Inspection on 24/02/09 for Frenchay Park Nursing Home

This inspection was carried out on 24th February 2009.

CSCI found this care home to be providing an Adequate service.

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

Frenchay Park Nursing Home 13/06/08

Frenchay Park Nursing Home 14/08/07

Frenchay Park Nursing Home 27/02/07

Frenchay Park Nursing Home 13/07/06

Frenchay Park Nursing Home 10/02/06

Frenchay Park Nursing Home 10/06/05

Frenchay Park Nursing Home 03/11/04

Frenchay Park Nursing Home 11/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Frenchay Park Nursing Home 140 Frenchay Park Road Frenchay Bristol BS16 1HB Lead Inspector Sandra Jones Key Unannounced Inspection 09:00 24 & 25th February 2009 th 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 DS0000034485.V374284.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. DS0000034485.V374284.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Frenchay Park Nursing Home Address 140 Frenchay Park Road Frenchay Bristol BS16 1HB 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) 0117 9659957 0117 9653936 frenchay@westburycare.co.uk Ms June Marilyn Phillips Mr Gordon Norman Brooking, Mr Derek Marsh Mrs Leanne Williams Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places DS0000034485.V374284.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 30 13th June 2008 Date of last inspection Brief Description of the Service: Frenchay Park is registered as a Care Home to take up to 30 residents requiring nursing care. The Home is on the edge of Bristol near to the ring road and motorway junction. It is a short journey away from the high street in the Fishponds district, which is the main shopping area. The home is 4 miles away from the centre of Bristol and can be accessed by car or bus as it is on a main bus route. The home is a converted older property with single and shared bedrooms on two floors. There are two lounges and a separate dining room. There is a passenger lift providing access to all service user areas. All parts of the home are accessible to wheelchair users. The cost per week to live at Frenchay Park Nursing Home will cost from £498 to £525. This weekly fee does not include provision for things such as hairdressing, chiropody, dental, ophthalmic, or audiology services. Prospective residents can get information about the home by looking at the Service Users Guide kept in the main entrance, which gives details of the services and facilities available at the home. The entrance table also has a copy of the most recent inspection report. DS0000034485.V374284.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. This key inspection was conducted unannounced in February 2009 over two days and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedures. During the site visit, the records were examined and feedback was sought from individuals and staff. Prior to the visit some time was spent examining documentation accumulated since the previous inspection, including Regulation 37 notifications, information from other professionals and other regulatory activity. “Have your say” surveys were sent to people who use the service, and health care professionals. Surveys were received at the Commission from twelve people living at the home and two health care professionals. The home is registered for up to thirty people and six people were case tracked. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. The views of the people living at the home, their relatives, qualified nurses and care assistants were gathered through face-to-face discussions. What the service does well: DS0000034485.V374284.R01.S.doc Version 5.2 Page 6 People consulted said that the staff knew how to meet their needs, the food was good and there were enough activities to keep them occupied during the day. The relative present during the inspection told us that the home keeps them informed about important issues. People living at the home and their relatives said they knew whom to approach with complaints. The following comment was made through surveys by two people at the home ‘ I am happy about the care and the staff.’ What has improved since the last inspection? What they could do better: There are seven requirements arising from this inspection and are based on reviewing and improving health and welfare processes. The Statement of Purpose must be reviewed to ensure that information meets the requirements of Schedule 4.1. This will ensure that people have sufficient information to base their decisions about moving into the home. Care plans must be more individualised and action plans must incorporate the individual’s wishes and feels. Action plans must be specific and guide the staff to meet the individual’s needs. Where individuals sustain injuries, risk assessments must be reviewed to ensure action plans lower the potential of further risks. The manager must ensure that individuals health care is monitored and where appropriate seek advise from specialists. The manager must ensure that references from the last employer are sought to ensure that staff are suitable to work with vulnerable adults. DS0000034485.V374284.R01.S.doc Version 5.2 Page 7 Fire risk assessments must be reviewed to ensure that where the potential for fire is identified measures are taken to reduce the level of risk. 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. DS0000034485.V374284.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 DS0000034485.V374284.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (1) & (3) Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The Statement of Purpose must be more detailed, for people to make decisions about moving into the home,. The admission process ensures that the needs of people wishing at the home can be met by the skills of the staff. EVIDENCE: There is a combined Statement of Purpose and Service User Guide that says the role of the home is to ‘help people gain and maintain as much control and independence in their lives. We emphasize strengths not limitations.’ The DS0000034485.V374284.R01.S.doc Version 5.2 Page 10 Statement of Purpose is not currently available in accessible formats and the manager must ensure documents are accessible for the people for whom it’s intended. For people to make decisions about moving into the home, information provided through the Statement of Purpose must be more detailed. The range of needs that can or cannot be met at the home, for example that people with dementia can be accommodated must be specified. The criteria for admission, the arrangements made for dealing with reviews, the number and sizes of the room must be included within the Statement of Purpose. This will provide people with full information to base their decisions about the home. The pre-admission procedure included within the Statement of Purpose confirms that assessments of needs are conducted, introductory visits are encouraged and trial periods offered. There were seven admissions since the last inspection and the case records of the two most recent admissions were examined. Pre-assessment forms show that steps were taken to determine that the needs of people wishing to live at the home could be met. Needs assessments are based on past medical history; medication, personal care need, communication and mobility along with mental health and social care needs. Where external agencies fund placements, a social worker’s or health care needs assessments are provided. Home’s care plans in place confirm that from the information gathered a care plan is developed. One person living at the home and a relative present during the inspection were asked about their experience of the admission process. One person said ‘ Its very different from living at home’ and the relative made more specific comments about the process followed. It was explained that the manager encouraged visits to the home and introduced them to other people living there. There was a friendly feeling and staff were respectful whenever they visited. Twelve surveys from people living at the home were received and six people said that they had received enough information about the home to make decisions about moving there and two people said they had not received enough information. DS0000034485.V374284.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (7), (8), (9) & (10) Quality in this outcome area is (adequate). This judgement has been made using available evidence including a visit to this service. People must be able to dictate the way their care is to be delivered and care plans must be crucial to provide consistency. Advice from health care professionals must be sought to ensure the individuals health care needs are met. Risk assessments must be reviewed following an accident or incident. EVIDENCE: Initial assessments conducted by the manager, at the time of the person’s admission are based on the social worker’s needs assessment. The manager told us that from the initial assessments, qualified nurses are allocated the responsibility to compile care plans, which they review monthly. Individual’s preferences are sought during admission along with their daily routines, which DS0000034485.V374284.R01.S.doc Version 5.2 Page 12 include times of rising and retiring and from the information gathered staffing levels are then allocated to meet peak periods. The manager then told us that care plans are developed with the person so that they have input into the way their care is to be delivered. Care plans are formally reviewed six monthly with the person, manager and where appropriate the family. It was then explained that where individual’s needs change, care plans are amended and usually occur following monthly monitoring check or six monthly reviews. Care plans are generic and social workers needs assessments are not related to the person’s home care plan. Staff personalise the care plans by the inclusion of the individuals name and needs. While each area of need identified is listed in the care plans, action plans require further development. Action plans must include the individual’s likes and dislikes to ensure care is delivered in the preferred way. Action plans must guide staff on the actions to be taken to meet the individuals assessed need. A care assistant on duty was consulted about the care planning process and explained that there is an expectation that staff read the care plans. Health care including medication is the responsibility of the qualified nurses. One relative at the home during the inspection said that care reviews are convened and they attend them. This relative was consulted about person centred care and it was stated ‘ When the staff know the person, the care is person centred.’ Wound care form part of the care plan and qualified nurses are responsible for dressing wounds. Qualified nurses currently dress the wounds of three individuals and photographs are in place show the progress. The deputy manager said that GP’s and hospital consultants prescribe the dressings to be applied and where there is no improvement, GP’s advice is sought. From the records examined, it is evident that one person sustained two separate injuries from the footplates of the wheelchairs. Accident reports specify the size of the wound and confirm that the wound was dressed. However, there is no evidence that a risk assessment was completed following the injuries or that a GP’s visit was requested. The manager said that a GP’s visit took place and the staff did not correctly report the size of the wound. The manager must ensure that where accidents or incidents occur, a risk assessment is conducted to ensure that risks are lowered. Daily reports also show that people with a diagnosis of dementia are accommodated at the home. However, their care plans are not clear about the way their care is delivered. Care plans must include the way the individuals dementia manifests itself and the support needed from the staff. Records completed by the staff show that there are individuals at the home that exhibit aggressive and violent behaviours. Care plans must be developed that include DS0000034485.V374284.R01.S.doc Version 5.2 Page 13 the actions that must be taken by the staff to divert or diffuse aggression or violent behaviours. Members of staff recorded concerns about one individual’s health and routine checks confirmed an element of the concerns reported. However, the GP and specialist health care professional support was not sought or monitoring checks introduced. Feedback from this individual was sought and it was stated that meals are not always eaten and confirmed that there were other health issues. This person also stated ‘I love it here, I get on well with the staff, they care for me well and they cream my legs.’ The deputy manager is the appointed Moving and Handling trainer and has yearly updates to maintain the training for trainer certificate. The deputy matron said that manual handling training is provided during induction before staff can undertake manual handling manoeuvres. It was also stated that two staff must undertake any hoisting manoeuvres. However, one member of staff was observed hoisting an individual without the assistance of another member of staff. It was also observed that one person was left sitting in the sling, which is not recommended. One person with mobility impairments was consulted about the aids needed and it was stated that staff use a hoist for transfers. When asked about the number of staff that will assist with the hoist, it was stated that there are times when only one staff will use the hoist to transfer. People at the home have continence needs and the deputy manager said that during admission a Primary Care Trust (PCT) continence assessment is conducted. Outcome of the assessments are provided and where appropriate the PCT will prescribe the best course of treatment. Medications are administered through a monitored dosage system by qualified nurses on duty. Administration records were checked against the medication held in the system and gaps in the recording were found, indicating that staff are not always signing records following administration. The manager was consulted about the gaps in the recording and stated that supervision with the member of staff concerned had taken place. Records confirmed that supervision had taken place and staffing levels were increased to support the qualified nurse. There are large quantities of stock medication held which makes drug rotation difficult, the manager must ensure that medications are used in correct order. A record of medications no longer required is maintained and the signature of pharmacist indicates receipt of the medication for disposal. Nine people made comments through the survey about the care provided and the way it’s delivered. Four people said that they always receive the care and support they need and four said this was usual. DS0000034485.V374284.R01.S.doc Version 5.2 Page 14 Two Health Care professionals responded about the care provided at the home. The GP that visits the home said that the home seeks advise and acts upon it and another said this was usual practice. Nine people responded through the survey about health care support and five said they received the medical support they needed and four said this was usual. The GP also indicated that the health care needs of his patients are met by the home while the other healthcare professional said this was usual. The Privacy and Dignity policy is not currently included in the Statement of Purpose and must be appended to inform people about the way their rights will be respected at the home. Four people living at the home were consulted about the way staff respect their privacy and dignity. One person said ‘ staff always knock before they enter my room and they explain what they are doing before doing it.’ Two people said that they are able to stay in their room and one said ‘I can have my meals in my room which respects my spiritual needs.’ Another two people made negative comments and these included ‘ I am not always assisted to get up until after lunchtime and this is painful because of my legs,’ and ‘laundry is not always returned, the trousers I am wearing are not mine.’ Feedback was sought from a care assistant on duty about the way individual’s privacy and dignity is respected. The examples such as making sure doors are closed when undertaking personal care shows that staff respect individual’s rights. DS0000034485.V374284.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (12), (13), (14) & (15) Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. People moving into the home can maintain their chosen lifestyles and meals served are good. Visitors are welcome at the home. EVIDENCE: An activities coordinator is employed to provide social interaction to the people accommodated at the home. The activities coordinator told us that at present they are undertaking a Reminiscence Therapist course, which includes activities for people with dementia. The activities coordinator told us that at the time of the individual’s admission, their preferred activities are sought so that group outings and activities can be organised. A daily activity schedule is then developed and records show that there are a variety of activities provided. Activities provided at the home DS0000034485.V374284.R01.S.doc Version 5.2 Page 16 include crosswords, bingo, puzzles and gentle exercises. A report following the activity is then compiled specifying the reasons for the activity, the level of success and the people attending. In addition to the organised activities provided, entertainers visit the home twice weekly to entertain the people living at the home. A notice board is used to inform people about the date and the daily activities organised. Pictures are used to convey the information and this format ensures that people with communication needs can understand it. The home must take steps to use these formats are used more widely, this will ensure that information is conveyed in formats that can be understood by the people for whom its intended. The coordinator was consulted about the interaction provided to people that do not participate in-group activities. The coordinator explained that for people that choose not to participate in any group activity, there is 1:1 time. There are brief chats, puzzles, and arts and crafts for people that prefer solitary activities. Nine people responded through surveys about activities at the home and six said that activities are arranged by the home and they participate, two said this was usual and one said it’s sometimes. The arrangement for visiting is included in the combined Statement of Purpose and Service User Guide. It is recognised through the policy that maintaining links with family and friends is important and for this reason visiting is open at the home. People consulted said that their visitors are made welcome by the staff and for additional privacy visits take place in bedrooms. A relative at the home was consulted about the home and it was stated that staff are respectful whenever they greet visitors. The staff keep them informed about important issues when visits to the home occur. We were told by the manager that two people have spiritual needs and both have specific dietary requirements. However, the cook said that this information had not been passed on and documentation was also inconsistent with the comments made. The people consulted at the home about the food, said that it was good and alternatives were provided. There is a two-week rolling menu prepared by the previous manager and the cook, which is to be reviewed to incorporate suggestions made by the people living at the home. The menu shows that there is three choices at lunch and teatime and staff ask the person to choose their preference at the mealtime. We were also told the home caters for special diets and catering staff are informed about the dietary needs of the people during admission. DS0000034485.V374284.R01.S.doc Version 5.2 Page 17 The cook said that there is a daily delivery of fresh vegetables and fruit, other provisions needed are ordered by catering staff and we were told that good quality food is ordered. The stocks of frozen, fresh and tinned foods held at the home confirmed this. Comments received from nine people about the food indicate that three people always enjoy the meals served and four people usually like the food at the home. DS0000034485.V374284.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): (17) & (18) Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The complaints procedure is effective and people feel able to approach the manager with complaints. Up to date Safeguarding Adults and WhistleBlowing policies will ensure that people at the home are protected from abuse. EVIDENCE: The Complaints procedure is included in the Statement of Purpose. Its aim is to resolve complaints at the lowest level before concerns develop into problems and formal complaints. The procedure confirms that complaints are taken seriously and guide complainants on further steps to be taken for unresolved complaints. There was one complaint since the last inspection and ten people sent Thank You cards to the home. The complaint was received at the Commission and we asked the home to investigate the complaint. Records show that the complainant was informed about the investigation conducted. Feedback about making complaint was sought from people living at the home and relatives visiting the home during the inspection. Members of staff were DS0000034485.V374284.R01.S.doc Version 5.2 Page 19 consulted about the expectation to support people to make complaints. The four people consulted said that they would either approach the manager or deputy with complaints. One person said ‘ When I first arrived, I made a lot of complaints because I was angry, I am more settled so I make less complaints.’ The visitor said that whenever concerns have arisen, the manager has been consulted and their concerns have been resolved satisfactorily. The member of staff on duty explained that their responsibility is to listen to the person making the complaint and refer it to the manager or deputy. Comments from ten people about the way complaints are managed at the home and four people said that they always know whom to approach with complaints; four said it was usual and one said it was sometimes. Regarding making complaints eight people said they know how to make a complaint and two said they did not know how to make a complaint. The manager told us that all staff have attended Safeguarding Adults training and will be attending Deprivation of Liberty to ensure people are safeguarded from abuse. The Safeguarding Adults and WhistleBlowing policy in place both require updating. The Safeguarding Adults policy must be reviewed to follow ‘No Secrets’ guidance and must make clear the factors of abuse and the actions to be taken by the staff. In terms of the WhistleBlowing procedure, the policy must reflect the philosophy of the home and must inform staff that it’s their duty to report poor practice. The manager told us that there are no outstanding Safeguarding Adults referrals. DS0000034485.V374284.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (19) & (26) Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Frenchay Park Nursing Home is comfortable, homely and well maintained. It is fully equipped to meet the needs of the people who live there. EVIDENCE: Seven people said through the surveys that the home was fresh and clean, one said it was usual and another said it was sometimes. Frenchay Park Nursing Home is a converted older property, with a newer extension, that provides accommodation for up to 30 people. There is car DS0000034485.V374284.R01.S.doc Version 5.2 Page 21 parking to the right of the home and gardens to the rear and the left side. The building appears to be well maintained. There is level access into the home. The accommodation is arranged over two floors and there is a passenger lift to the first floor. Communal areas consist of one dining room, a lounge and a smaller quiet room. Each room is well decorated and there is access out into the courtyards, where patio seating is arranged. There are a sufficient numbers of toilets and bathrooms located throughout the home. Commodes are also available for each person in their bedrooms. The bathrooms are fitted with hoists. There are five shared bedrooms and 20 single bedrooms. Not all the bedrooms were seen during the course of the inspection. They each contained all the necessary furniture and had matching curtains and bed linen. Some rooms had been personalised, people are encouraged to bring in items to make them feel at home. DS0000034485.V374284.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (27), (28), (29) & (30) Quality in this outcome area is (adequate). This judgement has been made using available evidence including a visit to this service. The manager must ensure that people employed at the home are suitable to work with vulnerable adults. The staff at the home have the skills to meet the individuals changing needs. EVIDENCE: A duty rota is in place and shows that the manager works supernumerary three days a week and ‘hand’ on’ two days per week. Qualified nurses are on duty throughout the day and night with six care assistants on duty 8:00-2:00 p.m. Between 2:00-8:00 p.m. staffing levels fall to four care assistants and at night there are two care assistants awake in the premises. Ancillary staff are employed for cooking and cleaning the home, there is also an activity coordinator rostered 10:00-6:00 p.m. 5 days per week. The manager confirmed the arrangements for staffing the home and further explained that senior care assistants are also employed and make up the staffing levels. It was also stated that at weekends and for a trial period, the DS0000034485.V374284.R01.S.doc Version 5.2 Page 23 staffing levels for care assistants were reduced and increased for qualified nurses. Ten comments were received through surveys from people living at the home and eight people said that the staff always listen and act on what they say. Two said that the staff do not listen and act upon what they say. Regarding the staff being available when needed, one said this was always, eight said it was usual and one said it was sometimes. Personnel records of the two most recently employed staff was examined. The completed application forms seek personal details, education and employment history, disclosure of criminal background and the names of two referees, one of which must be the last employer. For one member of staff, the recruitment process was robust, written references and Criminal Records Bureau (CRB) checks were obtained. For another member of staff, character references were accepted although we were told that the last place of work was a care home. However, a reference from this employer was not sought. The manager must ensure that professional references are sought for people seeking employment at the home. The induction programme followed for these staff was examined and cover a six-month period of employment. On the first day of employment, there is inhouse training that consists of familiarisation of the property, discussions about the principles of care and training needs. Statutory training that includes Safeguarding Adults, Manual Handling, Food Hygiene, Infection control and First Aid is provided during induction. A recently employed member of staff was asked about the induction programme in place. We were told that their employment started in January 2009 and explained that statutory training is being delivered. It was also said that vocational qualifications is encouraged and staff have the opportunity to undertake more advanced qualification. The manager said that vocational qualification is encouraged at the home and currently 15 care assistants have NVQ level 2 and above, 5 are registered onto NVQ level 2 and three are to be enrolled. Two nurses and one senior care assistant are attending NVQ courses in Leadership. Feedback was sought from the manager about the way practices are changed with good practice, which includes the training attended. The manager told us that training is cascaded during handovers but there is no formal structure for updating existing practices. In terms of supervision, the manager said it is shared between the manager and deputy. There are two types of supervision the essence of care for the nurses and the responsibility of the role for care assistants. DS0000034485.V374284.R01.S.doc Version 5.2 Page 24 People at the home were asked about the staff’s skills. Comments from the people at the home included ‘ I get on okay with the staff,’ ‘staff are very good’ and ‘I can’t always understand the staff.’ Another person said that the staff group is not stable and particularly at weekends the staff are not always trained. The GP responded through the surveys about the staff’s skills and said that it was usual for the staff to have the right skills to support individual’s social and health care needs. DS0000034485.V374284.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (31), (33), (35) & (38) Quality in this outcome area is (adequate). This judgement has been made using available evidence including a visit to this service. The views of the people who live there are important and are included in decision- making processes. Fire risk assessments and Infection Control policies must be devised to ensure people live and work in a safe environment. EVIDENCE: The manager was consulted about the way the home is managed to ensure consistent standards are maintained. The manager said that a pragmatic DS0000034485.V374284.R01.S.doc Version 5.2 Page 26 approach, a realistic way of solving problems is used which includes working ‘hands on’ and enabling staff to take ownership. In terms of consistency, the manager told us that the systems such as red folders for tasks that must be ticked when they have been completed were introduced. Handovers when shift changes occur and meetings are convened as a two-way communication. However, the last nurse meeting was cancelled and the one before that was six month previously. The care assistant and relatives meetings have taken place but the minutes are not available. Quality Assurance surveys from relatives were used to seek feedback about the standards of care in planes and regular contact with people at the home ensures the standards of care are consistent. A member of staff on duty was asked to comment about the systems that ensure consistency at the home. We were told that that teamwork can be good, handovers occur every morning where staff are allocated with specific individuals and tasks. The home operates a Quality Assurance system and, questionnaires were used for people living at the home and their relatives to seek feedback about the standards of care at the home. Completed questionnaires that focused on the environment, food and staffing were received from 3 relatives and 8 people living at the home. The manager told us that where negative comments were received, the feedback was passed onto the staff, information to improve practices was sought and an action plan was devised. Facilities for the safekeeping of cash and valuables exist at the home and a sample check of cash in safekeeping was conducted. Records of cash were consistent with the balances held in safekeeping. Receipts in place evidence purchases made on behalf of the people at the home. Fire risk assessments that assess the potential of fire in the home to then put measures in place to reduce the risk of fire are in place. However, the risk assessments were last reviewed in 2007. Fire risk assessments must be reviewed to ensure the measures in place to lower the level of risk remain appropriate to protect people at the home. The home ensures that there is compliance with associated legislation. Contractors are used to service appliances, systems and equipment to ensure they are safe for the people living at the home and the staff employed. Portable equipment checks, manual handling equipment and passenger lift are serviced annually to ensure they are safe to use. An Infection Control policy is not currently in place and must be devised to ensure that the home follows safe control measures. DS0000034485.V374284.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 2 x x 2 DS0000034485.V374284.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 Requirement The Statement of Purpose must be reviewed to ensure that information meets the requirements of Schedule4.1. This will ensure that people have sufficient information to base their decisions about moving into the home. Care plans must be more individualised and action plans must incorporate the individual’s wishes and feels. Action plans must be specific and guide the staff to meet the individual’s needs. Where individuals sustain injuries, risk assessments must be reviewed to ensure action plans lower the potential of further risks. The manager must ensure that individuals health care is monitored and where appropriate seek advise from specialists. The manager must ensure that large quantities of medications are not held. This will ensure that medications are used in DS0000034485.V374284.R01.S.doc Timescale for action 30/08/09 2 OP7 12 30/08/09 3 OP8 13.4 30/04/09 4 OP8 13.1 01/04/09 5 OP9 13.2 01/04/09 Version 5.2 Page 29 6 OP28 7,9,19 Sch. 2.3 7 OP38 23.4 correct date order The manager must ensure that references from the last employer are sought to ensure that staff are suitable to work with vulnerable adults. Fire risk assessments must be reviewed to ensure that where the potential for fire is identified measures are taken to reduce the level of risk. 01/04/09 30/04/09 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 OP18 Good Practice Recommendations The Safeguarding Adults and Whisltblowing policies should be updated to ensure that people at the home are protected from abuse. DS0000034485.V374284.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 DS0000034485.V374284.R01.S.doc Version 5.2 Page 31 - 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. 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