Inspection on 30/10/06 for Everley Care Home

This inspection was carried out on 30th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 16/04/07

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 Unannounced Inspection 30th October 2006 07:40 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.V316112.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.V316112.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) Shilpa Jethwa Mr Devshi Jethwa, Mrs Mani Jethwa Ms Michelle Louise Edwards Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Everley Care Home DS0000067211.V316112.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. 26 June 2006 Date of last inspection Brief Description of the Service: Everley Care Home is a detached property located in a residential area on the border of 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 residents. 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. Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on one day between 07.40 and 18.40 hours by two inspectors. A pharmacy inspector also accompanied the two inspectors and assessed the medication and medication systems. The inspection looked at the premises; lounge, dining room, a number of bedrooms, kitchen, bathroom and toilets. Four resident files were looked at to include their assessment information, care plans, daily notes and risk assessments. Records were looked at regarding maintenance, servicing of equipment, health and safety and quality assurance. Three relatives, six residents and three staff were spoken to. The new owner was involved in the inspection process. What the service does well: What has improved since the last inspection? Staffing levels have increased from 2 to 3 care staff during all waking hours. Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 6 A consultant was used by the home to implement and improve risk assessments, care plans and other documents. The home has been purchased by new owners who have a vested interest to improve the home and it’s overall functioning. Staff and relatives already feel that the new owners have improved the home by being on site everyday and monitoring it’s functioning. One staff member said; “ Things are very, very, very much better, they take an interest”. One resident without prompting in any way said;” The new owners are very nice, very friendly” and a relative said; “ I feel that the new owners will make a difference”. What they could do better: It must be acknowledged that the new owners only purchased the home approximately two months ago and are trying to improve all of its functioning. However, they were aware when they purchased the home that it was failing significantly and improvement to address the homes poor performance and reduce risk to the residents is needed quickly. Although improvement had been made in some areas concerns in other areas have been identified and the home continues to fail to meet a high proportion of the National Minimum Standards for Older People and breach a high proportion of the Care Home Regulations 2001. Areas of concern identified during this inspection were the delay in seeking a second doctor’s assessment when a resident deteriorated, unreported aggression from residents to two other frail residents, recruitment checking processes, food provision, some health and safety aspects and recording of information. Medication systems, if not approved and effective, pose a risk to all residents. A number of concerns were identified with medication processes as follows; the medication policy must be updated and reviewed to reflect how medications are controlled and handled and to make sure that service users medications are looked after safely. All trained staff who are involved with medication must be kept up to date with the procedures and policy and understand all aspects of medication control and handling. Systems for checking that medication has been given to the service users as prescribed by a GP must be implemented. The effectiveness of the management of the home continues to be a concern based on this and previous inspections and must be addressed. The home has a high number of unmet requirements from previous inspections along with others made following this inspection which must all be met quickly. Radical improvements are needed within short timescales to prevent the Commission taking further action which could include serious enforcement action. The new registered person for the home has been made fully aware of this. Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 7 Concern letters have been issued by the Commission and some issues referred to Social Services due to findings from this inspection. 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.V316112.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Prospective service users are not all being provided with sufficient information to enable them to make the decision if the home will or will not be suitable for them. Assessment of need processes need development and improvement to ensure that only service users whose needs can be met by the home are offered a place. Service users are moving into the home without being assured that their needs can be met. EVIDENCE: The new owner said that; “The homes statement of purpose and service users guide have been reviewed”. However, there were not updated versions Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 10 available in the home. The service user guide seen in one resident’s bedroom was the same as that in circulation when the former owners had the home and still made reference to them. One staff member and one relative confirmed that they had not seen the homes’ inspection reports although copy was under the table where the visitors signing in book is located. Actions must be taken to ensure that all staff and relatives are actively encouraged to read the inspection reports and know exactly where they can be found. Although assessment of need processes have improved in terms of recording. It was seen that the latest resident to be admitted had not signed their assessment of need documentation to confirm that they were aware of the process and had been involved. Requirements have been made previously regarding new admissions being admitted to the home having needs which fall outside of the homes registration categories, it was a concern to identify during this inspection that at least one resident who has been admitted recently possibly has a primary need of mental disorder, care which the home is not registered to provide. And again, although previous requirements have been made there was no evidence available to demonstrate that one new resident had been given written assurance by the home that her needs could be met. Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans need further development to ensure that all and changed needs are included. Health and personal care needs further development to ensure that service users health and personal care needs are met. Medication systems need further development and improvement as at the present time they are placing service users at risk’ Fine tuning is needed to ensure that the home fully upholds each service users rights to be treated with respect and dignity. EVIDENCE: It is pleasing that care plans have improved since the last inspection. However, shortfalls concerning new issues and past requirements made were still Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 12 identified. There was little evidence to show that (AT’s) care plan had been adequately updated when she deteriorated and no short term care plan had been produced when one resident had been suspected of having a urine infection. It is positive that risk assessment processes have also improved since the last inspection however, there was insufficient evidence to confirm that where residents have been assessed as being at risk nutritionally that these concerns are being referred to appropriate agencies or that staff are trying to obtain advice on how to deal with these risks or needs an example being; weight loss and soft diets. Further, there was a lack of recording of situations about changes in residents’ conditions and outcomes. For example; one resident was suspected of having a urine infection. The home rightly so, called the doctor and a urine specimen was sent for testing. However, the outcome of this testwhich was in fact negative for infection- had not been recorded. Another concern regarding care was identified as follows; resident (AT) deteriorated between the doctor being called on 28 October 2006 and the morning of the 29 October 2006. Yet there was a delay in requesting another doctors visit. Records described this deterioration as; 29/10/06 7-1 ‘ A remains poorly urine very concentrated fluids pushed taken well, poor diet continues to be nursed in bed. Remains hot please continue to monitor’. 29/10/06 8pm A still remains the same refusing all drinks, please encourage fluids. 9.15-7 A monitored closely- deteriorated during the night chest very bubbly- refusing fluids temp 41 dehydrated. Out of hours Dr contacted (no time was recorded- told verbally by staff member DW that this was 04.15) requested another GP visit - Dr arrived given a good examination would like to admit A to hospital very poorly pneumonia. A to be taken to emergency assessment unit at Russells Hall. Rang requiring more information and advice this given. A very poorly’. A fluid balance chart was started for A on 29/10/06 the following was recorded; 8am tea 100, 9.30 juice 200, 10.30 juice 150,11.00 water 100 mls, 11.30 water 100 mls, 12.00 juice 200 mls, 2.00 juice 100 mls, 4.00 chocolate 100 mls, 5pm refused, 6.30 refused any fluids, 10pm juice 100mls, 12pm sleeping- no further fluid intake records were made. It is questionable that a second doctors’ visit should have been requested at least at 6.30 on 29 October when A had refused fluids twice. Positive comments were received from relatives about personal/ medical care provided by the home one relative said;” The senior gets her the doctor. Staff tell us when she needs the doctor”. Another relative said; “ Staff always let me know if Mum is not well or if they have had to call the doctor”. She also added;” Staff give her lots of attention, she always looks comfortable”. Service users medicines are prepared and supplied by the pharmacy in a ‘Nomad’ cassette. The cassettes are stored in a locked medicine trolley, which is secured to a solid wall in the dining room. A trained member of staff administers service users medicines directly from the medicine trolley, which can be moved around the home. The morning administration of medication was observed. The member of staff administered Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 13 all service users medication with care and gently encouraged service users to take their medication. If a service user refused the medication this was correctly recorded on the medication administration record (MAR) chart. Information relating to service users medicines was recorded in the care plans. For example, one care plan detailed a change in medication requirements made by the General Practitioner during a recent visit. An up to date medicine resource book (British National Formulary - March 2006) was available in the medicine cupboard. This ensures that trained staff have access to current medicine details and can check doses and side effects of medicines if necessary. A controlled drug (CD) cabinet had been obtained and installed since the previous inspection. It met the Misuse of Drugs (Safe Custody) Regulations 1973. This ensures that service users CD medicines are stored in a safe and secure cabinet. A Controlled Drug Register (CDR) had been obtained since the previous inspection and was being used to record service users CD medicine requirements. This ensures that there is a detailed record of the administration of CD medication to service users. A small locked container was being used to store medicines that required refrigeration. It was stored in the kitchen refrigerator. The container was not adequate to safely store all refrigerated medication. For example, there was a bottle of Amoxil syrup stored in the door of the refrigerator, which was not locked or secure. External preparations (for example, creams and ointments) were stored separately from internal medicines (for example, tablets and liquid medicine). This ensures that service users medicines are stored correctly. The medicine policy did not reflect the control and handling of medication in the home and did not contain detailed information on the receipt, administration, disposal, storage and documentation of medicine. The policy available was a ‘Mulberry House’ document, which is a ready prepared policy. It had not been further adapted to the requirements of the service. This means that service users are not protected by a clear and detailed medication policy to ensure their medication requirements are being met. Care staff were not aware of the procedures to order, receive or dispose of medication. For example, there was no record of receipt recorded for the medication that was stored in the home. The records for disposal of medication were not available. Two members of staff who normally dealt with medication were both off sick and the remaining members of the trained staff team were not aware of the receipt or disposal procedure. There were no written procedures for the staff to follow. This means that service users medication requirements are potentially at risk. Some eye drop preparations for a service user had not been dated when opened. This is important because the eye drops had a 4-week expiry date when opened. Two audits were undertaken for medication that had recently been started. The two audits were correct, which means that the records show that the service users had received the correct medicine at the correct time. Not all audits Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 14 could be fully undertaken because there were no dates of opening recorded on the original container. Some hand written MAR charts had not been double-checked and signed by two members of staff. The MAR charts did not document the allergy status of service users’. A signature and initial list of staff who were trained to administer medication was available, however it was not up to date. Most staff observed during the inspection were polite and respectful to the residents. One staff member observed did not look happy in her work and did not portray positive approaches during interactions with the residents. A concern was identified which the owner was made aware of during the inspection in that a display board on the dining room wall detailed personal information about residents and named them, which does not accord with privacy and dignity protocols. Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Daily routines must be organised to meet the needs and preferences of the service users. The home actively encourages service users to maintain contact with family and friends. Generally, service users are helped to exercise choice and control over their lives. Meal provision needs improvement to ensure that each service user has sufficient nutrition and choice of foods. EVIDENCE: It is extremely positive that the home has determined the preferred daily routines for each resident. However, it was disappointing that these are not always adhered to by staff. For example; one resident explained that she;” had to have a bath” that afternoon when in fact she; “Preferred to be bathed at night”. Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 16 To date the new owners have not set a schedule of resident meetings to enable residents to give their views and ideas about the running of the home and discuss things important things to them such as meal provision. Although it is acknowledged that activity provision within the home has improved in that the new owner has purchased some equipment for the staff to use and the interests of each resident have been explored further improvement is needed. This to be done by employing a dedicated activities co-ordinator or another member of staff (additional to the required three on duty) to provide dedicated, structured, planned activities. Residents observed during the inspection for a number of hours were sat in chairs without any stimulation or engagement. It is pleasing that the home encourages residents to maintain contact with family and friends. A number of relatives visited during the inspection who were welcomed by the staff. Visiting hours are open and flexible. One staff member said; “ One visitor comes at nine o’clock at night”. It was concerning however, that one visitor was described by staff as being; “Very loud and aggressive in manner. ” An entry was made in daily notes as follows; “ .. and.. rowing very loudly no consideration to other service users”. This kind of behaviour can not be tolerated in a home where residents are elderly and frail and may be frightened. Action must be taken to prevent instances like this and to ensure that all visitors are aware of visiting rules. It was positive to see that information was on display within the home regarding external advocacy services to allow residents or relatives to get advice or input if they wish to. It was also positive to see that residents had brought into the home with them personal belongings examples being; pictures and ornaments. A concern was identified in that when inspectors enquired about the communal TV in the lounge one said; “ That belongs to (RR)”. This situation must be explored to determine why a resident’s TV is being used for communal purposes in the lounge. Although the supervision of residents at meal times has improved due to increased staffing levels meal provision in general leaves a lot to be desired. It must be acknowledged that the owner said; “The I do the shopping on a Monday”(the inspection was carried out on a Monday) however, food stocks in the home could not be described as plentiful. The owner did also say; “ I do not let the residents go hungry. We have had problems with menus and other aspects that is why I am in the process of recruiting a permanent cook”. Food intake charts seen did not include supper and therefore prevented a judgement being made as to whether or not each resident is having sufficient food and nutrition daily. Menus were not available to inform residents what was being offered for meals. Further menus in operation need to be assessed by a dietician or other appropriate person to ensure that food offered is sufficient in terms of variety and nutrition for example; the tea for that day contained two pastry foods containing fat which could be detrimental to health. Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 17 On the day of the inspection only one choice for the main meal was offered and no special provision was made for soft diets apart from liquidising food into a puree’. One relative said; “ The food is not always very good- not much variety. Meat is tough- the way it is cooked”. It must be acknowledged that the new owner is looking into food provision within the home and has given assurance that improvements will be made. Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Developments are needed concerning complaints procedures to ensure that they are produced to aid the understanding of each service user. Protection processes in the home are poor potentially placing service users at risk. EVIDENCE: A previous requirement was made for the complaints procedure to be produced in a format ‘ appropriate to all residents’. Since this time the home has been given a condition to allow them to care for 3 named residents already accommodated who have dementia (who may need information produced in a pictorial format to aid understanding) yet this requirement has not been met. Neither the Commission nor the home have received any complaints. There have been no reported incidents of abuse occurring in the home, however, concerns were identified during the inspection. Staff since the last inspection have received some informal abuse awareness training which is positive but the adequacy of this/ or the information retained by staff must be questioned as staff spoke of ‘ A number of incidents’ where one resident had shown aggression to other frail residents some of which had Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 19 been recorded as follows; 14/9/06 “ T pushed passed L on his way to the toilet this morning and caused L to catch her hand slightly on the wall”. 2/10/06 “ T pushed passed N in the hallway this morning. F family were present at the time. T upset N pushing passed her. These incidents had not been reported to Social Services or the Commission as they must and little had been done to monitor T’s behaviour or to prevent further occurrences. Past requirements concerning prevention of abuse have not been met as there was no evidence to show that staff have read Dudley MBC’s protection procedures these are the ones that must be activated in the event of an allegation or incident of abuse. Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25,26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Internal aspects in this home are maintained to a poor standard. Improvements are needed to ensure that service users live in a safe environment. Improvements are needed to ensure that the home and processes within enhance hygiene and infection control. EVIDENCE: As stated in the previous report general maintenance of the home has deteriorated this over the last year or so. Décor and paintwork in many areas Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 21 is battered and looks ‘tired’- well passed its best. Carpets especially in corridors and the dining room and lounge are also passed their best. The flooring in both the lounge and the dining room is uneven in places which could present as a tripping hazard. The new registered person said; “ Rooms are being measured for new carpets”. It was highlighted to her the importance of having the floors rectified before new carpets are laid. The dining room is also in need of redecoration. Chair seats in the dining room are badly stained and need replacing. The wood by one toilet is badly blistered as it has not received attention although this was highlighted in the last inspection report. A thorough audit of the home is needed to identify other maintenance needs and for these needs to be included in a refurbishment plan complete with timescales. A concern was raised last inspection in that hot water temperature recordings could not be provided. Records were available during this inspection but were seen to be inconsistent. One recording in particular was well in excess of 43oC which presents a risk of scalding. On arrival at the home all but one radiator felt by inspectors was cold. One staff member said; “ The heating has caused problems for some time”. The new owner said; “ There has been a problem with the heating and I have arranged for an engineer to come and replace a part this Wednesday”. One resident said to another; “I am cold”. There continues to be a lack of adequate policies in the laundry to prevent infection transmission which could potentially place residents at risk. One staff member was observed during the inspection wearing gloves and an apron which she had worn to provide personal care to a resident. The staff member wore these items whilst pushing the resident into the dining room then still wore them when fetching a blue apron for the resident to wear during her meal. This poor practice again could present a risk of infection transmission to residents. Another concern was that the kitchen mop and bucket were stored in the laundry where dirty washing is dealt with and commode pots washed. It was positively noted that hand wash signs are provided in toilets and other high risk areas along with liquid soap and paper towels. Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing numbers generally are adequate. Over 50 of these staff have achieved NVQ level 2 or above in care. Recruitment practices again were identified as poor potentially placing service users at risk. Improvement is needed to ensure that all staff are trained and competent to do their jobs. EVIDENCE: It is positive that the registered person is adhering to a previous requirement made by providing 3 care staff during all waking hours. Rotas are being forwarded to the Commission weekly however, to date these have been the set rotas rather than a true reflection of the hours and shifts that may have to have been covered due to holiday or sickness. Staff during the inspection were very helpful. Most were seen to be friendly and caring. Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 23 Positive comments were received about the staff in general one relative said; ” The care staff are very caring and give Mum lots of attention”. Another said;” Can’t fault the staff, looking after her, good as gold”. It is positive that at least 50 of the care staff have achieved NVQ level 2 or above in care. Although it is positive that staff files have been better organised, staff recruitment continues to be a concern. Following the last inspection a serious concern letter was issued by the Commission about a staff member (TP) who had been employed without the required checks being carried out. The requirement was that (TP) could not work at the home until these required checks had been carried out. The Commission at this time was assured by the previous owners that (TP) was no longer working at the home. It was extremely concerning to identify during this inspection that the new owner had reemployed (TP) without even receipt of a Pova first check. Other shortfalls were identified for example; one staff member commenced employment without a second reference being obtained. There was little evidence of initial in-house induction and no evidence of named supervisors for new starters. Skills for Care induction standards have yet to be obtained and used for new starters. Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management of the home continues to be questioned in terms of competence and effectiveness. The home is not being run in the best interests of the service users. Concern again was identified regarding the management of service users finances. There are shortfalls in the overall heath and safety processes within the home. EVIDENCE: Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 25 Concerns regarding the management of the home have been highlighted in at least the last three inspection reports due to the number of outstanding requirements in areas generally that are of a high risk. With this in mind the previous owners secured a consultant to work along, supervise and support the manager. The manager to date has failed to provide official documentation to evidence that she has commenced on a NVQ level 4 course in management or the Registered Managers Award. She has also failed to provide original certified evidence to the registered person or Commission of her NVQ level 4 in care. Since purchasing the home the new owners are addressing concerns regarding the management. In the mean time a suitable consultant must be secured again. The previous registered persons purchased a quality assurance manual. There has been some signing off of sections but only a small proportion and no evidence of what in terms of precise documents/ processes/practices etc have been audited. The previous registered persons also purchased a manual of policies and procedures which have all been signed. However, there was no evidence that staff have read and signed these or are aware of these procedures. Further, many of these policies and procedures are not personalised to Everley apart from the name on the top of them. The management of service users money continues to be of a concern. A serious concern letter was issued to the previous registered persons about the lack of official receipts for expenditure regarding AD’s money. To rectify arrangements were made by the home for Dudley Council to hold and manage this service users money. The previous registered persons did not however, inform the Commission that over £300 was in their account belonging to this service user which was given to the new owners on transfer of the business. Money since this transfer has again been spent for this service user without a valid receipt being given. The receipt seen for trousers purchased was dated 2000 when this purchase was made in 2006. Staff supervision sessions must be arranged there was insufficient evidence to demonstrate that staff are receiving one to one sessions six times per year as required to ensure that they are clear of their work roles and other aspects of their jobs. It was difficult as experienced during previous inspections to determine the level of staff training received as there was no current matrix or certificates to evidence training. Concern was raised when two inspectors observed banned moving and handling techniques being used namely the ‘ Underarm lift’ for a resident who should have been hoisted. Wheelchairs were seen a number of times without footrests being used which could be dangerous as limbs could be injured. When staff were asked about this they said; “ There are not many wheelchairs that have correct fitting footrests”. When they were asked about one resident (M) they said; “ She does Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 26 not like footrests” which was surprising as her risk assessment dated 9 October 2006 stated; “ Use of wheelchair- risk – entrapment of limbs, control measures- ensure foot plates are in use at all times”. It was concerning to see records of bed rail checks for resident (LK). A serious concern letter was issued to the previous registered providers about bed rails and the checking of. The bedrail checks for (LK’s) bed from 8 October 2006 to 26 October 2006 were recorded every day in the same handwriting yet different staff initials had been entered. This was brought to the attention of the registered person who was asked if the records were authentic as it was unlikely that the same staff member had been on duty for 19 consecutive days without a break. Everley Care Home DS0000067211.V316112.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 2 x 2 1 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 1 x x x x x 1 1 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 1 x 1 2 x 1 Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 28 Yes Are there any outstanding requirements from the last inspection? 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 OP1 Regulation 4(2)5(2)6 (a) Requirement The registered persons and manager must ensure that; The statement of purpose and service user guide are fully reviewed and made available to all residents /relatives/visitors etc. A copy of the reviewed statement of purpose and service user guide must be forwarded to the CSCI. 2 OP1 4,5 The registered persons and manager must ensure that the homes inspection reports are shown to residents, relatives and staff. The registered persons and manager must ensure; That an assessment of need is carried out in respect of each prospective resident and that records are made to evidence this. That evidence is available to demonstrate that residents’ or Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 29 Timescale for action 05/01/07 15/12/06 3 OP3 14(1)(a) 20/11/06 their chosen representatives have been involved in their assessment of need process and concur with the outcomes of such. Timescales of 4/10/05 and 25/07/06 not fully met. 4 OP4 14(1)(d) The registered persons and manager must ensure that each prospective/ new resident is given written acknowledgement that their needs will be met. Timescale of 07/07/06 not met. 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 and again during a meeting held on 09/11/06 The registered persons and manager must determine from a reliable source and confirmed in writing ( for example a doctor) the primary need of (D and SD). If it is depression a variation application must be made to the CSCI. The registered providers and manager must ensure that all DS0000067211.V316112.R01.S.doc 20/11/06 5 OP4 14(1)(a) 15(1) 09/11/06 6 OP4 14(1)(a) 15(1) 01/12/06 7 OP7 15(1) 15(2)(b) 01/12/06 Everley Care Home Version 5.2 Page 30 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 and 26/07/06 not fully met. This to include oral care plans. 8 OP7 15(1) 15(2)(b) 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. Timescale of 20/07/06 not met. 9 OP8 13(4) The registered providers and manager must ensure that where concerns are identified from the tissue viability and nutritional scoring tools that these are followed through, appropriate guidance obtained where needed , and the information be included in the residents’ care plan. (SD). Timescales of 01/05/05, 01/11/05 and 20/07/06 not fully met. 30/11/06 25/11/06 The day along with the month and year that risk assessments are carried out must be entered on the risk assessment documentation. Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 31 10 OP8 12(1)(a) The registered providers and manager must ensure that enhanced records of all doctors visits are made detailing the outcome of the assessment/consultation.(JM) Timescale of 20/07/06 not fully met. The registered providers and manager must ensure that where it is needed/ being used pressure relieving equipment used and instruction for usage is included in the resident’s care plan.(LK) Timescale of 26/07/06 not fully met. 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. The registered providers and manager must ensure that all residents’ glasses are adequately clean and that they are of a good fit. Timescales of 20/07/06 and 25/07/06 not fully met. 30/11/06 11 OP8 12(1a) 13(4(c) 15(1) 30/11/06 12 OP8 12(1)(a) 30/11/06 13 OP8 12(1)(a) 13(4)(a) The registered persons and 14/11/06 manager must ensure that where treatment is prescribed / written as an instruction for example; two hourly turns’, ‘4 hourly oral care’ that these treatments/ instructions are carried out and records are made to evidence this. Where for whatever reason it is not possible a record must be DS0000067211.V316112.R01.S.doc Version 5.2 Page 32 Everley Care Home 14 OP8 12(1)(a) 13(1)(b) made and this must be reported back to the person who gave the instruction for example; the district nurse. The registered persons and 30/10/06 manager must ensure that the doctor ( or ambulance depending on circumstances) be requested to reassess any resident where deterioration has been noticed/identified. A concern letter was issued by the CSCI in which this requirement was included. 15 OP8 12(1)(a) 13(4)(c) The registered persons and manager must ensure that all residents are weighed on admission and regularly thereafter. Where it is not possible to weigh residents other appropriate/ suitable tools must be used. 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. The registered persons and manager must ensure that trained staff who are involved with medication must be able to order, receive and dispose of medication in accordance with the medication policy. The registered persons and manager must ensure that the receipt of medication is recorded and documented. The registered persons and manager must ensure that the DS0000067211.V316112.R01.S.doc 30/11/06 16 OP9 13(2) 30/11/06 17 OP9 13(2) 30/11/06 18 OP9 13(2) 30/11/06 19 OP9 13(2) 30/11/06 Page 33 Everley Care Home Version 5.2 date of opening of all medication containers is recorded and the balances of medications carried over onto new medication charts to ensure that a medication audit can be completed. 20 OP9 13(2) The registered persons and manager must ensure that all prescriptions are seen by the home to check the medication order for residents. 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. 30/11/06 21 OP9 13(2) 30/11/06 22 OP9 13(2) 23 OP9 13(2) 24 OP10 12(4)(b) The registered persons and 30/11/06 manager must ensure that any known allergies or ‘ none known’ must be clearly documented on each service users’ medication administration record chart. The registered persons and 30/11/06 manager must ensure that the signature and initial list of all trained staff who administer medication be kept up to date and current. The registered providers must 01/12/06 explore in greater detail the cultural and religious needs of each resident to determine for example; if they wish to follow their religion and how this can be addressed. Timescale of 01/08/06 not fully met. The registered persons and manager must cease putting personal information regarding residents on display. DS0000067211.V316112.R01.S.doc 25 OP10 12(4)(a) 25/11/06 Everley Care Home Version 5.2 Page 34 26 OP12 12(3) 16(2)(m) The registered providers and manager must ensure that a schedule of service user meetings is produced and displayed. These meetings must be held regularly and be recorded. Standing agenda items must include; recreation, activities, meals, menus, complaints procedures and daily routines. Timescales of 25/02/05, 20/05/05, 01/11/06 and 26/07/06 not met. 01/12/06 27 OP12 12(3) 28 OP12 12(2)(m) (n) 18(1)(a) The registered persons and manager must ensure that daily routines ( preferred bath times etc) are arranged to meet the needs of the residents rather than to meet the needs of resources available. The registered provider and manager must ensure that an activities co-ordinator 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. Timescale of 25/07/06 not met. The registered persons must review and reissue to all visitors a suitable policy on the rules of visiting an example being; that loud aggressive behaviour will not be tolerated. The registered persons and manager must explore the reasons why (RR) TV is being used for communal purposes in the lounge. If it is determined that the TV does belong to (RR) then it should be returned to him and a DS0000067211.V316112.R01.S.doc 30/11/06 01/01/07 29 OP13 12(4)(a) 01/12/06 30 OP14 23(2)(h) 01/12/06 Everley Care Home Version 5.2 Page 35 31 OP15 17(2) Sch 4 replacement purchased for the lounge. The registered person and manager must ensure that food consumption charts reflect all food eaten by the residents during the day. ( Do not show supper). Timescales of 18/10/05 and 15/07/06 not fully met. The registered persons and manager must ensure that the food provided each day is of an acceptable quality to the residents’. Timescales of 18/10/05 and 16/07/06 not fully met. The registered persons and manager must ensure that suitably qualified and competent catering staff are provided seven days per week. This requirement was made in October 2005. A cook is due to commence employment week commencing the 6 November 2006. 25/11/06 32 OP15 16(2)(i) 25/11/06 33 OP15 18(1)(a) 25/11/06 34 OP15 12(1) (a(b) 13(1(b) The registered providers and manager must contact the community dietician about the nutritional content of meals and advise about soft diets or need for increased nutritional content for residents’ who have poor appetites/are prone to tissue damage. Timescale of 26/07/06 not met. 01/12/06 35 OP15 16(2)(i) 16(4) The registered providers and manager must ask each resident DS0000067211.V316112.R01.S.doc 25/11/06 Page 36 Everley Care Home Version 5.2 their choice of milk fresh, UHT, full fat, etc to meet their preferences and nutritional needs. Timescale of 26/07/06 not met. This must be then recorded on their personal file and be provided for each. 36 OP16 22(2) The registered person and manager must; Produce the complaints procedure in a format that is appropriate to all residents’ and relatives. Actively ensure that all residents’ and relatives are reminded of the home’s complaints procedure. Timescales of 15/11/05 and 10/08/06 not met. 15/12/06 37 OP18 17(2) The registered persons and 30/10/06 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. Timescale of 11/07/06 which was contained in a monitoring letter following a serious concern letter has not been fully met. The registered person (SJ) present during the inspection was informed of this requirement. 38 OP18 13(6) The registered persons and DS0000067211.V316112.R01.S.doc 25/11/06 Version 5.2 Page 37 Everley Care Home manager must contact Dudley Social Services department and ask for advice on what to do with the cash for (AD) that was handed over from the previous owner when the home was sold. 39 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. The registered providers and manager must ensure that; All staff read, sign in-house policies concerning the protection of vulnerable adults. All staff read and sign Dudley MBC multi-agency policies and procedures. A quick reference flow chart is made available detailing names and telephone numbers of agencies that would need to be contacted is an allegation or incident of abuse were to occur. Timescale of 01/08/06 not met. 41 OP18 17(2) The registered person and manager must ensure that a robust reporting system is established for staff to record any violence/ aggression that has been displayed to them by residents or others. Timescales of 01/11/05 and 15/07/06 not adequately met. 20/11/06 15/12/06 40 OP18 13(6) 01/12/06 Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 38 42 OP18 13(6) The registered persons and manager must ensure that a recording system to document TD’s behaviour is established and implemented. All incidents must be recorded, the information must be easy to audit/ retrieve. A concern letter was issued by the CSCI in which this requirement was included. The registered persons and manager must ensure that processes are implemented to prevent incidents of this nature reoccurring ( caused by TD). You must provide written evidence of how you have met this requirement. A concern letter was issued by the CSCI in which this requirement was included. 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. A concern letter was issued by the CSCI in which this requirement was included. 30/10/06 43 OP18 13(6) 09/11/06 44 OP18 13(6) 30/10/06 45 OP19 16,23. The registered persons and manager must produce a routine maintenance programme complete with timescales this to include the following; The redecoration and carpet replacement in the downstairs corridor. The replacement of the stair carpet. 10/01/07 Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 39 The redecorating of bedrooms where damage occurred when the windows were installed. The replacement of the stained chair in the dining room. Timescales of 01/11/05 and 15/07/06 not met. This also to include the replacement of dining room chairs as they are all stained and are well past their best. 46 OP19 13(4)(c) 23(2)(b) The registered persons and manager must ensure that the carpet in the lounge is stretched to avoid tripping. In the interim risk prevention strategies must be implemented. Timescale of 26/07/06 not met. The flooring under the carpet needs to be investigated and remedied as it is uneven. 47 OP19 13(4)(c) 23(2)(d) The registered persons and manager must ensure that the following work is carried out; The paint work in all corridors, landings is repainted this to include skirting boards and door frames. The dining room to be redecorated. The toilet room next to the food store cupboard to be redecorated to include the blistered wooden board below the toilet cistern. Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 40 25/11/06 15/01/07 48 OP19 13(4)(c) 23(2)(b) Timescale of 26/08/06 not met. The registered persons ands manager must have the flooring by the door in the dining room investigated as it looks uneven and could be a potential tripping hazard. In the interim risk prevention strategies must be implemented. The registered persons and manager must ensure that the call system in each residents bedroom is in good working order at all times. Residents must be able to easily access their call systems throughout the night. 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. A concern letter was issued by the CSCI in which this requirement was included. 20/11/06 49 OP19 23(2)(n) 25/11/06 50 OP25 13(4)(a) 01/11/06 51 OP25 23(2)(c) 23(2)(p) The registered persons and manager must ensure that the heating system is in good working order at all times. Written evidence that this has been confirmed by a competent engineer must be provided to the CSCI. A concern letter was issued by the Commission in which 09/11/06 Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 41 this requirement was included. 52 OP25 37(1)(d) (e) The registered person and manager must ensure the `CSCI are informed if at any time the heating is not working. The registered person was informed of this verbally during the inspection. The registered persons must ensure that lighting in each residents bedroom is adequate (lux 150). The registered person must ensure that the home (each room) is audited on a regular basis by a manager to ensure that the cleanliness is sufficient. Records to evidence these audits must be made. Timescales of 01/11/05 and 26/07/06 not met. The registered persons and manager must ensure that; All mop heads are cleaned using disinfectant cycles daily and that records of this are made. That mop heads are hung to dry in between use. Timescale of 15/07/06 not met. The registered persons and manager must ensure that the kitchen mop and bucket is stored in the kitchen. 56 OP26 13(3) The registered persons and manager must ensure that; Clear infection control Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 42 30/10/06 53 OP25 23(2)(p) 20/11/06 54 OP26 13(3) 23(2)(d) 01/12/06 55 OP26 13(2) 23(2)(d) 25/11/06 01/12/06 procedures for the laundry are produced aimed to prevent contamination from clean to dirty washing and that these are displayed in the laundry. Information about the management of community infections ( MRSA etc) are available within the home for reference. Timescale of 26/07/06 not fully met. 57 OP26 13(3) 58 OP27 18(1)(a) The registered persons and manager must ensure that where staff have been undertaking personal care/ other tasks that require the wearing of disposable gloves that the gloves are removed and their hands are washed before they leave the area (toilet, bathroom) that the task was undertaken in. The registered persons must provide the CSCI with a written proposal concerning the appointment of a senior staff member. The registered persons must continue to provide weekly to the CSCI staff rotas. These must; Be exact photocopies of the previous weeks rota showing changes/ alterations. Clearly show the hours the manager HAS worked each day of any given week. 25/11/06 25/12/06 59 OP27 17(2) Sch 4, 7 25/11/06 60 OP29 19(5)(c) The registered providers and manager must ensure that a health declaration form DS0000067211.V316112.R01.S.doc 30/10/06 Everley Care Home Version 5.2 Page 43 completed by all staff. Timescales of 30/01/05, 10/11/05 and 26/07/06 not fully met. 61 OP29 17(2) 19(1) 19(3-11) 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 not met. As this requirement was not met in full a further requirement was made as follows; 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). . An immediate requirement was issued followed by a concern letter in which this requirement was included. 62 OP29 17(2) 19(1) The registered person and manager must ensure that all documents required (as detailed above) and contained within the serious concern letter issued , dated (27 June 2006) are obtained for (TP). Until a file (including all of the required documents as detailed above and contained within the serious concern letter ) for (TP) she can not work at the home. DS0000067211.V316112.R01.S.doc 30/10/06 30/10/06 Everley Care Home Version 5.2 Page 44 Timescale of 03/07/06 not met. Evidence was available this inspection to show that the new registered provider had allowed (TP) to commence employment without her firstly receiving at least a POVA first check. 63 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. The registered person (S.J) was fully informed of this during the inspection. 64 OP30 18(1)(a) The registered person and manager must ensure that; A current/ up to date training plan is on each staff members file. Copies of all training certificates are held on each staff members files. Timescale of 26/08/06 not met. The registered person and manager must provide to the CSCI an up to date training matrix in which each staff members name must be detailed along with training/ dates received and the date when DS0000067211.V316112.R01.S.doc 30/10/06 01/01/07 65 OP30 18(1)(a) 10/12/06 Everley Care Home Version 5.2 Page 45 66 OP30 18(1c) 18(2a) (b) refresher training for each subject is required. The registered persons and manager must ensure that evidence is available at all times to demonstrate that new staff have received in-house induction and formal induction training. A named supervisor must be allocated to new staff for their induction period. The registered persons must inform the CSCI of; The actions they intend to take concerning the management of the home. 30/11/06 67 OP31 9 25/11/06 68 OP31 9 The name of the consultant secured and a copy of the contract. The registered persons and 20/11/06 manager must ensure that from receipt of this report urgent action is taken to ensure that the home is run in accordance/ in compliance with the National Minimum Standards for Older People, The Care Home Regulations 2001( and amendments) The Care Standards Act 2000 and any other secondary legislation and good practice that mat apply. Timescale of 21/07/06 not met. The registered persons must provide evidence of the following; The managers NVQ level 4 certificate in care. Confirmation of enrolment onto a suitable NVQ level 4 course in management or the Registered 69 OP31 9 01/12/06 Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 46 70 OP33 24(1)(2) (3) Managers Award ( for the manager). 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. 01/12/06 71 OP32 18(1)(a) 72 OP36 18(2) The registered persons and manager must ensure that staff meetings are held regularly. Standing agenda items must include; direction to staff, discussion about the content of inspection reports and how to rectify shortfalls. A schedule of meetings must be produced and written records made of these staff meetings. The registered providers and manager must produce a schedule of staff supervision/ appraisal sessions. Each staff member ( including the manager) must receive six supervisions per year as per standard 36. Timescales of 25/02/05, 01/05/05, 01/12/05 and 01/08/06 not met. 30/12/06 01/12/06 73 OP37 17(2) 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. 20/12/06 Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 47 74 OP38 13(4)(c) 75 OP38 13(4)(c) 23(2)(c) 76 OP38 18(1)(a) The registered persons and 25/11/06 manager must ensure that wheelchairs all have correctly fitting footrests and that they are used. In cases where residents refuse for footrests to be used then a risk assessment must be undertaken and the risks explained to the resident . If the risk assessment identifies risk then the resident’s social worker should be informed. The registered persons and 01/12/06 manager must have all wheelchairs serviced and replaced where needed. Wheelchairs must be serviced regularly thereafter. Written invoices/ certificates must be available to demonstrate that this has/ is being done. The registered providers and 01/01/07 manager must ensure that all staff have received the following training; First aid, food hygiene, fire safety and drill training and adequate moving and handling training. The registered person and 20/11/06 manager must ensure that daily bedrail checks are undertaken by a competent person, that a record is made of what checks are undertaken and that accurate records are made. The registered persons and manager must provide to the CSCI evidence that the TV and music system in the lounge have been PAT tested. That the hoist brake cables have been replaced. 01/12/06 77 OP38 13(4)(a) 13(4)(c) 78 OP38 23(4) Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 48 79 OP38 17(2) 80 OP38 13(4)(c) 13(5) The registered persons and manager must provide the CSCI with copies of all accident records from 01 June 2006present. The registered persons and manager must ensure that at all times (JM) is moved and handled correctly and safely. The ‘underarm lift’ must not be used. 30/11/06 20/11/06 81 OP38 16(2)(j) The registered persons and manager must ensure; That all opened packets are dated when opened and then stored in airtight containers. Timescale of 01/08/06 not met. The registered persons must forward to the CSCI risk assessments as follows; Deep fat fryer, knife usage. 20/11/06 82 OP38 16(2)(j) 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard OP15 Good Practice Recommendations 1 2 OP18 The registered provider and manager are strongly recommended to obtain CSCI guidance on meal provision titled ‘ Highlight of the Day’. www.csci.org.uk 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. DS0000067211.V316112.R01.S.doc Version 5.2 Page 49 Everley Care Home Everley Care Home DS0000067211.V316112.R01.S.doc Version 5.2 Page 50 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.V316112.R01.S.doc Version 5.2 Page 51 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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