Inspection on 16/04/07 for Everley Care Home

This inspection was carried out on 16th April 2007.

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

Other inspections for this house

Everley Care Home 05/11/08

Everley Care Home 13/11/07

Everley Care Home 30/10/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Everley Care Home 15 Lyde Green Halesowen West Midlands B63 2PQ Lead Inspector Mrs Cathy Moore Key Unannounced Inspection 16th April 2007 06:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Everley Care Home DS0000067211.V330370.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. Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Everley Care Home Address 15 Lyde Green Halesowen West Midlands B63 2PQ 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) Care Home 16 Shilpa Jethwa Mr Devshi Jethwa, Mrs Mani Jethwa Category(ies) of Old age, not falling within any other category registration, with number (16) of places Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Three service users in the category of DE(E). This condition will revert back to OP when the placements are terminated. Five service users in the category of PD(E). This condition will revert back to OP when the placements are terminated. 29/01/07 Date of last inspection Brief Description of the Service: Everley Care Home is a detached property located in a residential area between Halesowen and Cradley Heath. The home was extended and converted by previous owners to its present form; a care home providing personal care to a maximum of 16 service users’. The home offers a lounge, dining room, kitchen, laundry and a choice of personal care facilities as it has both a shower and an assisted bath. There are gardens to the rear and car parking space at the front of the property. The home is not located close to shops or other amenities. Since the last inspection the home has been purchased by new owners. The weekly fee for this home is £339 at the present time subject to this years Social Services increase which has yet to be confirmed. Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One regulatory and one pharmacy inspector carried out this unannounced key inspection on one day between 06.30 and 16.45 hours. Prior to the inspection questionnaires were sent to the provider and service users’ relatives for completion with the aim of gaining views about the service from a range of people. Six service user/ relative questionnaires were completed and returned information from these will be referenced in the body of this report. Unfortunately, the provider did not provide her questionnaire until the day of the inspection, which was not fully completed. We carried out the inspection mostly in the lounge and dining room in order for observations to be made about the service given and staff involvement with the service users’. We spoke to most of the service users’ during the day, four in detail. We spoke to four staff. The manager and provider were involved in the inspection throughout the day. We looked at the premises which included; the lounge, dining room, three bedrooms, the bathroom, ground floor toilet, laundry, kitchen and garden. We looked at medication systems and safety and records concerning for example; recruitment, training, assessment of service users’, meals, care planning and activities. What the service does well: We saw information about the home was readily available, displayed within the home including; the new statement of purpose, service user guide and last key inspection report. The new manager and provider are totally committed to improve the home in all aspects. They are interested in their work and have great enthusiasm and drive. Staff observed during the inspection were alert, friendly, polite and engaged with the service users well, giving them time and attention. A high quality new assisted bath is available on the ground floor. We found the homes’ atmosphere to be positive, warm ,welcoming and friendly. During meals times there was continual conversation between service users’ much friendly banter, laughing and joking. Food intake records are detailed and are being completed fully. Service users’ are very much encouraged to maintain links with family and friends. One service user said; “The home is marvellous and the staff are lovely”. Service user and relative questionnaires used asked them to state their views on what the home does well the following comments were made; We feel well satisfied with the service given and are very happy with all aspects of care. Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 6 Provides a homely feel for the residents, for my .. in particular, they leave her alone most of the time as she prefers her own company in the surroundings of her own room most of the time. Provides adequate care for my mother. Choice of meals available is now an option. Look after peoples needs and expectations well. The care home provides a comfortable environment for elderly people. Takes care of my .., keeps him well fed and clean he seems happy and well looked after. What has improved since the last inspection? The changes to this home over the last seven months are dramatic and extremely positive. The new provider and manager give some confidence in terms of improvements made and their professionalism. New crockery has been purchased, a nice white matching set was seen in use. A full time cook ( Monday to Saturday) commenced work two weeks ago. A choice is now given for each meal including lunch, where two hot options are offered. Records are made each day to evidence that choices are given. Better recordings are now being made regarding food and fluid intake. These are some of the best the inspectors have seen. A new call system has been installed throughout the building. A number of bedrooms have been redecorated and have been provided with new furniture. New carpet has been provided in ground floor corridors, the lounge and dining room. The dining room has been repainted. The warped , blistered, wooden surface in the ground floor toilet which has been highlighted during previous inspections has now been made good. This area has been fitted with ceramic type tiles. Staff handovers between shifts have been implemented. I observed night to morning then morning to afternoon handovers which, were comprehensive and informative. Training has been received by staff in a number of subjects and secured/ arranged for others. A system for regular one to one staff supervisions has been put into operation. Schedules for staff and service user meetings have been produced. A service user/ relative meeting was held in January 2007. A regular newsletter is being produced. One for March 2007 has been sent to service users’ and relatives. A suggestion box has been put in place for service users’, relatives and staff to make suggestions or comments if they want to. Dudley MBC protection procedures and a quick reference flow chart concerning any referrals have been issued individually to all staff to give them clear guidelines on what should be done of an allegation or incident of abuse occurs. Staff spoken to told me that they feel that the home has improved as follows; “ Better with the new owners’, better run, more training. The new manager is Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 7 brilliant, home is run in best interests”. “ Things are much better- more training, better for the service users. There are still things to do though. Manager and owner very approachable- open door policy”. “ Good, better especially for the residents’. Its better managed, more organised, staff have lots of training”. “ Things are much better now, I did not realise how bad things were before. Shilpa ( provider) 100 dedicated everything’s a lot better”. What they could do better: This home has been a concern to the Commission for some considerable time. The new providers inherited a lot of unmet requirements and work that needed to be done. However, improvements as mentioned above have been made and are on-going. The providers and staff should congratulate themselves on improvements made so far. Work is still needed in a number of areas to improve outcomes for service users’ and ensure safe practices. Medication systems need some further development and improvement to ensure safety. Care planning processes and review need to be improved upon as does record keeping in areas such as; personal care delivery, risk assessment and admissions processes. Service user involvement and consultation about the care planned and that they receive needs further development and improvement. Of particular concern were the non- reporting of alleged abuse to social services and the Commission and the shortfalls in recruitment processes both areas are potentially placing service users’ at risk. Gaps remain in training but generally there is evidence that this is being addressed. Some fine tuning of recruitment practices is needed to ensure that service users are looked after by staff who have been fully checked and if needed risk assessed. The premises need attention in terms of redecoration. The garden would benefit from a good tidy. Service user and relative questionnaires used asked them to comment on areas where they feel the service could improve the following comments were received; Providing occupational activities outings-shopping Trips out etc. I think a lot of these things are already in the pipeline at the home. Still awaiting the arrival of a cook- meals can still be very hit and miss . More activities would be helpful together with some exercises. Have single rooms for each person not a shared situation as in my .. case, otherwise, I am very happy with everything else at Everley. Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 8 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. Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information about the home was available for prospective service users to look at. Improvements are needed to evidence that service users’ are involved in their assessment of need and that they have a contract and are assured that their needs can be met. EVIDENCE: One of the six completed service user/ relative questionnaires confirmed that they always received enough information about the home before they moved in so that they could decide if it was the right place for them, the remaining five answered usually to the question. Three of three questionnaires confirmed that the home always meets their needs. Three of three confirmed that the home usually meets their needs. I was pleased to be given a service user guide and statement of purpose dated Jan 2007 which showed that these had been reproduced and updated. I saw Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 11 that a copy of the statement of purpose, service user guide and last key inspection report were available by the visitors signing in book and front door. One service user told me. “ I wanted to go into a home because I could not look after myself and did not want to be a burden. My daughter came and looked at this one. I trusted her completely. The home is marvellous and the staff are lovely”. I identified from records, observations and conversation that a number of service users’ recently have been admitted to the home for short stays. I discussed this issue with the manager and provider highlighting some of the potential problems that could occur such as; the impact this turn over of service users’ could have on other ‘ long term’ service users and the need to ensure that assessment and care planning, records for these people must be of a very good standard to ensure that staff are aware of needs and how to care for these people. Although I saw completed terms and conditions documents on file for some existing service users this was not the same for the two new respite admissions, this means these two service users have not been informed in writing about their rights during their stay, how much it will cost and what is and what is not included in the weekly fee. I was very pleased to see written evidence to confirm that an assessment of need had been carried out for the new service users’ but disappointed that there was no evidence to confirm that they had been involved in their assessment process or had been given written confirmation that the home could meet their needs. The manager told me that she had extended one new service users’ trial period as she was unsure if the home could meet her ongoing needs. This is positive as it shows that the manager is being careful about who to admit to ensure that needs can be met and that there will be no bad impact on people already living at the home. Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Shortfalls continue with care plans in terms of content and availability. Health care issues and medication safety need some further improvement and development to ensure needs are met and service users are safe. Generally service users’ feel that they are treated with respect. EVIDENCE: We looked at five care plans, two in more detail and found present systems to be confusing as formats and layouts were differed. Whilst it is acknowledged that a new care planning system is being introduced it would be better for staff if this process had been completed quickly. I saw that old and new care plans were in use. I was told where there were gaps, “Other parts of the care plan are being worked on- or they are in the office- which is locked when the manager is not here”. This not allowing staff access to vital records. I did not see any care plan regarding one service user whose behaviour has changed, someone and who at times displays behaviours that challenge the service. Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 13 I was extremely disappointed to see that no care plan was available for a service user who had been admitted for a short stay. To confirm I asked staff where the care plan was and got mixed messages examples being; “ Its in the office”, “ one has not been done”. Without a care plan being available for this service user means that staff have not got instruction on how to care for herwhich potentially could place her at risk. There was no evidence available to confirm that service users’ or their relatives are being consulted about care plans which means they are not being given the opportunity to say how they want to be cared for. A number of previous requirements have been made regarding care plans it is concerning that these have not to date been met. I was further disappointed to determine from records that one new service user ( who had been in the home for three weeks) had not been weighed on admission and had not had risk assessments carried out. I was concerned to learn that this service user had been admitted to the home after having a fall where she sustained a fracture yet, not even a falls risk assessment had been carried out to prevent further falls. No moving and handling assessment had been carried out either to instruct staff of any moving techniques needed to prevent further damage to the fracture. I was also concerned to see that personal records regarding bathing are not being made properly. Two separate records showed that two service users’ had only one bath since the beginning of April- they stated ‘ Bed wash’. The manager told me that these service users’ have had a bath but it has not been recorded. Feedback from completed service user/ relative questionnaires confirmed the following; As with care plans I found that new methods have been introduced to record health care visits. Whilst I acknowledge that this has been done to improve systems I found it difficult to track what healthcare had been accessed. However, I did see some evidence of chiropody visits, evidence that service users had the flu vaccine last winter and records of a visit by a psychiatrist for one service user which is positive. I was interested to be told by staff about recent eye testing that had been undertaken for service users for example one staff member said; “ They tested everyone’s’ eyes then gave us some training. It was very good they told us about putting dark food on light plates and light food on dark plates so that the service users can see it better. They also told us about conditions such as glaucoma”. I observed during the inspection that a number of service users’ have walking aids an example being; zimmer frames. I saw that these were used by service users’ who needed them meaning that they could walk more safely and be more independent. Medications During the inspection the Acting manager, two senior care assistants and one service user were spoken with. All of the service users medicine charts were looked at. Two service users care plans were looked at regarding medication. Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 14 An undated medicine policy was available, which was accessible to staff. It included information on the receipt, administration and disposal of medication. The acting manager stated that ‘ the policy had been reviewed and checked with the help of the supplying pharmacy’, however it was not detailed regarding disposal of medication or for the safe storage and recording of controlled drugs. All medication storage was seen. Medication was generally secure and locked. Some creams and ointments were stored next to tablets and liquids instead of separately. A controlled drug cabinet was secured to a solid wall for safety and security. There was a lockable container available for the safe storage of medication requiring refrigeration, however it was not large enough for the safe storage of eye drops and syrups. Eye drops for two named service users were not safely secured in the domestic kitchen refrigerator. The registered provider stated that a ‘separate refrigerator is to be purchased soon’. The trained care staff team have received training from the new supplying pharmacy on the use of the new monitored dosage system, which is used to supply and administer medication to the service users. There was an up to date signature and initial list of the trained care staff team who administer medication to the service users. The acting manager collected the prescriptions from all of the GP practices to check the order before sending them to the pharmacy. The majority of the medicine charts were pre-printed by the supplying pharmacy. They were clear and contained full directions to administer the medicines. Overall the records were well documented with a signature for administration of a medicine or a suitable code recorded if medicine had not been given for any reason. When the directions on the medicine chart stated ‘one or two tablets’ it was noted that some staff were not always recording the actual quantity of medication given. Hand written charts completed by members of staff in the home were not always checked and signed to ensure accuracy of information. For example, the medicine chart for one service user recently admitted to the home for respite care, did not record the service users date of birth, address, GP name, allergies, and there was no month or year recorded on the chart. Also one of the strengths of a medication was incorrectly transcribed onto the medicine chart, which had not been noticed by the care staff team. Directions for the administration of eye drops did not state which eye or eyes the drops were indicated for or the amount of drops to be administered. The receipt of medicine was recorded and the date of opening on the original container (box or bottle) was recorded. There was a disposal record available at the inspection. These records helped to check that medication had been given to service users as prescribed by the GP. It was noted that there was no Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 15 record for the receipt of medication for one service user recently admitted for a respite stay. Some medication audits were not accurate from the available records. The preparation and administration of medication to service users was observed. One of the senior care staff team took the locked medicine trolley into the lounge to administer medication. The medicine trolley was able to move around the home to ensure that all service users received their medication safely. Two care plans were seen together with their medicine charts. The acting manager stated that ‘none of the service users self medicated’ and she explained that the care plans were new and were in the process of being updated. The first care plan documented some of the service users medication but it was not a complete or current list. The acting manager said that at the time of the service users admission into the home the medication was brought in a plastic bag with no written documentation of current medication. The acting manager stated that she had requested an immediate medication review with a GP. This shows that management ensure the safe administration of medication by contacting a healthcare professional when necessary. There was no written evidence of this available in the care plan. The second care plan documented all of the service users current medication requirements. The care plan stated ‘Does the service user wish to self medicate’ and the response ‘no’ had been circled. The service user was spoken to about their medication and they said ‘I can do my own inhaler very well. I have said let me do it but it is too much bother to argue with them’. The care plan did not document a self-medication assessment and did not show that the service user had been involved in the decision to allow staff to administer medication. I was very pleased to see that the preferred name for each service user had been determined and recorded on their personal file. One staff member told me “.. is her proper name but she likes to be called..”. A service user told me; “ My name is.. but I like to be called..”. I heard staff calling service users by their preferred names. I observed staff / service users interaction during the inspection. I heard staff speaking to service users’ they were polite and friendly. One issue I raised with staff and management was that of confidentiality in that a staff shift hand over was started but this was done in the dining room where two service users were sitting which could mean that they could hear personal information about other service users’ which is not appropriate. Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 16 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users find the lifestyle in the home matches their expectations in terms of daily routines, family contacts and choice and control, further development is needed to ensure that social activities provided meets their individual needs. EVIDENCE: When I arrived at the home at 06.30 two service users were up and sat in the dining room. I detected that these two service users’ had some poor memory. I asked them if they liked getting up this early, both indicated that they did not but did not know what time it was. I asked the night carer about the rising times for the two service users’ she told me; “ They were both up out of bed. I always ask people if they are awake if they would like to get up or if they would like to go back to bed- I would never get anyone up unless they told me they wanted to”. I asked the owner about rising times for service users and was told the same. I spoke with another service user who got up shortly after I arrived at the home. She told me; “ I have always got up early, when I was younger I worked in a paper shop and had to start work at 5 so I am used to it. Once I wake, I like to get up”. Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 17 I looked at records and was pleased to see that the preferred daily routines including rising and retiring times had been recorded for each service userincluding the two spoken to first. I saw from reading records and talking to staff and management that development is still needed regarding activity provision in terms of its regular provision and recording of what has been offered. However, it was also clear that staff are trying to improve in this area. One staff member told me, “ More for the residents to do like entertainment”. Another staff member told me” Easter, we had a Easter bonnet competition. The service users helped decorate the hats with chickens- it was packed here with families and we had a singer. The residents loved it, it was really good”, this event was confirmed by a service user who stated what a good time everyone had. The owner told me; “ I am allocating a staff member extra hours to do activities. These will be carried out in the afternoons”. I was pleased to see one service user reading a morning daily newspaper. It is clear that the home encourages service users to maintain contact with family. I saw one service user going out with her family. Another service user told me; “ My daughter comes to see me often”. Bedrooms I viewed held a range of personal belongings service users have brought in from their homes’ to personalise their rooms. It is extremely positive that a full time cook has started work at the home, which should improve meal provision. She told me; “ I work Monday to Saturday. I have worked in a home before as a cook. I enjoy my job. I like to see people enjoy their food”. I saw written evidence to confirm that the dietary likes and dislikes of the service users’ have been established and that the cook is in the process of producing new ‘ summer’ menus. Service users’ and staff confirmed that everyday some fresh fruit is cut up and taken around/ offered to all service users. One service user I spoke to has a bowel complaint. She told me; I cannot eat anything with skin or pips in. The staff are very good, they know what I can and can not eat”. I was disappointed in that the service users I asked, did not know what was for lunch that day. Staff had forgotten to complete the board in the dining room. However, I did see written evidence to prove that they had been given a choice of gammon or fish. I also heard staff asking service users individually what they would like for breakfast. I observed part of the breakfast time. One service user had cereal and toast. Others had sandwiches of bacon and tomato or sausage. The main meal of the day was gammon or fish. The meals I saw were of generous portions, well presented and colourful with peas and carrots. One service user told me; “ The food is always good” another said; “ The food is marvellous”. It was positive to hear continual conversation in the dining room between service users, friendly banter and laughing. Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 18 I saw that food intake charts are of a good standard. They are being consistently completed detailing times food and drink are taken and even what type of milk is used in the tea such as semi-skimmed. Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users’ are confident that their complaints will be listened to. Processes concerning the management and reporting of allegations are inadequate putting service users’ at risk. EVIDENCE: The Commission about the home has received no complaints and no complaints have been received by the home. I was provided with a copy of the homes updated complaints procedure dated 8/12/06. This had a 28 day deadline for responding to complaints and contact details for both the Commission and the Parliamentary Ombudsman which is positive. I did note however, that this new complaints procedure has only been produced in writing, which may make it difficult to understand for people with poor eyesight or dementia. Five of the six completed service user questionnaire confirmed that they know how to make a complaint the other one could not remember. Four of the six confirmed that if they raise concerns they are always responded to appropriately, two answered usually to this question. I was pleased when I read the relative/ service user meeting minutes to see that complaints processes had been discussed. An incident occurred during the inspection which I did not observe where one service user was being verbally aggressive to staff. I saw that the staff member following this incident recorded in detail what had happened. I also saw written evidence to confirm that the home has referred this service users’ Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 20 behaviour to his doctor. I did not see however, a care plan for staff to follow to inform them fully of triggers that may start this behaviour or how to manage it. It is very positive that all staff have been provided with a copy of Dudley Councils protection procedures and a quick reference flow chart to accompany these. I saw that all staff but one have signed a sheet to confirm that they have received these procedures. Past requirements have been made about the need to report any issues of concern to the relevant agencies. I was concerned when I read the following in a service users’ daily record; 18.3.07 “ Agency shouted at .. due to her coming out of the toilet with her pants down. … very upset and I told the agency not to talk to .. like that as she is confused”. Although the manager told me that she had rung the agency to tell them what had happened and not to send this staff member again there were no records of this. Further, no report was made to social services or the Commission. Similarly, a service user made an allegation of abuse on 2.4.07 and this was not referred via the proper procedures to social services or to the CSCI potentially placing her at further risk and other service users’ at risk. Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 21 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): 19,25,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ live in an environment which is comfortable and clean. Work is needed regarding redecorating and replacement of items and attention needed regarding water temperatures. EVIDENCE: Since the new provider has owned the home improvements have been made. I saw that new carpet has been fitted in the ground floor corridors and living areas making these areas feel fresh and bright. The dining room has been repainted. A number of bedrooms have been redecorated and provided with new carpets. I saw three bedrooms. These looked fresh and bright and had been provided with new furniture. I discussed with the provider the need for her to ensure that bedrooms are to service users satisfaction regarding what is provided in them and that an assessment against the items listed in standard 24 should be carried out with the involvement of each service user. Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 22 I saw that a new wardrobe in one service users’ bedroom was not secured. The new owner told me ; “ We will get that done as soon as possible.” The provider told me of plans she has for the premises, including work to the garden. I saw that the garden is in need of a good tidy. Problems have occurred in the past regarding the call system. To address this I saw that a complete new call system has been installed throughout the home. I saw from records that water temperatures are not always as they should be. For example one temperature was only 29°c when it should be at least 38°c, I also saw that one temperature was 49°c when it should be no higher than 43°c. The provider told me that she has had an engineer look at the system. Further assessment is needed to solve the water temperature problem. Infection control processes have improved since the new owner has had the home. I found it very positive to learn that all staff have received infection control training. I saw that he warped wooden surface in the ground floor toilet has been remedied by the use of ceramic tiles and I saw that the manager has obtained information on common infectious diseases. Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor . This judgement has been made using available evidence including a visit to this service. Service users’ needs are met by the number of staff provide however, recruitment practices are not safe and sound, potentially placing service users’ at risk. EVIDENCE: It is pleasing to see that the new provider is maintaining staffing levels as required by the Commission. From observation and records it confirmed that three care staff are being provided during all waking hours and two waking staff throughout the night. During business hours and other times the manager and provider are on site. I saw that there was also a cleaner and cook on duty. As the inspection started at 06.30 I was fortunate as I was able to speak to the night staff, one of whom was provided by an agency. The permanent night carer was very pleasant and friendly and clearly knew about the running of the home both for nights and days. I was concerned when going off duty at 07.30 hours she said; “ I’ll see you and 1 o clock”. The provider confirmed that this night carer was returning at 1 o clock to do an afternoon shift. The issue of staff working excess hours, a night followed by a day shift and the safety implications was raised with the previous owners by means of a serious concern letter. I observed staff during the inspection. They were supportive to each other, were friendly and polite to the service users. I heard many pleasant verbal Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 24 exchanges between staff and the service users. I saw service users confidently approaching staff with requests or to ask them questions. One service user said; “ The staff are wonderful”. I looked at records concerning recruitment. Although improvements have been made such as; evidence of a Criminal Records Bureau ( CRB) on file for all staff, I identified shortfalls in processes which could potentially place service users at risk as follows; There was no reference from the previous ‘care’ provider for one staff member. I saw written evidence that the agency providing the night carer had checked her against the ( Protection Of Vulnerable Adults) POVA list but her records did not confirm whether or not her CRB check was clear or not which could place service users’ at risk . One staff member had highlighted that she had past convictions. Although it was confirmed later that she had completed this wrongly, it had not been picked up at application stage. I noted that the last two carers to be employed had started on a POVA list check before their CRB had been received yet no action had been taken to prevent any risk to service users’ such as; a named supervisor or risk assessment, in fact it was one of these staff who had highlighted that they had a past conviction that was not noticed or explored. A number of staff have achieved NVQ level 2 or above. The overall attainment level for this award is nearly 50 which is positive. Although I saw evidence to suggest that staff are working to specified induction packages there was no evidence to confirm initial induction processes. I was pleased however, when the agency staff member told me; “ The staff showed me around, told me about the fire procedures and how to use the new call system”. Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is acting in her present role. Staff confirm that under her leadership the home is better and more organised. Staff training has improved and developments have been made with quality assurance processes. However, on-going improvements are needed to ensure that progress and improvement continues particularly in the area of the management of service user finances to reduce risk to service users’. EVIDENCE: A new acting manager has been appointed. Conclusion with the processes with the previous manager is needed before firm plans can be made for the future management of the home. Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 26 Staff spoken to confirmed that; “ Things are better, more organised.” And that they did not realise how bad things were before”. Quality assurance processes are being developed. A suggestions box has been made available to service users’, staff and visitors which is good as it gives them extra opportunities to make their views known and offer new ideas. Schedules for staff and service user meetings have been produced and a service user/ relative meeting was held in January 07 with the aim of giving information and for them to discuss any issues. However, further development is needed to ensure that all service users where they want to are given the opportunity to be involved in the running of the home or give their views of satisfaction or other. I checked three service users’ monies held by the home in safe keeping. I saw that he actual money was correct against the standing balance, however, records were not totally accurate. I saw three receipts for one service user with three different dates, yet only one record of expenditure on one date was recorded. This system of recording money transactions was not accurate and therefore open to error. It is pleasing that a schedule for staff supervisions has been produced in order for supervisions to be received on a regular basis. Records show that the majority of staff have now received some formal one to one supervision which is positive. Staff training has improved. A training matrix has been produced in order for the manager to track the training needs of all staff. I saw records to confirm that staff for example; received fire training in April 2007, infection control in Feb or March 2007 and moving and handling in February 2007. The manager told me that she will in future ensure that all training is up to date. I looked at health and safety records and saw that valid service certificates were on file for the following; emergency lighting, gas landlords safety certificate, fire alarm system and fire fighting equipment which is positive as this increases service user safety. I did not see a service certificate for the stair lift which could be potentially dangerous. A new cook has been employed within the last two weeks, which is good, as she can maintain food and health and safety within the kitchen. I saw records to confirm that fridge and freezer temperatures are satisfactory which means that food safety is increased. However, there were no hot food temperatures for the month of April 2007 and a number of short life products such as sauces had not been date labelled or they were still in the fridge well after they should have been according to their opening date therefore putting service users at risk. Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 27 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 2 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 2 x x x x x 2 3 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 2 3 x 2 Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14(1)(a) Requirement The registered persons and manager must ensure; That evidence is available to demonstrate that residents’ or their chosen representatives have been involved in their assessment of need process and concur with the outcomes of such. Timescales of 4/10/05 , 25/07/06 and 20/11/06 not fully met. 2 OP2 4 The registered provider must ensure that a contract or terms and conditions document is issued to each service user on admission ( this to include those accessing respite care). The registered persons and manager must ensure that each prospective/ new resident is given written acknowledgement that their needs will be met. Timescales of 07/07/06 and 20/11/06 not met. Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 29 Timescale for action 01/05/07 01/05/07 3 OP4 14(1)(d) 01/05/07 4 OP4 14(1)(a)1 5(1) The registered person and manager must not offer a place/ admit any new residents to the home who have needs which fall outside of the homes’ categories of registration. And If a residents needs change to the extent that their needs are difficult to meet then a decision must be made about the continuing placement of the resident. The registered person was informed of this during the inspection regarding NW. The registered providers and manager must ensure that all needs are included in the residents care plans including their physical, emotional, psychological, medical, social and recreational needs. Each care plan must be reviewed at least monthly or earlier if changes occur. Timescales of 01/05/05, 01/11/05, 26/07/06 and 01/12/06 not fully met. This to include issues such as fragile skin an area identified in one service users care plan. The registered providers and manager must ensure that a short term care plan is produced for each resident if they become ill for example; have a urine infection or chest infection. Timescales of 20/07/06 and 25/11/06 not fully met. (R behaviour) 26/04/07 5 OP7 15(1)15 (2)(b) 01/05/07 6 OP7 15(1)15 (2)(b) 10/05/07 Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 30 7 OP7 15(1)(a) A care plan must be produced for 26/04/07 each service user as near to their admission as possible. This was discussed with the provider and manager during the inspection. The registered providers and manager must ensure that enhanced records of all doctors visits are made detailing the outcome of the assessment/consultation. Timescales of 20/07/06 and 30/11/07 not fully met. 28/04/07 8 OP8 12(1)(a) 9 OP8 12(1)(a) The registered providers and manager must ensure that records are made each day of all personal care delivered to each resident; shaves, nails, teeth etc. This to include baths. Timescales of 20/07/06 25/07/06 and 30/11/06 not fully met. 28/04/07 10 OP8 12(1)(a)1 3(4)(c) The registered persons and manager must ensure that all residents are weighed on admission Timescale of 30/11/07 not fully met. 28/04/07 11 OP8 12(1)(a) 13(4)( c) The registered provider must ensure that a full range of risk assessment ( tissue viability, nutritional, falls risk, moving and handling) are undertaken on admission for each service userincluding those on respite stays. 28/04/07 Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 31 12 OP9 13(2) The registered persons and manager must ensure that there is a written policy and procedure for the receipt, recording, storage, handling and safe administration and disposal of medication which accurately reflects how medicine is controlled and handled. Timescale of 30/11/06 not fully met. The registered persons and manager must ensure that the receipt of medication is recorded and documented. Timescale of 30/11/06 not fully met. The registered persons and manager must ensure that all medications requiring refrigeration are stored in a lockable container in the refrigerator or a dedicated secure and lockable refrigerator must be obtained. Timescale of 30/11/06 not fully met. The registered provider must ensure that creams and ointments are stored separately from tablets and liquid medications to prevent possible cross contamination. The registered provider must ensure that staff record the quality of medication administered. The registered provider must ensure that all contacts with healthcare professionals in relation to medication issues are available in the individual care plans. DS0000067211.V330370.R01.S.doc 01/06/07 13 OP9 13(2) 16/05/07 14 OP9 13(2) 16/05/07 15 OP9 13(2) 01/05/07 16 OP9 13(2) 28/04/07 17 OP9 13(2) 01/05/07 Everley Care Home Version 5.2 Page 32 18 OP9 13(2) The registered provider must ensure that there is a record available to demonstrate that service users’ are involved in their self medication assessments. The registered provider and manager must ensure that an activities co-ordinator ( dedicated staff hours) is employed no less than 15 hours per week or one staff member is allocated this many hours per week solely to provide activity provision. Timescales of 25/07/06 and 01/01/07 not fully met. The registered person must ensure that concise records are made to evidence each service users’ activity participation. The registered person and manager must; Produce the complaints procedure in a format that is appropriate to all residents’ and relatives. Timescales of 15/11/05, 10/08/06 and 15/12/06 not met. A complaints procedure has been produced but in average sized print and writing only. 01/05/07 19 OP12 12(2)(m) (n)18(1)( a) 17/05/07 20 OP12 17(2) 01/05/07 21 OP16 22(2) 01/06/07 22 OP18 17(2) The registered persons and manager must ensure that robust records be maintained in respect of all residents money held in safe keeping along with official receipts of any transactions. DS0000067211.V330370.R01.S.doc 28/04/07 Everley Care Home Version 5.2 Page 33 Timescales of 11/07/06 and 30/10/06 not fully met. This to include two signatures for each transaction and recordings for each transaction to match dates and amount spent on receipts. 23 OP18 13(6) The registered persons and manager must ensure that all staff receive the following training that is delivered by a competent and suitably trained person; Violence and aggression and physical intervention. Timescale of 15/12/06 not met. 24 OP18 13(6) The registered persons and manager must ensure that any incidents of aggression/ violence/abuse/concern be reported immediately to the applicable Social Services department and the CSCI. Timescale of 30/10/06 not fully met. A concern letter was issued to this effect. 25 OP19 16,23. The registered persons and manager must produce a routine maintenance programme complete with timescales this to include the following; The redecoration in the downstairs corridor. The replacement of the stair carpet. 01/07/07 21/04/07 15/06/07 Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 34 The replacement of the stained chair in the dining room. Timescales of 01/11/05, 15/07/06 and 10/01/07 not met. This also to include the replacement of dining room chairs as they are all stained and are well past their best. The paint work in all corridors, landings is repainted this to include skirting boards and door frames. 26 OP25 13(4)(a) The registered persons and manager must ensure that the hot water from each hot water outlet throughout the home does not exceed 43oC. Evidence that this has been addressed must be provided to the CSCI. Timescale of 01/11/06 not always being met. 27 OP26 13(2)23 (2)(d) The registered persons and manager must ensure that sure that the kitchen mop and bucket are not stored in the laundry. The registered persons must provide the CSCI with a written proposal concerning the appointment of a senior/ deputy/ floor manager. The registered provider must ensure that staff, do not work, excessive hours for example; a night shift followed by an afternoon shift. DS0000067211.V330370.R01.S.doc 25/04/07 25/04/07 28 OP27 18(1)(a) 17/05/07 29 OP27 18(1)(a) 25/04/07 Everley Care Home Version 5.2 Page 35 30 OP29 19(5)(c) This issue was raised and discussed during the inspection. The registered providers and manager must ensure that a health declaration form completed by all staff. Timescales of 30/01/05, 10/11/05 and 26/07/06 not fully met. 01/05/07 31 OP29 17(2)19 (1) 19(311) The registered persons and manager must ensure that all staff files ( before they are employed contain all of the required information as per Regulations 17 and 19. Timescales of 15/02/05, 01/05/05, 04/10/05, 03/07/06, 30/10/07 not fully met. You must not allow any staff member to commence employment unless you have undertaken all of the required recruitment checks and have received all of the required documents stated in Regulations 17(2), 19(1)(a)(b)( c) and 19(7)(8)(9)(10)(11). . A concern letter was issued to this effect. 21/04/07 32 OP29 19(9)(10) (11) The registered persons and manager must if they decide to allow a staff member to commence employment on a POVA first ( which must only in ‘exceptional circumstances’) ensure that all requirements detailed within Regulation 19(9)(10)(11) have been met and the CSCI have been informed. 01/05/07 Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 36 Timescale of 30/10/06 not fully met. 33 OP29 19 The registered persons must have evidence provided to show that agency staff have all the required training; and clear written evidence that a POVA list check was undertaken with their CRB and whether or not the CRB/ POVA list check was clear. The registered person and manager must ensure that; A current/ up to date training plan is on each staff members file. Timescales of 26/08/06 and 01/01/07 not met. 35 OP33 24(1)(2) (3) The registered providers and manager must implement a suitable quality assurance/monitoring system preferably being one that is professionally recognised. Timescales of 01/03/05, 01/06/05, 01/12/05 and 01/08/06 not fully met. The registered persons and manager must ensure that all staff are aware of and are familiar with all policies and procedures relevant to them. This must be evidenced by staff signing to confirm that these have been read and that they understand their content. Evidence was available to confirm that work to meet this requirement is in progress. 37 OP38 13(4)(a) 13(4)(c) The registered person and 01/05/07 manager must ensure that daily bedrail checks are undertaken by DS0000067211.V330370.R01.S.doc Version 5.2 Page 37 25/04/07 34 OP30 18(1)(a) 01/07/07 01/07/07 36 OP37 17(2) 01/06/07 Everley Care Home a competent person, that a record is made of what checks are undertaken and that accurate records are made. Timescale of 20/11/06 not fully met. 38 OP38 23(2) The registered provider must ensure that; All short life foods such as sauces are date labelled when opened. Once opened and dated they are discarded within the timescale set in the manufacturers instructions. Hot food temperatures are taken and recorded at each meal. 30/04/07 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 OP9 Good Practice Recommendations It is strongly recommended that any hand written medication charts are double checked and signed by a second member of staff to agree that the medication details recorded are correct. It is recommended that the controlled drug cabinet is bolted to a solid wall for safety and security. The registered persons and manager should seriously consider asking for abuse awareness training ( for all staff) from the Social Services training department at Parke’s Hall. 2 3 OP9 OP18 Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Everley Care Home DS0000067211.V330370.R01.S.doc Version 5.2 Page 39 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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