Inspection on 12/08/07 for The Firs

This inspection was carried out on 12th August 2007.

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

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

Other inspections for this house

The Firs 08/03/10

The Firs 24/11/09

The Firs 24/11/08

The Firs 10/10/06

The Firs 01/12/05

The Firs 22/07/05

The Firs 01/03/05

The Firs 18/05/04

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 Firs and 16 Margaret Road, The 141 Malvern Road Worcester Worcestershire WR2 4LN Lead Inspector Andrew Spearing-Brown DRAFT Unannounced Inspection 12th August 2007 11:50 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 Firs and 16 Margaret Road, The DS0000018684.V343396.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. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Firs and 16 Margaret Road, The Address 141 Malvern Road Worcester Worcestershire WR2 4LN 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) 01905 426194 F/P 01905 426194 Eldahurst Limited Mrs Sandra Lynne Ghalamkari Care Home 19 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (19), of places Physical disability over 65 years of age (15) Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The Firs may accommodate a maximum of 15 people in categories OP, and PD(E) and DE(E). 16 Margaret Road may accommodate a maximum of 4 people. The Firs may only accommodate a maximum of 2 residents with a dementia type illness. Margaret Road may not accommodate any person with a physical disability. 10th October 2006 Date of last inspection Brief Description of the Service: The Firs provides board, accommodation and personal care for fifteen people over the age of sixty-five years with physical disabilities. 16 Margaret Road is a separate semi-detached house that is divided from The Firs by their joint back gardens. The two properties are registered as one care home. The home is located in the St Johns area of Worcester. The two buildings are adapted and extended domestic dwellings providing four single bedrooms in Margaret Road and eleven single bedrooms and two double bedrooms in The Firs. There is one single room in The Firs that measures slightly less than ten square meters. All other bedrooms meet or exceed the National Minimum Standards. A shaft lift is provided in The Firs and a stair lift in 16, Margaret Road. The registered proprietor is the company Eldahurst Limited. The responsible individual and the registered provider is Mrs Sandra Lynne Ghalamkari. The registered provider stated that fees at The Firs and Margaret Road currently range from £353.00 to £425.00 per week. Charges / fees do not include hairdressing, chiropody (private) newspapers, clothing, spectacles, cigarettes and alcohol. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One regulation inspector based at the Worcester office of the Commission for Social Care Inspection (CSCI) undertook this unannounced key inspection. This inspection was conducted over a period of two visits to the home. The first visit took place on a Sunday while the second was on a weekday. This inspection takes into account information received by the CSCI in relation to the home since the previous inspection as well as the visits to the home. Prior to this inspection a Annual Quality Assurance Assessment (AQAA) document was requested. The AQAA is a self-assessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for providers to share with the CSCI areas that they believe they are doing well. It is a legal requirement that the AQAA is completed and returned to the commission within a given timescale. The registered provider completed this document and returned it the commission within the given timescale. Comments from the AQAA are included within this inspection report. As part of the inspection process a number of questionnaires were sent to a sample number of people using the service, their relatives as well as health and social care professionals. A number of completed questionnaires were returned to the commission from relatives and health professionals before the inspection and are taken into account as part of this report. The registered provider was present throughout the majority of this inspection. Discussions took place with some members of staff as well as a number of people using the service. One visitor was consulted during this inspection. A look around the home took place, which included a number of bedrooms as well as communal areas. The care documents of a number of people using the service were viewed including care plans, daily records and risk assessments. Other documents seen included medication records, service records and staffing records. What the service does well: Since the last inspection the registered provider has reviewed the information available to potential users of the service and their family. This information is available within the entrance hall and within each bedroom. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 6 A care needs assessment is completed before new admissions in to the home at which time an initial care plan is drawn up. The Firs and Margaret Road is registered to care for older people with a dementia type illness. The majority of staff have attended basic training with more advanced training due to take place in the future. One relative on a survey form stated ‘ I would have no hesitation in recommending The Firs to anyone who is looking to place their relative into a home.’ Another relative stated that the home ‘ shows genuine care, affection and attention towards its residents and their relatives.’ ‘ I am confident in the quality of care given to my **’. The same person stated that her relative had said ‘If I can’t live in my own home, then there is not another place I would rather be than here.’ Another survey received stated in answer to the question ‘ how the service could improve’. ‘They cannot, they are brilliant. Always helpful – this comes through when you enter the home the atmosphere is brilliant.’ Following the conclusion of the visits to the home but prior to the completion of this report a letter complementing the care provided at The Firs was received at the Worcester office of the commission. Medication records were well maintained and boxed medication had the date of opening recorded upon them. A range of social events are available including the provision of a number of external persons to undertake activities such as light exercises. Discussions were taking place with people using the service about outings and a possible short holiday. Communal areas within the home are warm and welcoming, people using the service seemed to be at easy with members of staff. The registered provider has made some temporary arrangements to address the requirements of recent smoking regulations. The grounds between the two properties were well maintained. Comments regarding the staff were complementary including ‘ Very caring and experienced.’ The number of staff who have completed their National Vocational Qualification (NVQ) training is above the National Minimum Standard for care homes providing care to older people. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 7 The registered provider demonstrated good caring skills throughout the whole of this inspection and clearly sees the welfare of people using the service as paramount. What has improved since the last inspection? What they could do better: The registered provider needs to ensure that all prescribed medication including creams and gels are held securely at all times in order to prevent the wrong person gaining access to them. The recording of any concerns or complaints needs to happen in order that the actions taken can be monitored and assessed. A number of shortfalls or concerns were noted within the environment. Some of these could be addressed without significant delay such as the lack of light bulbs in working order. Others shortfalls such as unsecured wardrobes and some cross infection risks need to be addressed. Although sufficient staff are usually on duty during the week the number on duty when staff are on holiday or at weekends is lower and needs to be reviewed. Recruitment procedures are not sufficiently robust to safeguard people using the service from people working within the home who may potentially be unsuitable. Policies and procedures within the home are in need of reviewing. Some concerns were apparent regarding health and safety systems within the home including a fridge whereby staff had continued to record very high temperature readings. Some cleaning materials were found to be unsecured and fire safety records were not up to date. One window was able to be opened in excess of the recognised amount posing a potential hazard and water delivered to one bathroom was too hot. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3, 4 and 5. Standard 6 is not applicable. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who may use the service have they needs assessed beforehand to ensure that care needs will be able to be met. Information is available to people to assist in their decision as to whether the home is suitable and people are invited to visit the home prior to admission. EVIDENCE: Since the last inspection the registered provider has reviewed both the homes statement of purpose and service users guide. These documents were not viewed in any great detail and therefore not fully assessed however one item seemed to be scant in content during the first visit to the home. The registered provider made this amendment between the two visits. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 11 It was pleasing to note that copies of these documents were available in the entrance hall of the home. The registered provider stated that a copy of the service users guide is within each bedroom therefore providing ease of access to people using the service. Evidence that people using the service receive a statement of terms and conditions was not sought during this inspection. One relative did comment on a survey that they had not received any formal papers. The file of a recently admitted person using the service contained a pre admission assessment carried out by the registered provider. The information available was sufficient to prepare an initial care plan. The Firs and Margaret Road is registered to care for up to six persons who may have a dementia type illness. As the care of people with such an illness is specialised staff need to be suitably competent. The previous inspection report noted that the vast majority of staff had received basic dementia care training. It was reported that the training needed to be on going and relevant to the needs of people using the service. Although we do not know the content of further planned training (advanced dementia) it is pleasing to see that the training is to continue. It continues to be evident that potential users of the service are invited to spend time within the care home prior to their admission. Intermediate care is not offered at either The Firs or Margaret Road. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 and 11. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health and personal care of people using the service is based on individual need and are well met. Care planning and risk assessing are improving in order that staff are provided with sufficient and suitable information to carry out care in a consistent manner. Medication administration is good although some aspect of security need improving. EVIDENCE: Individual care plans are in place for each person using the service. As part of this inspection a sample number of care plans were viewed. The previous inspection noted that care plans had improved however the information on them was cramped and difficult to comprehend. The registered provider has made a number of additional changes since the last inspection and has implemented further changes to the care planning process. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 13 The progress made is good and needs to continue over the coming months. The Commission is confident that the progress made will be sustained. Risk assessments were in place covering matters such as moving and handling, pressure sore prevention and nutrition. One visiting professional confirmed that staff at the home call a G.P if they have concerns about the health of anybody using the service. It was of some concern that unsecured medication was located within the office. Some painkillers were on a shelf while other items including inhalers and some gel were elsewhere within the office. The management of medication was generally in good order. Staff members complete a sheet at the end of each shift to verify that they had signed all the MAR (Medication Administration Record) sheets. A photograph to aid in recognition of people using the service was located prior to the majority of MAR sheets. The MAR sheets were signed as required to demonstrate that medication was administered as prescribed. If medication was not given for a particular reason this was suitably recorded on the MAR sheet concerned. Additional information such as whether individuals had any allergies was recorded. Handwritten amendments to MAR sheets were double signed and medication was booking in as necessary. The medication trolley was secured to the wall. The contents of the trolley were in good order. Boxed and bottled medication had the date of opening recorded upon them as required. A small amount of controlled medication was held and checked against the CRD (Controlled Drugs Register). The records were in good order and balanced accordingly. Post addressed to a person using the service was displayed in the entrance hall waiting to be collected by a relative. It was noted that the postmark was dated over 3 weeks prior to this visit. People using the service appeared to be well dressed taking into account both gender and weather conditions. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 14 The registered provider demonstrates a caring attitude and philosophy especially in relation to the care of poorly or terminally ill people. The caring nature of the registered provider was highlighted in a recent letter received at the commission. Firs and 16 Margaret Road, The DS0000018684.V343396.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): Standards 12, 13, 14 and 15. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A wide range of social activities and entertainment is provided for groups and individuals to take part in as a means of stimulation and interest. A limited choice of menu is provided so that people using the service can select the meal they prefer. EVIDENCE: Visitors are able to call to see their relative / friend at any reasonable time. Visitors are able to use communal areas such as the lounge or dining room as well as the bedroom belonging to the person living in the home as they wish. A signing in and out book is maintained and completed by visitors. During this inspection one visitor was consulted who made a number of positive comments regarding the home. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 16 It was stated that opportunities are available for people using the service to partake in quizzes and movement to music. Another person stated ‘plenty of activities.’ A range of activities take place led by care staff. Other activities are led by people who visit the service such as musicians or somebody to take light exercises to music. During this inspection evidence was seen of a recent quiz and a member of staff were leading a game of I Spy. Bingo with small prizes occurs three times per week. During this inspection we observed somebody attended the home to carry out nail care including a number of people using foot spas. One person was seen doing a jigsaw puzzle. The registered provider was aware that the picture was not really age appropriate and was seeking some more suitable ones. Activities within Margaret Road tend to be less formal such as involvement in daily tasks or going for a walk. People using the service at Margaret Road join people within The Firs when entertainment is provided. Discussions were taking place between people using the service and staff regarding a proposed day outing to the coast. A small number of people may also be going on a short holiday in the near future. Religious care needs are meet by means of services occurring within the home. Once a month a communion service happens in addition to a monthly visit which involves hymn signing. We joined people using the service for lunch on the day of the second visit. The meal was cold turkey, chips, peas and a side salad. A number of people had faggots in place of the turkey. The sweet was a choice between baked peach and ice cream or rice pudding. The lunchtime was a pleasant social event, which seemed to be enjoyed by people in the dining room. The meals were plated up in the kitchen. Meals were well presented and appetizing. One person needed some assistance and encouragement to eat her lunch; this was carried out by the registered provider and was done with respect, sensitivity and patience in an unhurried manner. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 17. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Differing information regarding complaints within the home could be confusing. Complaints need to be fully recorded to ensure that comments are suitably actioned. Forthcoming staff training upon safeguarding adults should assist in protection against potential abuse or harm. EVIDENCE: The registered provider stated upon the AQAA document that the home had received one complaint over the last 12 months. It was stated that the matter was in relation to some missing towels. During the inspection it was reported that a relative had recently voiced some concerns to a member of staff. Following the initial contact the registered provider discussed the concerns with the complainant and believes that the matter is now resolved. The registered provider is readily available to visitors should they have any concerns regarding the care provided within the home. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 18 A complaints procedure is included within the service users guide and statement of purpose, which are available in the entrance hall and within bedrooms. In addition a file containing sheets to record complaints were available within both The Firs as well as Margaret Road. The complaints procedure within the complaints log was different to the one in the service users guide. Having two complaints procedures could be confusing and therefore one needs to be adopted as the homes actual procedure. Neither of the complaints mentioned above or the action taken to resolve the matters were recorded as required. The commission for social care inspection have received no complaints regarding the service offered at The Firs and Margaret Road. A number of cards complimenting the service were on display. The registered provider had a copy of the Worcestershire Adult Services procedure regarding adult protection. The homes own policies need to be revised and made more individual to the service. Information was displayed within the home regarding safeguarding adults. Training regarding the protection of vulnerable adults is booked for all members of staff during October 2007. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 19 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): Standards 19, 20, 23, 25 and 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People using the service reside in a comfortable and relaxed environment however a number of further improvements are needed to safeguard people against potential risks. EVIDENCE: The Firs has a pleasant lounge as well as a parlour and dining room. The dining room is within a conservatory, which can be affected by extremes of heat. Over recent inspections the registered provider has indicated a desire to improve the roof however this has proven to be unpractical. At the time of this inspection a large fan was situated within the dining area to reduce the air temperature. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 20 Communal areas within the main house are warm and welcoming. Pictures are displayed in the dining room of Worcester as well as events within the home. Both properties are generally well maintained with any maintenance work receiving prompt attention. A door was found to be hanging off its hinge; the registered provider had no knowledge of this matter. It is disappointing that nobody had reported this potential hazard however once discovered the matter was addressed. The lighting within the main building was of some concern due to the number of light bulbs not working. Within the main lounge 50 of the bulbs were not working. One person within the lounge stated that they had not worked for a week. Further lights were found to not be working in a bedroom and a corridor area. Radiators seen were covered to prevent accidental scalding. Some pipe work along a corridor was warm to the touch therefore requiring a risk assessment and suitable action to reduce the potential risk. A sample number of bedrooms were seen. It was evident that people using the service are able to bring personal belongings into the home with them. The previous report highlighted that a wardrobe was not secured to prevent accidental toppling, this remained to be the case. A sliding door to a toilet in Margaret Road closed fully however it would be possible to see somebody using the facility from the hallway therefore a privacy and dignity issue that needs to be resolved. The previous inspection report demonstrated a potential risk of cross infection due to having bars of soap within communal area. During this inspection bars of soap were found to be in place as well as linen towels. The seal on the fridge in Margaret Road was dirty. During previous inspections the small lounge which is also used for hairdressing and chiropody was available for people using the service to smoke. Following recent changes in legislation the registered provider has designated an area outside which is covered by a gazebo as a smoking area. During the current warmer weather this arrangement was reported to be working satisfactorily. The garden between the two properties is very well maintained with a pleasant lawned area and flowerbeds including a garden of remembrance. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 21 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): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staffing levels at weekends remain adequate. The number of staff qualified to National Vocation Qualification level 2 is above the minimum standard required. Recruitment procedures are not sufficiently robust to ensure that people using the service are fully safeguarded. EVIDENCE: Either during the inspection visits or upon the questionnaires returned to the commission staff working within the home were described as: ‘ Very caring and compassionate’ ‘Very caring and friendly.’ ‘Very caring and experienced.’ A letter within the home stated that staff ‘ take good care of me’ and ‘always do more than expected.’ Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 22 It was commented by one person that the home requires more staff at the weekend. Weekend staff within The Firs consists two carers plus a domestic. During the week there are usually four carers on duty however on the day of the second visit to the home only two carers were on duty plus domestics and catering staff due to staff holidays. The vast majority of carers working at the home are female. No agency staff are used at The Firs and Margaret Road as the registered provider wishes to ensure consistency as far as possible. Currently a total of eight carers hold a NVQ (National Vocational Qualification) level 2 in addition three hold a level 3 qualification. As the staff team consists of a total of nineteen carers the number of staff holding a NVQ represents over 50 of the workforce. An additional two carers are about to commence on their NVQ training in the near future. The files of some recently appointed staff were viewed. Recruitment procedures, although improved from previous inspections, remain insufficient in order to meet the National Minimum Standard and therefore safeguarding people using the service. Shortfalls found during the inspection included a lack of application forms and references. Suitable PoVA (Protection of Vulnerable Adult) first checks and enhanced CRB (Criminal Records Bureau) disclosures were available for staff who had not worked within the home in the past, however these were not carried out on staff who had worked within the home in the past. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 23 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): Standards 31, 33, 34, 35, 36, 37 and 38. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The registered provider has extensive experience in managing a residential care setting and provides a service which is run in the best interests of people residing in the home. Documentation and safe systems are in need of improvement in a number of health and safety areas to ensure people using the service are safe. EVIDENCE: The registered provider is suitably experienced to manage a care home. She has undertaken the Registered Manager Award and is planning to commence Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 24 upon level 4 National Vocational Qualification in management in September 2007. No cash is held on behalf of people using the service. Any expenditure such as hairdressing is invoiced to either the individual concerned or their representative. The certificate of public liability insurance was on display. The previous report showed some improvement regarding the formal supervision of staff; the associated National Minimum Standard remains unmet, as progress has not continued. The previous inspection report highlighted that the registered provider had sought external advice to carry out some work and introduced a quality assurance system. The completed document, dated April 2006, needs to be reviewed and evaluated to assess the progress made since that date. Policies and procedures were not viewed as part of this inspection. In the past we have made comments regarding the need to ensure that they are suitable and individualised to the home rather than generic. The registered provider acknowledged that work to complete this task needs to take place and stated that this work is in hand. Temperature records were maintained regarding the fridge in the kitchen at Margaret Road. It was however of some concern that the recorded temperature were extremely high meaning that either the fridge or the thermometer was malfunctioning. Systems need to be in place to bring such malfunctions to the attention of the senior staff so that appropriate action can be taken to safeguard people using the service. It was of some concern that cleaning materials were unsecured within Margaret Road. One container clearly stated ‘ Keep away from eyes.’ As a similar concern was highlighted within the previous report and taking into account the mental health needs of people using this service this is a worry and must receive suitable attention to prevent any further reoccurrence. A cupboard containing other items had a lock available but it was not in use therefore leaving the area open to people using the service who have a dementia type illness. A bedroom window in the Margaret Road property could be opened in excess of the guidance issued by the Health and Safety Executive. Suitable measures need to be taken to ensure the health, safety and welfare of people using the service regarding window opening to prevent accidental or deliberate falling to the ground. The required health and safety poster was on display however the details upon it appertaining to the home were faded and therefore in need of redoing. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 25 Environmental risk assessments continue to need further improvement. The records regarding the servicing of hoisting and lifting equipment were viewed. The passenger lift (located in the main house) and chair lift (located in Margaret Road) were serviced during June 2007, however the bath hoist was last serviced during December 2006 and therefore out of date. Portable electrical items were recently tested and the gas safety certificate was still in date. Fire safety records were not up to date. It was evident that the weekly testing of the alarm had taken place in sequential order. However monthly testing / visual checking of fire fighting equipment, self closing doors and emergency lighting had not taken place since April 2007. The vast majority of staff had received fire training during February 2007 with further training having taken place during May 2007. Water temperature records were found to be in good order however the temperature of the hot water in the downstairs bathroom was considered to be hotter than 43 ° C. On viewing training records it was evident that the vast majority of staff have undertaken mandatory training. It was however noted that some shortfalls in moving and handling and food hygiene remain. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 2 X X 3 X 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 3 3 2 2 2 Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15 (1) Requirement Improvements within the care planning documents must continue and cover all area of care need. Care plans must be available to carers with up to date and sufficiently detailed to identify care needs. Medication within the care home must be held securely at all times Any concerns or complaints made must be recorded along with the action taken to resolve the matter. Timescale for action 30/10/07 2 OP9 13 (2) 12/08/07 3 OP16 22 30/09/07 Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 28 4 OP18 13 (6) Staff must have sufficient knowledge regarding the safeguarding of vulnerable people and the associated procedures. The above requirement is similar to a requirement with a timescale of 28/02/07. This requirement is unmet. A revised timescale is given for full compliance. 30/11/07 5 OP19 13 (4) Environmental risk assessments must be carried out throughout the care home and appropriate action must be taken in relation to identified hazardous situations such as the securing of wardrobes to prevent accidental toppling over, the delivery of hot water and hot pipe work. The above requirement is similar to a requirement with a timescale of 31/12/06. This requirement is unmet. A revised timescale is given for full compliance. 31/10/07 6 OP26 13 (3) A further review must take place within the home regarding the risk of cross infection by means of having bars of soap available within communal areas of the home. The above requirement is similar to a requirement with a timescale of 31/01/07. This requirement is unmet. A revised timescale is given for full compliance. 31/10/07 Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 29 7 OP29 19 Recruitment procedures must be developed and implemented in accordance with the requirements of Regulation 19, Schedule 2 and Standard 29. Previous timescale of 31/03/05 and 05/07/05 not met. Revised timescale of 01/12/05 and 10/10/06 part met. This requirement must now be met without further delay 30/09/07 8 OP37 17 Policies and procedures within the home must be specific and relevant to the home. Previous timescale of 31/01/07 not met. A revised timescale is given. 30/11/07 9 OP38 13 Risk assessments must be carried out and recorded for all the safe working practices topics covered in Standards 38.2 and 38.3 Previous timescales not fully met. A new timescale is given for full compliance. 30/11/07 10 OP38 13 (4) All hazardous items, including cleaning materials must be held securely at all times. The previous timescale of 01/12/05 was not met. This requirement must be met immediately and must be on going Previous timescale of 01/12/05 and 17/11/06 not met. This requirement must now be met without further delay 30/09/07 Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 30 11 OP38 13 Systems must be in place to promote the health safety and welfare of people using the service. The above requirement replaces a similar requirement following the previous inspection with a timescale of 31/12/06 A new timescale is given for full compliance. 30/09/07 12 OP38 23 4 (A) Accurate and up to date fire records must be maintained. 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP33 OP37 Good Practice Recommendations It is strongly recommended that the quality assurance document is reviewed and evaluate. A business or financial plan should be available for the establishment that is open to inspection and reviewed annually. (Not assessed on this occasion) 3 OP36 All members of staff should recieve formal supervision that includes all aspects of practice, philosophy of care in the home and career development needs at least 6 times a DS0000018684.V343396.R01.S.doc Version 5.2 Page 31 Firs and 16 Margaret Road, The 4 OP38 year. It is strongly recommended that person who carry out in house fire awareness training undertake fire warden training. This recommendation remains in place although believed that training is now booked. Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Firs and 16 Margaret Road, The DS0000018684.V343396.R01.S.doc Version 5.2 Page 33 - 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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