prevention. Health and Safety Training needs to be undertaken by staff and the acting manager reported that this was to be carried out on 1st March 2006. The home has two qualified in house trainers in manual handling. In addition a number of staff are being supported to complete their NVQ training. Abuse training was last provided for staff in 2004, it is recommended that this be updated. The Care and development manager reported that a video has been purchased and workshops will be arranged on this subject. Care of the Dying training records showed no staff had undertaken this topic. Information on staff was sparse. The acting manager reported that staff personal records are held at the head office, however this is not satisfactory Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 21 and even with some information that was faxed through the inspector was unable to assess if the recruitment practices were satisfactory. Through discussion with the Care and Development Manager, it appeared that the necessary recruitment checks are carried out prior to employment of staff, however the present system for evidencing this is unsatisfactory. Extracts from the current guidance for Registered Providers are provide below: 2.3 Good recruitment and vetting: The lessons from the Bichard Inquiry highlight the importance of a robust recruitment process in keeping children and vulnerable adults safe. Good recruitment and vetting requires attention to all of the pre- employment checks including written references, identity and qualifications checks, full employment history as well as the checks undertaken by CRB. In order for us to fulfill our safeguarding role it is essential that during inspection visits CSCI inspectors check that appropriate recruitment and vetting takes place. The standards covering this have been designated as “key standards” ensuring that they will be looked at within each inspection year. 3.11 Storage and Retention Although CRB guidance on some other employment sectors states that Disclosures should be destroyed after 6 months, the guidance states that, for CSCI regulated services, Disclosures should be kept for up to 12 months or more to enable CSCI inspectors to see a sample at the next inspection, one of the legal requirements for retaining Disclosures. CRB have confirmed that where CSCI’s inspection frequencies stipulate a longer interval than 12 months as in the case of boarding schools inspected on a three yearly basis then it is permissible to retain disclosures for this period. The same principle will also apply following any amendments to the regulations governing inspection frequencies that enable CSCI to determine inspection frequencies in relation to risk and quality of service. There are variations within service specific regulations with regard to what specific records are required to be kept in the home. For example, the Care Homes Regulations as amended by The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004 stipulate the following records: SCHEDULE 4 Regulation 17(2) OTHER RECORDS TO BE KEPT IN A CARE HOME 6. A record of all persons employed at the care home, including in respect of each person so employed, including - Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 22 (a) his full name, address, date of birth, qualifications and experience; (b) a copy of his birth certificate and passport; deleted (c) a copy of each reference obtained in respect of him; (d) the dates on which he commences and ceases to be so employed; (e) the position he holds at the care home, the work that he performs and the number of hours for which he is employed each week; (f) correspondence, reports, records of disciplinary action and any other records in relation to his employment. (g) a record of all training undertaken, including induction training This has been problematic where umbrella bodies and corporate providers seek to retain centrally all the Disclosures (and other elements within personnel records). An insistence on the storage of all of these within the care home or children’s home may be impractical due to issues of safe storage and restricting access and the data protection obstacle in relation to CRB disclosures (the Registered Body or Umbrella Body cannot legally photocopy the Disclosure). These issues must be reconciled with the need to enable CSCI inspectors to assess the provider’s practice in the recruitment, selection and retention of staff. CSCI is adopting a proportionate approach that clarifies what must be available in the care home and what can be retained centrally. With the agreement of CSCI, providers who have a centralised HR department should ensure that the information required of records to comply with Schedule 4, paragraphs 6(a), (d), (e) and (g) are made available within the care home. Relevant details can be recorded on a proforma (validated by the registered provider or manager) to allow the inspector to assess the provider’s practice in the recruitment, selection and retention of staff. An example of a pro forma which may be used is attached as Annex 4. Where the provider does not wish to adopt this pro forma or has already developed their own, the minimum expectation with regard to evidence of CRB checks is that on receipt of the Disclosure, the umbrella organisation or corporate body should issue a letter to providers stating : • • • • • • • the name of the person; date of Disclosure; Level of disclosure; Including POCA Check (if requested) Including POVA Check (if requested) Disclosure reference number; Date POVAFirst check was received (if this was sought); and POVAFirst Reference number The Inspector should accept the letter as evidence of the providers meeting the requirement for staff to be CRB checked. Letters (rather than Disclosures) should be kept on file in the home. This will assist Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 23 CSCI inspectors when they sample Disclosures to confirm that employers have followed robust recruitment practices. Subject to written agreement with CSCI (see draft letter - Annex 3), records held under Sections 6(c) & (f) of Schedule 4 for care homes (shown in bold in the above extract from the schedule), could be kept within the provider’s centralised HR department. The agreement with the organisation should set out clear criteria for accessing these records within certain parameters. These would include one or more of the following: i. ii. iii. Records for staff being made available at announced inspections; Agreement that CSCI staff can access records from the central HR department within working hours without notice; and Records to be made available within the care home within a given period of time. In this case, as with any other, storage should conform with CRBs Code of Practice on storage. After the inspection, the Disclosures relating to the service can be destroyed, whether held locally or centrally. Disclosures received post inspection should be kept until the next inspection. 3.9 Checks on staff recruited from abroad Government advice in relation to boarding schools, residential special schools and FE Colleges is that if an applicant has never previously lived in the UK, no purpose will be served by seeking a CRB check on their arrival in this country. The person will not have a criminal record in this country, nor will he or she appear on List 99 or the PoCA List. (For further information see para. 4) For those applicants, agencies should nevertheless ensure that checks in the persons country of origin are made wherever possible, in accordance with the guidance in Annex E of the Guidance Notes for Teacher Employment Businesses and Agencies. It is important to note that this does not apply to other regulated settings where the service specific regulations require that all staff working in the home or service have to be CRB checked including staff recruited from abroad. Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 24 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,37,38 An application has not yet been submitted for the manager to be registered. Quality monitoring systems are in place. Records keeping is not satisfactory. The health and safety of service users is not fully promoted and protected and action is identified for the home to address some issues. EVIDENCE: The acting manager has been in post since July 2005 and an application to register has not been submitted to CSCI to date. An application must be submitted at once to meet with regulation. Quality monitoring is undertaken by means of questionnaires and feedback. A recent questionnaire was sent out to visiting professionals of the home. The results have yet to be consolidated and published, however comments about what improvements are needed were made about the décor of the home. One GP reported that the home was the best nursing home in the area. Regulation Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 25 26 visits are undertaken and copies are sent to CSCI. Health and safety audits are carried out, the quality monitoring and development systems would benefit from some further development but are currently satisfactory. Health and safety training for staff appears to be in hand. Fire safety management was satisfactory. Maintenance and Servicing of equipments was generally up to date. The following areas require attention: The last records for water outlet temperatures held in the home was dated October 2004 and leigionella test dated January 2003. The nurse call service is overdue as last undertaken 4/3/04 There was no evidence that the gas safety test was actually carried out on the date arranged by letter. There was no evidence that the electric circuit safety has been checked [five yearly] Incident records were not completed in respect of the number of incidents of vandalism and nuisance caused by children and youths in the area that had been discussed with the acting manager, neither had these incidents been reported to CSCI under the requirement of Regulation 37. A medication error was recorded in the homes records, but this had not been forwarded to CSCI under Regulation 37. Although it appeared that appropriate action was taken at the time in relation to the service users safety, there was no follow up action documented or what action had been taken to ensure further prevention of incidents of this nature. Accident records were examined and generally well reported, however it was noted that on every occasion where service users had suffered an injury to their face or head, that medical examination by a doctor had not been accessed. Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 3 X 3 3 3 STAFFING Standard No Score 27 X 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X X 1 2 Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 27 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 12,13,17 Requirement Ensure the Safe Management of Medicines in relation to: Ensure the storage temperatures of medicines is taken and documented. Ensure drug errors are reported to CSCI under Regulation 37. Ensure service users are administered medication as prescribed and where changes are needed, full consultation and agreement with the GP is obtained. Where mediation is not given the reason must be appropriately documented on the medication record sheet. Ensure Safeguarding adults referrals are made in line with Nottinghamshire’s agreed referral and reporting protocols. Ensure the issue identified during the inspection is duly reported to the service users social worker for action and the Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 28 Timescale for action 17/03/06 2 OP18 13,17 17/03/06 3 4 OP19 OP29 16,23 7,9,19 outcome reported to CSCI Replace the damaged windowpane in the identified room. Ensure recruitment procedures and practices meet with the requirements, as specified in the report and provide evidence that they do so to CSCI. An application must be submitted to CSCI in relation to the registration of the manager. [Failure to comply may result in the fitness of the provider being questioned.] The Registered person must ensure that records required by regulation to be kept are available for inspection. Ensure notifications required by regulation are made to CSCI. Evidence of the following records must be submitted to CSCI as follows: An up to date Gas Safety certificate. An up to date Electrical circuit safety certificate Evidence that water outlet temperatures are monitored regularly for bedrooms and bathrooms. Evidence that systems are in place for the prevention of legionella 17/03/06 17/03/06 5 OP31 9 17/03/06 6 OP37 17,37 27/02/06 7 8 OP37 OP38 17,37 12,1 3, 16,17 27/02/06 17/04/06 Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 29 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 Refer to Standard OP8OP7 Good Practice Recommendations Ensure care plans are specific to the individuals needs, detail the actions to be taken by staff to meet those needs, are reviewed at least monthly and information about health care needs are consolidated into one central record file. Ensure service users or their representative sign agreements for personal activity monitors and bedrails. Good practice recommendations in medicines management are made as follows: Provide photographs of service users on record sheets Provide a sample of staff signatures of those staff authorised to give medication. Provide an up to date BNF. Separate drugs keys from general keys. Provide evidence of service dates of medical equipment use don the premises such as suction machines. Provide training for managers in Safeguarding Adults protocols Confirm to CSCI when the training for Health and Safety has taken place. Further develop the audit and systems for quality monitoring.[Provide evaluation feedback to service users and supporters of the home] Where service users suffer injury to their head or face, advice should be sought from a medical professional such as a doctor and recorded as such. 2 OP9 3 4 5 6 OP18 OP18 OP33 OP38 Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ernehale Lodge Care Home DS0000026435.V279667.R02.S.doc Version 5.1 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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