Inspection on 19/07/07 for Foxwood

This inspection was carried out on 19th July 2007.

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

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

Other inspections for this house

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

CARE HOMES FOR OLDER PEOPLE Foxwood 1 Ridgeway Road Sheffield S12 2TW Lead Inspector Nadia Jejna Key Unannounced Inspection 09:30 19th July 2007 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 DS0000067337.V331354.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. DS0000067337.V331354.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Foxwood Address 1 Ridgeway Road Sheffield S12 2TW 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) 0114 239 4414 0114 239 4284 susan.spooner@sheffield.gov.uk None Sheffield Care Trust Miss Susan Denise Spooner Care Home 19 Category(ies) of Dementia - over 65 years of age (19) registration, with number of places DS0000067337.V331354.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Where additional services are provided eg day care, outreach, escort duty, staffing for this must be over and above that provided to service users required by the home care. 16th October 2007 Date of last inspection Brief Description of the Service: Foxwood is a purpose built care home located in the Manor area of Sheffield. It is easily accessible by public transport and is within walking distance of the local shops. The home specialises in providing short term respite care/short breaks to people with dementia. Up to nineteen people over the age of 65 can be accommodated in single bedrooms. The home is on one level and all areas are easily accessible to people of all abilities. There are two dining rooms, two comfortable lounges and an open seating area. The home stands in its own grounds but the land is not fenced in and not safe for people to walk around because it is close to the main road. There is an open patio area in the centre of the building, the quadrangle, that has been provided with garden furniture and pot plants making it a pleasant area for people to sit in when the weather permits. Attached to the home is a day care service that works with over 60 people. People staying at the home for respite breaks often attend the day centre and are welcome to use the day centre facilities when staying in the home. Infromation about the service is avaiable to people in the Statement of Purpose and Service User Guide. Copies can be provided on request. Before people come to the home for their first stay this information is sent out to them with a ‘welcome pack’ of information. Files containing this information are kept in every bedroom. Information received from the manager in April 2007 said that weekly fees for services provided ranged from £90 to £371. DS0000067337.V331354.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One visit was made on 19th July 2007. The home did not know that this was going to happen. Feedback was given to the operations manager at the end of the visit. The manager was on annual leave at the time of the visit and was contacted by telephone on 25th July so that feedback could be provided and for some further information to support the findings of the visit. Before visiting the home information was asked for from the manager in the pre inspection questionnaire (PIQ). This asks about what policies and procedures are in place and when they were last reviewed, when maintenance and safety checks were carried out and by who, menus used, staff details and training provided. Comment cards were sent to the home to be given to people living in the home, their relatives, other visitors and staff to find out what their views of the home were. The views of healthcare professionals who visit the home were also asked for. At the time of writing this report two staff, one healthcare professional and three responses from people living in the home had been returned. Because people living in the home have some form of dementia some had been helped by staff or relatives to complete their responses. In order to find out how well staff knew people care plans were looked at during the visit and people were spoken to. Interactions between staff and people living in the home were observed. Other records in the home were looked at such as staff files and complaints records. What the service does well: Information about services provided by the home is available and people can visit to look round at any time to see if it will be suitable for them. People said that the home was warm, friendly and welcoming. Visitors said that they could call in at any time. The atmosphere in the home was cheerful and it was clear that staff had good relationships with the people living there and their visitors. People living at the home and their visitors said that: • They were satisfied with the care and services provided. • They got the care and support they needed. • They liked the food and got enough to eat. DS0000067337.V331354.R01.S.doc Version 5.2 Page 6 • • • They could choose when to get up, go to bed and where and how to spend their time. They knew who to speak to if they had any concerns. Relatives were kept informed of any changes. Staff have good insight and understanding of individual’s strengths, abilities and needs. The staff respect and treat people as individuals and make sure that their dignity is maintained. What has improved since the last inspection? What they could do better: In order to make sure that people fully understand the services provided by the home and staff team additional information provided should be made available. For example: • How referrals for short breaks and respite care are made and what people should do if they want to receive this type of care. • When the home might say they cannot provide a service to somebody or ask them to stop coming. For example if the person has challenging behaviour that presents a risk to other people in the home and staff. • More information about staff training, especially the dementia training that should be given to all staff because it is a specialist unit for people with dementia. • What the homes policy is around staff escorting people to hospital at night or in emergency situations. • More detailed information about the homes policy around medications and what people need to do to help staff look after their medicines safely. To make sure that staff can meet individuals needs detailed care plans must be in place that provide information and guidance about the persons strengths, abilities and needs and how they can help them. In order to reduce the risk of mistakes being made when dealing with medications the manager must make sure that safe systems are in place for dealing with medications, appropriate records are kept and that all staff are appropriately trained. DS0000067337.V331354.R01.S.doc Version 5.2 Page 7 When the next redecoration of the home is being planned the manager should look at guidance that is now available around décor and environments for people with dementia. This will help people living in the home to find their way around more easily. 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. DS0000067337.V331354.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 DS0000067337.V331354.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, 2, 3 and 5. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can visit the home and are given enough information to be able to make an informed choice that it will be suitable for them. EVIDENCE: Since the last inspection in October 2006 the home has come under the ownership of the Sheffield Care Trust. Information given to people about the services provided has been changed to show this. The documents seen would benefit from additional information that would provide people with more clarity about the service, for example: • How referrals for short breaks and respite care are made and what people should do if they want to receive this type of care. • When the home might say they cannot provide a service to somebody or ask them to stop coming. For example if the person has challenging behaviour that presents a risk to other people in the home and staff. DS0000067337.V331354.R01.S.doc Version 5.2 Page 10 • • • More information about staff training, especially the dementia training that should be given to all staff because it is a specialist unit for people with dementia. What the homes policy is around staff escorting people to hospital at night or in emergency situations. More detailed information about the homes policy around medications and what people need to do to help staff look after their medicines safely. Information from people using the service and their relatives said that they had been provided with all the information they needed about the home and services provided. One said they had called in to look round and staff had been very helpful and answered all their questions. Because the home provides a specialised service all people who come for short breaks have had their needs and abilities assessed by social workers, and in some cases by community psychiatric nurses. Staff at the home request copies of these assessments before making arrangements for the person to stay. They use the information to make sure that the persons can be met. Staff said that sometimes this information is late in being sent to them. An assessment of needs for one person who came to stay on the Monday had been sent by fax late on Friday the week before. The assessments had been carried out nearly nine months ago and were not up to date. The manager was advised to ask social workers to make sure that assessments were up to date at the point of requesting short term breaks from the home. Information from people using the service and their relatives said that: • They had received contracts for services provided. • The staff were very friendly and helpful. • Their relative looks forward to the visits to the home and the day centre. DS0000067337.V331354.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 and 10. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s needs are identified and met but there is a risk that they may be overlooked because the care plans do not always evidence this. The practices around dealing with medication need to be made more robust to prevent the risk of mistakes being made. EVIDENCE: The Service User Guide and the homes principles of care state that people will be treated with dignity and respect. Information from people using the service confirmed that this does happen. They also said that: • They got the care and support they needed. • Staff listened to them and acted on what they said. • They received the medical support they needed. • Relatives were kept informed of any changes. DS0000067337.V331354.R01.S.doc Version 5.2 Page 12 Information from a visiting health care professional said that staff sought advice and followed recommendations made. They said that people’s privacy was respected. Staff had a very good understanding of individuals needs, what their abilities where and what help they needed. They said they were aware of peoples needs from looking at the care plans, getting to know them as individuals and talking to them and relatives. Information about peoples needs, how to meet them and daily records are kept in two files. There was no care plan in place for a person who had arrived at the home for their first stay three days ago even though the social workers assessment information had been sent to the home the previous Friday. Two other care plans for people on repeat visits were looked at. They showed that the person’s strengths, abilities and needs had been identified; but did not provide detailed guidance about how to meet them. They did not say how the type of dementia the person had affected them or what staff could do to help them. The operations manager and the manager said that they were aware of problems with the care plans and were working to resolve them. This includes recruiting team leaders who will be responsible for writing care plans. It is recommended that all staff involved with care planning receive training in person centred care planning. The manager said that they are asking peoples relatives for more information about their social and life histories and have had a good response. This information will be used to make the care plans more personalised to the individual. Senior staff/team leaders are involved with looking after people’s medications. The operations manager said they have all had training from the local authority and were ‘deemed competent’. Now that the home comes under the Care Trust there is a new training programme. The operations manger and a team leader have completed a two-day training course around medication and they will be responsible for providing this training to other staff. A workbook will be used which when completed and ‘signed off’ will show whether or not the individual is able to handle medications. People bring their own medications with them when they come to the home and they are advised that it should be in containers with the original pharmacy label on it. Staff said that sometimes people forget to bring the medication with them or it is not in the original container it was dispensed in. They were advised to make the information about medication easier to understand and clearer in the Service User Guide and welcome packs that are sent out to people. During the visit some problems with medication were found. The medication administration records one person showed they had been at the home for three nights but only been given their night time medication on one occasion. The tablets were checked and only one had been taken each pack. There was no information on the MAR, the daily record or the staff communication book to explain this. Staff recalled why it had not been given DS0000067337.V331354.R01.S.doc Version 5.2 Page 13 on the first night but were reminded that it should have been recorded clearly in the care plan. There was no explanation why it had been missed on the third night. When looking through incident forms and reports it was found that there had been two incidents where drug errors had been made. These had not been reported to CSCI as required under Regulation 37. They had been investigated by the Care Trust and appropriate action taken to maintain the health and well being of the people involved. The investigations found that when the people had been admitted the medications had not been properly checked and staff were told to be more vigilant. A requirement has been made about care and safety when dealing with medications as well as a referral to the CSCI pharmacy inspector. DS0000067337.V331354.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can maintain contact with their family and friends and can exercise choice and control over their lives. EVIDENCE: During the visit it was clear that staff promoted and respected peoples choices about how they wanted to spend their day. People said that they chose when to get up and go to bed, where they wanted to eat their meals and whether or not they wanted to join in with planned activities. The atmosphere in the home was warm, welcoming and friendly. Visitors said that they could call in at any time and it was clear that there were good relationships between people living in the home, visitors and staff. When staff were not busy with other duties they spent time sitting and chatting with people. The specialist day care centre is part of the building and many people who come to the centre also come for regular respite care. The day centre is well DS0000067337.V331354.R01.S.doc Version 5.2 Page 15 equipped with lots of different recreational aids and people staying in the home can use them and spend time in the centre. The home has three lounge/seating areas that have been comfortably furnished and equipped. People can choose if they want to sit in a quiet room, the TV room or the music area. It had been identified in a visit by the responsible individual in April 2007 that people had commented there was not much to and staff must make sure activities take place and that all tastes are catered for. Activities are not planned rigidly but do take place every day. Staff spend time with people doing different things. On the morning of the visit they had watched a musical and sung along with it, a carer had given some people a hand massage and manicures. There was a music hall sing along in the afternoon and after tea a carer sat with people looking at books of days gone by and talking about the memories brought back by the pictures. The staff do a lot of fundraising to raise money to purchase equipment for activities and pay for entertainers to come into the home. Many have donated videos, games and books for people staying in the home to use. They are to be commended for all their efforts in this area. The home has two dining rooms, a larger one for people at the day centre and another for people staying at the home. People can choose which room they want to use. The tables were nicely set at lunchtime and people staying in the home can help with this if they want to. The meals served looked appetising and people were not rushed, allowing it to be a sociable occasion. People said that the food was good and they got enough to eat. The chef provides one main course at lunchtime but said that alternatives such as omelettes, sandwiches etc. were always available. DS0000067337.V331354.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are safe and protected from abuse. EVIDENCE: There is a complaints procedure in place and people are given a copy of it with the Service User Guide and Statement of Purpose. The welcome and information pack in each bedroom also has a copy included. There have been no complaints about the services provided by the care home since the last inspection. The manager said that systems are in place to deal with complaints should the need arise. Information from people using the service said that they knew what do if they had a concern and they knew whom to speak to if they were unhappy. The home has copies of the Care Trust and local authority adult protection procedures. Not all staff have received training around abuse and adult protection but plans are in place to make sure they get it. Staff spoken to said they would not hesitate to report actual or suspected abuse. DS0000067337.V331354.R01.S.doc Version 5.2 Page 17 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, 20, 24 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in clean, well-maintained home that is suitable for their needs. EVIDENCE: The home was clean, tidy and appeared well maintained. The last fire safety officer’s visit was in March 2006 and the PIQ said that all recommended work had been done. Information from surveys said that the home was always fresh and clean. Because the home is built on one level all areas are accessible to people of all abilities. There are three lounge/sitting areas and two dining rooms. They have been comfortably furnished and have views of the outside areas. The home has an open patio area in the centre of the building (The quadrangle) where people can sit when the weather permits. Through their fundraising efforts staff have been able to provide garden furniture and plants to make it more DS0000067337.V331354.R01.S.doc Version 5.2 Page 18 attractive. This is a safe outdoor area for people to use. The gardens on the outskirts of the buildings are not safe because they have not been fenced in and are close to a very busy main road. Some of the fire exits that open out into these areas have had to be bolted so that people cannot leave the building by these routes. The manager said that this had been discussed with the fire safety officers. The home was redecorated and refurbished four years ago. All areas were bright and clean but they were all the same and it was difficult to know which part of the building you were in. Bedroom doors had numbers on them but they were small and high on the door and could be difficult to see, it was the same with signing on bathroom and toilet doors. All bedrooms were decorated and furnished in the same way. Because of this it could be difficult for a person with dementia to find their way around the home. This was confirmed by a member of staff saying that when they when they first started working at the home they had struggled to remember the layout of the building. During feedback at the end of the visit the manager said that she had been looking into what would make good environments for people with dementia and would take this into consideration when planning the next redecoration of the unit. The laundry room is small and staff have done their best to follow good infection control practice with the way dirty and clean laundry is dealt with. Peoples clothes looked well laundered and looked after. DS0000067337.V331354.R01.S.doc Version 5.2 Page 19 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 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are enough competent staff on duty to meet peoples needs. EVIDENCE: Copies of staff rotas received on the day of the visit showed that there were enough staff on duty to meet the needs of people living in the home. This was confirmed in information received from people living in the home, their relatives and staff. Because of staff vacancies and sickness agency staff are used to make sure numbers on duty are maintained. Some staff have been at the home for more than five years and this provides people with continuity and stability. At night there are two staff on duty which is sufficient to meet peoples needs; but if there is an incident where a person has to go to hospital they cannot send an escort with them. There is an ‘on call’ manager for them to contact but people will be at hospital alone under the care of hospital staff. For people with dementia this might cause added distress and confusion and they would benefit from having somebody familiar with them. The manager was advised to make it clear in the information about the service that this is what happens and that at these times the relatives may need to be contacted to meet the person at hospital. DS0000067337.V331354.R01.S.doc Version 5.2 Page 20 The records for two staff employed since April 2007 were looked at. They showed that all the required pre employment checks had been carried out, including two written references, proof of identity and satisfactory enhanced Criminal Records Bureau disclosures. The application forms should be revised as they asked for ten years employment history rather than a full one. The manager said that interview records were made but the files seen did not have them. The operations manager said that new staff would attend a trust one day induction training course within the first month of employment. They are then enrolled on the local authority induction training, which is to Skills for Care common induction standards within two months. One of the new staff had completed this training and the second was doing it in July 2007. Some staff have done dementia care mapping training in the past but not used the skills for some time. Some staff have done training around dementia awareness, conflict resolution, ‘break away’ techniques and diversity. Caring for people with dementia is the homes speciality and all staff should receive this training. The manager and operations manager are aware that there are gaps in the training and updates provided to staff and are in the process of identifying who needs what training. This must include training to maintain the health, safety and well being of people living in the home and staff such as health and safety, moving and handling, fire safety, infection control, food hygiene as well as specialist care needs of people. The PIQ said that out of twenty-two care staff, twelve had NVQ (National Vocational Qualification) level 2 or higher. Staff said they had enjoyed this training and achieving the qualifications and hoped to progress further. DS0000067337.V331354.R01.S.doc Version 5.2 Page 21 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, 32, 33, 35 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is run and managed in the best interests of people using its services. EVIDENCE: The manager has been at the home for some time and is experienced in looking after people with dementia. She is in the process of completing an NVQ level 4 in care and will then enrol on the registered managers award training. Information from people using the service, their relatives and staff said that the management team was open, approachable and supportive. People felt confident to talk to the manager or senior staff with any concerns or issues that they might have. Staff said that regular team meetings were held when DS0000067337.V331354.R01.S.doc Version 5.2 Page 22 they could talk about any problems, issues or ideas that they might have. They said that the staff team worked well together. The Trust has quality assurance systems in place that includes monthly visits to the home by a Trust representative. Written reports are produced after these visits and copies are sent to the manager and made available to CSCI. The PIQ said that policies and procedures are in place and available to staff. They were revised in January 2007 and the updated versions were being made available. Managers and team leaders have been given training around the policy updates and will share this with staff. People using the service are asked to complete a survey after each stay giving the manager their views and saying if they were satisfied or not with services provided. The completed survey forms are sent to the ‘Patient Experience and Practice Development’ department. The information is collated and a summary returned to the home. Copies can be provided on request and will be included with the Service User Guide. Because people come to the home for short breaks the home does not get involved with looking after their finances. If people want money to be held in safekeeping for them during their stay there are facilities for this. There is a safe in the team leaders office and receipts are issued for all monies taken into safekeeping and returned to people. The recording system was looked at and it showed that all monies received and returned were accounted for. Details of when last the safety and maintenance checks of equipment in the home were carried out, including details of servicing contracts for equipment such as bath aids/hoists, central heating systems and boilers were included in the PIQ. They showed that these checks were up to date. Incident and accident reports are kept which are audited each month. On looking at these two incidents were found where drug errors had been made. They had been properly dealt with and appropriate action taken to make sure the person involved was safe. But the incidents had not been reported to CSCI as required by law. The manager was made aware of this. She said that the Trust had said they would deal with this but that in future she would make sure she made the reports to CSCI herself. The accident reports seen would benefit from addition information about when the person was last seen before the accident/incident and by whom. This will help with auditing and following outcomes of accidents. DS0000067337.V331354.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X X 3 X X 2 DS0000067337.V331354.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement In order to make sure that staff have enough information about peoples needs and how to meet them the manager must make sure that detailed, individual care plans are in place. The care plans should provide detailed guidance about how to meet the person’s health, social, personal and specialist care needs. Staff involved with writing care plans must receive appropriate training. 2. OP9 13(2) In order to maintain the health, safety and well being of people needing help with their medications, the manager must make sure that safe systems are in place for dealing with medications, appropriate records are kept and that all staff are appropriately trained. In order to maintain the health, safety and well being of people living in the home and DS0000067337.V331354.R01.S.doc Timescale for action 30/11/07 31/08/07 3. OP30 18(1)(a) (c)(i) 30/12/07 Version 5.2 Page 25 themselves staff must receive appropriate training. For example health and safety, moving and handling, fire safety, infection control, food hygiene and specialist care needs of people such as dementia and dealing with challenging behaviour. 4. OP38 37 The manager must make sure that reports of incidents that affect the well being of people living in the home are reported to CSCI as required by Regulation 37. 30/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations In order to make sure that people have access to all information they need about services provided by the home the provider should consider adding the following information to the Statement of Purpose and Service User Guide. • How referrals for short breaks and respite care are made and what people should do if they want to receive this type of care. • When the home might say they cannot provide a service to somebody or ask them to stop coming. For example if the person has challenging behaviour that presents a risk to other people in the home and staff. • More information about staff training, especially the dementia training that should be given to all staff because it is a specialist unit for people with dementia. • What the homes policy is around staff escorting people to hospital at night or in emergency DS0000067337.V331354.R01.S.doc Version 5.2 Page 26 • situations. More detailed information about the homes policy around medications and what people need to do to help staff look after their medicines safely. 2. OP18 In order to protect people using the service the manager should make sure that all staff receive training around adult protection and abuse. DS0000067337.V331354.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 DS0000067337.V331354.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!