Inspection on 08/11/05 for Field View

This inspection was carried out on 8th November 2005.

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

Field View 01/08/06

Field View 22/04/05

Field View 08/12/04

Field View 03/06/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Field View Spark Lane Mapplewell Barnsley South Yorkshire S75 6BN Lead Inspector Mrs Jayne White Unannounced Inspection 8th November 2005 08:45 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 Field View DS0000018253.V263799.R01.S.doc Version 5.0 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. Field View DS0000018253.V263799.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Field View Address Spark Lane Mapplewell Barnsley South Yorkshire S75 6BN 01226 390131 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) Field.view@fshc.co.uk Chapelfield View Limited Mrs Lynne Simms Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Field View DS0000018253.V263799.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd April 2005 Brief Description of the Service: Field View is a 40-bed purpose built care home for elderly persons, initially registered in 1989. The home has provision for permanent and short stay residents. It is located in the centre of Mapplewell Village and is within easy access to shops, local post office, pubs, clubs and places of worship. There is parking at the front and side of the building. Accommodation is on two floors served with a passenger lift and stairs. There are 28 single and six double rooms, three lounges and one dining room. The garden areas are mainly lawned and have sitting areas with garden furniture. Field View DS0000018253.V263799.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over seven hours from 8:45 to 15:45. Opportunity was taken to make a partial inspection of the premises, inspect a sample of records, observe care practices and talk to residents, a relative, staff and the manager. The majority of residents and staff were seen during the inspection and the inspector spoke in more detail to three of the staff on duty about their knowledge, skills and experiences of working at the home, four of the thirty three residents about their views on aspects of living at the home and a relative. A postal questionnaire was sent to residents and their closest advocate subsequent to the inspection to increase this sample. What the service does well: What has improved since the last inspection? Staff had, had training in the protection of vulnerable adults, which had given them a good understanding of the procedures to be followed should they suspect any abuse at the home. Field View DS0000018253.V263799.R01.S.doc Version 5.0 Page 6 What they could do better: 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. Field View DS0000018253.V263799.R01.S.doc Version 5.0 Page 7 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 Field View DS0000018253.V263799.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 2 and 3 were inspected Contracts/terms and conditions for residents were not evident in residents’ files. Residents moving into the home had, had their needs assessed although the home’s own assessment lacked detail and was not fully completed. EVIDENCE: One resident’s file was inspected to ensure contracts/terms and conditions were in place. One was not evident. The manager said contracts/terms and conditions had been sent to advocates but had not been returned. The manager was advised to keep a copy on file without signatures until one was returned as evidence. One resident’s file was inspected who had recently moved into the home. A summary of the assessment completed through care management arrangements had been received by the home. The home had also completed their own assessment, however, some of the assessment lacked detail and there were parts not completed and it was not signed or dated by the person undertaking the assessment. Field View DS0000018253.V263799.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 7 and 9 were inspected. A plan of care was in place for each resident, however, more detail was required including risk assessments. The system used for the administration of medication could place residents’ welfare at risk. EVIDENCE: Three residents’ plans of care were inspected on a sample basis. Omissions were noted including a documented risk assessment where a risk is identified, action to be taken to reduce the level of risk, confirmation or not that the resident and/or their advocate agreed or not with that assessment and then identifying the action on the care plan. A member of staff was observed during a medication round. The correct procedure for administration was not being followed which could have placed residents at risk. The recording of medication was inspected on a sample basis. The amount of medication carried forward from one month to another was not recorded. Medication instructions identified on the MAR sheet correlated with the medication administered. When medication has been audited the action taken to rectify discrepancies including amending record sheets was not recorded. Field View DS0000018253.V263799.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for all the above standards were inspected All but one resident spoken with said the daily routines within the home allowed for them to make their own choices and decisions with regard to their daily lives. Residents were encouraged and assisted to maintain contact with their family, friends and the local community as they wished. Residents received a wholesome, appealing and balanced diet in pleasant surroundings. EVIDENCE: Comments made by residents about their lifestyle at the home included “Not a thing I like about living here – I don’t like been told what to do”, “couldn’t be better”, “it’s decent and comfortable”, “very good, nothing to grumble about”, and “can’t go to any other home and get better service”. Residents were observed to spend time in the lounges, whilst others chose to spend their time in the privacy of their bedroom. Discussions with residents demonstrated they spent their time in different ways including, reading, completing word puzzles and watching TV quietly in their room, including Songs of Praise and playing cards – this was observed during the inspection. Residents spoken with said there were some trips out. One resident said there was not much to do. Residents were motivated on the day of the inspection as it was the day the hairdresser came. The manager said a carer was employed to provide activities for the residents in the afternoons on a certain number of days in the week. Field View DS0000018253.V263799.R01.S.doc Version 5.0 Page 11 Residents confirmed that they maintained links with their family and friends and that they could visit “at anytime”. The dining room was clean and welcoming. Comments from residents about the meals were positive. These comments included “meals good”, “get enough to eat”, “dinners are lovely” and “can’t grumble about meals”. The menus supplied, demonstrated a choice of meal and this was identified in discussions with residents. Field View DS0000018253.V263799.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 16 and 18 were inspected All but one resident spoken with were confident that any complaints they had would be listened to. The complaints procedure did not include sufficient information for complainants should they wish to make a complaint without having to ask at the office. Staff had a good understanding of the procedures to be followed should they suspect any abuse at the home and had, had training in the protection of vulnerable adults. EVIDENCE: The complaint procedure did not contain details as required by the Care Homes Regulations. Discussions with residents identified all but one were confident that any complaints they had would be listened to, however, the one who was not confident did say they knew how to complain but when they had done so said “nothing much was done about it. I was told, look around, there’s a houseful of people, you don’t want special treatment do you”. They also said “the office has given them permission to complain”. Another resident said “it’s peoples’ own fault if they don’t complain because I have done and it always gets seen to”, “we have residents meetings”, “we’re never frightened to go to manager or staff but some residents don’t voice their opinion, so if they don’t, there’s nothing the home can do about it”. The homes own adult protection policy/procedure did not include the contact details of the local adult protection officer, but the home had now obtained the local multi agency procedures that included those details. The manager said that there were no allegations of abuse. Staff spoken with could describe the action they needed to take if they suspected abuse and could define the types of abuse they would report. Staff were receiving training in Adult Protection. Field View DS0000018253.V263799.R01.S.doc Version 5.0 Page 13 One staff member said there wasn’t a policy in place for the physical and/or verbal aggression by residents’. The manager confirmed this. Field View DS0000018253.V263799.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): See below EVIDENCE: Outcomes for this section of the report were checked on the last inspection. Field View DS0000018253.V263799.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for all the above standards were inspected The numbers and skill mix of staff met residents’ needs. Residents were not fully protected by the home’s recruitment procedures. There was a staff training programme in place to equip staff with the knowledge to complete their role in a competent manner. EVIDENCE: The manager provided a rota for the month. It was not clear as it did not identify the designations of staff and the hours worked. The manager’s hours and the hours worked by a carer as to provide activities were not identified on the rota. Eight days of the rota were sampled including the day of the inspection. The staff working correlated with those staff working on shift. Three of the days identified a full complement of staff were not working. Discussions with residents identified this had not affected their care needs being met. One staff file was inspected. A comprehensive recruitment process had not been followed including demonstrating a full employment history and a documented risk assessment as to the suitability of the staff member’s recruitment, as a result of a written reference and previous history known to the home. Documentation identified a training programme was in place. Discussions with staff identified that they had received training in protection of vulnerable adults, moving and handling, first aid, food hygiene and NVQ Level 2 in Care. A third of care staff were trained to at least NVQ Level 2 in Care. Field View DS0000018253.V263799.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standards for 31, 33, 35, 37 and 38 were inspected The manager had worked at the home for a number of years, had now completed an appropriate qualification and on the whole facilitated an open atmosphere where residents felt their opinions mattered. Systems were in place to safeguard residents’ financial interests. Improvements were required with some of the records kept by the home to safeguard residents’ rights and best interests. The safety and welfare of residents’ were not sufficiently promoted and safeguarded, as comprehensive recruitment practices were not in place. Field View DS0000018253.V263799.R01.S.doc Version 5.0 Page 17 EVIDENCE: Discussions with all but one of the residents spoken with demonstrated the manager promoted an atmosphere of openness and respect where residents and their advocates felt their opinions mattered. Quality assurance systems formalised this process with a quality audit completed by the manager in place, regulation 26 visits by an area manager and residents meetings. The quality assurance process did not include consultation with residents and other stakeholders of the service to ascertain their views on the quality of the service provided. The manager had completed her NVQ Level 4 in Management and Care but had not yet submitted it for verification purposes. All personal allowances are paid into one account, with signatories being persons employed by Four Seasons. The account did not pay interest. Reconciliation of the account and float is completed monthly and a weekly transaction of monies spent by and deposited by each resident is kept together with receipts. There were safe facilities to store the float. Current CSCI guidance acknowledged this practice for payment of personal allowances and finances met the regulation. The inspector inspected a sample of the records that the home was required to keep. These have been commented upon throughout the report and where necessary requirements made. Records were securely stored. Safety posters were on display. When the building was inspected no fire exits were blocked and the fire extinguishers seen had been serviced. Fire records confirmed weekly testing of the fire alarm system and monthly checks of the emergency lighting occurred, but there was no record that demonstrated monthly checks of fire fighting equipment occurred. Fire training and/or drills for staff were in place. Servicing of gas and electrical systems and equipment were in place. Risk assessments were in place for the risk of legionella and water temperatures were checked and a record maintained. Notifiable incidents were being reported as required by the regulations. Also please see outcome for standard 29 re recruitment practices. Field View DS0000018253.V263799.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 2 2 Field View DS0000018253.V263799.R01.S.doc Version 5.0 Page 19 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 OP2 Regulation 5 Requirement All service users must have a copy of their individual terms and conditions (contract). Previous timescale not met. All parts of the homes assessment must be completed, dated and signed. Previous timescale of 30/6/05 not met. Further information must be added to care plans to meet residents’ needs including risk assessments. The medication record for the administration of medication must be completed after the medication has been administered to the resident. Amendments to medication records must be supported by a documented reason why. Documented discussions must be held with every resident at the home to ascertain their views and experiences of living in the care home. Action must be taken to address any concerns raised. The records must then be submitted to the CSCI. DS0000018253.V263799.R01.S.doc Timescale for action 31/03/06 2. OP3 14 31/01/06 3. OP7 15 31/01/06 4. OP9 13 31/01/06 5. 6. OP9 OP12 OP14 OP16 OP18 OP33 13 12 & 24 31/01/06 31/03/06 Field View Version 5.0 Page 20 7. OP16 22 8. OP18 13 9. OP27 17 10. OP29 19 11. OP33 24 12. 13. OP37 OP38 17 23 & 17 The complaints procedure must include the reply timescale and the name, address and telephone number of the CSCI. Previous timescale of 30/06/05 not met. Contact details of the local adult protection officer must be included in the homes adult protection policy/procedure. Previous timescale of 31/08/05 not met. All staff must be identified on the rota identifying the position in which they are working and the number of hours. A comprehensive recruitment process must be followed and demonstrated as required by the regulation and schedule 2. The quality assurance process must include consultation with residents and other stakeholders of the service to ascertain their views on the quality of the service provided. All records required by the Regulations must be maintained. Monthly checks must be made of fire fighting equipment. 31/01/06 31/01/06 31/01/06 31/01/06 31/03/06 31/01/06 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Field View Refer to Standard OP9 OP18 OP28 Good Practice Recommendations That medication carried forward from one month to another is recorded on the MAR sheet. A policy/procedure for physical and/or verbal aggression by a resident should be in place and understood and dealt with appropriately by staff. A minimum ratio of 50 of care staff should be trained in DS0000018253.V263799.R01.S.doc Version 5.0 Page 21 4. OP31 NVQ Level 2 in Care or equivalent. The registered manager should have a qualification at NVQ Level four in management and care (or equivalent) by 2005. Field View DS0000018253.V263799.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Field View DS0000018253.V263799.R01.S.doc Version 5.0 Page 23 - 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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