Inspection on 19/09/06 for Glebefields Resource Centre

This inspection was carried out on 19th September 2006.

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

Glebefields Resource Centre 04/08/07

Glebefields Resource Centre 14/12/05

Glebefields Resource Centre 14/12/04

Glebefields Resource Centre 06/07/04

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

CARE HOMES FOR OLDER PEOPLE Glebefields Resource Centre Strathmore Road Tipton West Midlands DY4 OTT Lead Inspector Mrs Cathy Moore Unannounced Inspection 19th September 2006 07:15 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 Glebefields Resource Centre DS0000035175.V309452.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. Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glebefields Resource Centre Address Strathmore Road Tipton West Midlands DY4 OTT 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) 0121 569 5940 0121 557 7438 Sandwell Metropolitan Borough Council Ms Avril Nott Care Home 19 Category(ies) of Dementia - over 65 years of age (19) registration, with number of places Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All requirements contained within the registration report of 22 January 2003 are met within the timescales contained within the action plan agreed between Sandwell Metropolitan Borough Council and the National Care Standards Day care provision must not encroach on the facilities, staffing and services provided to residential service users. 14/12/06 2. Date of last inspection Brief Description of the Service: Glebefields is owned and managed by Sandwell Council. It is registered to provide care to a maximum of nineteen older people who have been diagnosed as having dementia. Glebefields is located in a residential area of Tipton. Local amenities are close by which include a fish and chip shop, small shops and a library. Adjacent to the home are playing fields. The home has gardens to the front and the rear. The back garden is attractive, safe and appropriate to the needs of the residents’. Car parking space is available at the front of the home. The home comprises of two floors. Both floors are accessible via stairs or the passenger lift. Communal areas, offices, the laundry, kitchen, and toilets are located on the ground floor. All bedrooms are situated on the first floor. All are single occupancy. The home is maintained to a good standard overall. The lounges are of a very high standard. The weekly fees for this home range from £94 - £467. Additional charges are made for some services which include ; private chiropody and hairdressing. Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector on one day between 07.20 and 17.25 hours. The inspection process assessed all of the key National Minimum Standards for older people. To aid the inspection process a number of questionnaires were forwarded to the home for completion before the inspection. A proportion of the inspection was conducted in the living areas where care practices and staff/resident interaction could be observed. During the course of the inspection three residents’ files to include assessment of need and care plan documents were assessed. Three staff files to include recruitment documents and training were also assessed. The premises were part assessed to include the lounges on both floors, the dining room, three bedrooms, the laundry, kitchen, garden, bathrooms and toilets. Medication systems and the safe keeping of resident money were assessed. Both breakfast and main meal times were partly observed. six residents, three staff and four relatives were spoken to during the inspection. Senior staff and the manager were on site during the inspection process. What the service does well: The layout of the home and garden gives the residents freedom to wander in an environment which is safe. The provision of six lounges (four on the ground floor and two on the first floor) offers a generous variety of communal space giving space to the residents and promoting choice and privacy to receive visitors. One relative commented; “ The home has a lot of different rooms for residents to use”. The rear garden is attractive with its established trees, shrubs and raised flowerbeds. The garden has ramped access and adequate fencing to all boundaries to enhance safety. The garden is private as it in not overlooked. The atmosphere of the home as during previous inspections was warm, welcoming and positive. The communal/ outdoor space provision has been given a score rating of 4 which is the highest possible. Visiting times are open and flexible. The staff encourage residents to maintain contact with family and friends. Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 6 The management and staff team continue to be committed to improving the home and providing a good standard of care to the residents. Staff are kind and caring and have a good knowledge of the individual needs of the residents in their care. Food provision has been given a score rating of 4 which is the highest possible. This is not just for the food provided but the monitoring of food intake, the atmosphere of the dining room and the attention given to residents by staff during meal times. The home has a high attainment level of care staff having N.V.Q’s. Positive comments about the home and the staff were made by both residents and relatives and included; “ The home is superb and the staff are brilliant”. “The home is very good”. “ The staff are very good. Everything is ‘fit’, o.k”. “The home is very nice. The carers are very good”. What has improved since the last inspection? A ‘wing’ has been obtained in the home that was used by another agency before. This area has been redecorated and has been rearranged to be used for day care. The movement of day care to this area from within the residential facility means that two lounges on the first floor have been freed totally for resident use giving them more space, choice and privacy. The area by the lift has been altered to give greater space and freedom of movement on the ground floor which benefits the residents further. A room by the dining room has been totally refurbished and is now a fully equipped hairdressing salon. A number of bedrooms have been redecorated and have been provided with new furniture. New metal gates have been fitted externally to give the building better security. A treatment room is now available for treatments and assessment/ consultations from doctors and nurses. The home secured input over a ten week period from an artist to work with the residents to do artwork. Work produced in this period is amazing. The ceramic work is displayed in the garden and pictures made of fabric and other materials throughout the home. Care plans and their content have improved considerably over the last year, as have processes regarding staff supervision. The senior/management team up to full numbers according to budget allocation. Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Glebefields Resource Centre DS0000035175.V309452.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 Glebefields Resource Centre DS0000035175.V309452.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3. The overall outcome for this group of standards is judged to be good. Service users are issued with a contract/ terms and conditions document. Except for emergency admissions, no service user moves into the home without having their needs assessed and assurance given that these needs will be met. EVIDENCE: It is positive that information about the house was readily available within the front entrance hall an example being; the last inspection report. Six of the twelve completed resident questionnaires returned confirmed that they had been given sufficient information about the home prior to admission to enable them to make the decision that the home would be right for them. However, a high proportion of other questionnaires were returned as ‘resident unable to answer due to condition’. A high proportion of the completed questionnaires suggested that the respondent had not been issued with a contract/terms and conditions however, again this may have been due to residents not understanding the question. All Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 10 resident files seen did have a contract/ terms and conditions document included. However, some fine tuning is needed to ensure that the information contained is valid and up to date. In at least one section the NCSC is named rather than the current organisation CSCI. The weekly fee rate for new residents detailed on their terms and conditions was correct £467, but for residents who had been living at the home for some time their weekly fee had not been updated for this financial year. Evidence was available to demonstrate that each resident (except for one who had been transferred from another home internally) had been visited by a staff member before admission and a documented assessment of need had been produced covering main core areas. Glebefields Resource Centre DS0000035175.V309452.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. The overall outcome for this group of standards is judged to be good. Service users health and personal care needs are set out in an individual plan. Fine tuning and development is needed to ensure that each service users health care needs are fully met. Some improvement is needed to ensure that medication systems are fully safe. Service users feel that they are treated with respect. EVIDENCE: Care plans viewed were of a good standard. Care plans for both night and day were in place with sufficient detail and information included to cover assessed needs examples being; incontinence, well being, sleep patterns, rising and retiring, safety and personal hygiene. Care plans are being updated where changes occur for example; a continence assessment for one resident and the deterioration of another. The manager did say that care plans are being changed in the near future where it is hoped that they will improve further. Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 12 Generally, the health care needs of the residents are being met. Personal case wise residents seen were clean and wore appropriate clothing. A number of females were seen wearing earrings and beads. One relative said; “ She is always clean and well presented”. Another relative said; “ Their clothes are changed everyday. If they spill any food they are changed after the meal”. Records of daily care delivery although improved are not being consistently completed as they should. This area therefore, needs more attention. There was records available to demonstrate visits from district nurses, doctors, the dentist, optician and chiropodist. One relative said; “ If there are any problems the doctor is called right away”. Nutritional scoring mechanisms and action taken if concerns are identified is very good. There was ample evidence of correct action taken for one resident who had lost weight for example; referral to her doctor and the dietician. During the inspection the organisations dietician visited the home unannounced to carry out an audit of nutritional scoring and actions taken her feedback from this exercise was very positive. It was extremely positive to see evidence that staff had spoken to relatives and discussed as a staff team with the doctor whether or not certain residents who do not have capacity should have the flu vaccine. A few shortfalls were identified that need to be addressed for example; accident analysis showed that at least two residents are prone to falls there had been no referral to the falls prevention team for these residents. The home at the present time does not use a tissue viability assessment tool to determine who is at risk from tissue breakdown. Medication systems generally are robust. Medications are stored correctly and the staff example initial list is up to date. The staff member administrating the medication stayed with each resident to ensure that they had taken their tablets etc. Drinks were available to take with tablets and medications were not touched by hand. The homes medication provider carries out regular audits of the homes medication system. Medication is administered from a monitored dosage system. There was no oxygen on site at the time of the inspection. No resident was self medicating and no controlled drugs were being prescribed which all reduces risk. A number of shortfalls were identified which need attention and include; medication records where handwritten must be signed by two staff members to verify that the instructions are correct. One medication Ferrous Sulphate had not been counted correctly on receipt. The application instructions for a topical preparation for one resident had been changed from regular application to ‘as needed’. A number of staff initial gaps were identified on medication administration records. Although staff who have a responsibility for medication received medication training in 2004 it is unclear what level of training this was. The homes medication provider is able to provide medication training and this must be secured. Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 13 Staff observed during the inspection were polite and caring towards the residents. Staff are aware of and use the preferred form of address for each resident. A new treatment room has been made available for doctor/ nurse consultations to enhance privacy. Either this is used for treatments or the residents own bedroom. All bedrooms are single occupancy giving residents their own private space and enhancing privacy and dignity. Toilet and bathroom doors were all seen to be closed when in use which is good. One relative said; “The staff are always polite and caring”. One resident said; “ The staff talk to me good”. Glebefields Resource Centre DS0000035175.V309452.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. The overall outcome for this group of standards is judged to be good. Activity provision needs some fine tuning and development. The home has an open visiting policy and encourages service users to maintain contact with family and friends. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet, in pleasing surroundings. EVIDENCE: Precise documentation was not available to demonstrate that the daily routines of each resident are being determined. However, there was plenty of written information which said; .. to go to bed/ get up on request”, which is positive. Observations on the day of the inspection revealed that residents did get up at different times. One stayed in bed until late morning. The manager has identified that activity provision is lacking in some ways and has/is taking action to address this. Staff are encouraged to undertake activity provision with the residents during the day. Social evenings are arranged every other month to which both residents and relatives can join if they want to. Social evenings arranged include ‘Old time music’ and a ‘ Black Country poetry night’. Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 15 It was really interesting to hear about an art initiative that was undertaken by an artist in the summer 06. This was undertaken over an eight week period. All residents were encouraged to participate and work produced was of a very good standard and has been displayed in the garden and the home. The evening of the inspection one of the residents was going with staff to an awards night where they had been nominated for an award for the art project and work produced. The home has recently purchased an activity project produced by Bradford University called ‘ Making a difference’. This will enable different activities to be carried out based on needs and ability with the aim of improving cogitative function. This project is to commence early October 2006. Bedrooms viewed held a number of residents’ personal belongings which made them feel homely and personalised. The home has information for residents/staff/ relatives to access if they wish to secure input from an independent advocacy service. It was pleasing to see that the home ensures that those residents who want to can vote. A care plan was in place giving instruction to staff on how to achieve this. Meal provision in the home is very good. As previously stated the home is fortunate in that the organisation employs a dietician to give advice and assist in menu production and planning. She also gives guidance on special diets for residents’ who are loosing weight or where there are concerns. The home has a set menu which is being reviewed for autumn at the present time. There was ample evidence to prove that fresh fruit and vegetables are being used and added to meals where possible. The home offers a range of smoothies in an attempt to encourage greater intake of fruit and vegetables or to use as a build up nourishment source for residents who need this. A large wipe clean board in the dining room details all meals on offer for any given day which include; breakfast, lunch, tea and supper. Breakfast and lunch were briefly observed. The dining room although it is in need of redecoration was a pleasant environment. The tables were nicely laid, there was matching crockery of a good standard. Breakfast- there was a range of cereals, fruit juice and hot options. For lunch there was two choices, spaghetti Bolognaise or lamb. Staff were on hand to give assistance where needed. Staff were heard giving resident food choices and asking residents if they had enough food or if they wanted more, or if they wanted another drink. One staff member who had observed that a resident had not eaten much of their meal gave encouragement for them to eat. Another resident was offered another option when they did not eat much. Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 16 Finger foods are offered between meals examples being; fruit or malt loaf. Drinks and snacks are available at all times. Fresh fruit was available in the lounges for residents to help themselves to. Positive comments about the food were received from residents and relatives which include the following; “ That was nice. The food is very good”. “ Food nice”. “ Nice food”. “ There are two choices”. “The food is very good”. Glebefields Resource Centre DS0000035175.V309452.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The overall outcome for this group of standards is judged to be adequate. Compliant and protection processes need further development. EVIDENCE: The home has a written complaints procedure. A complaints procedure must be produced in a format for example; pictures, to enhance resident understanding. One complaint has been received by the home since the last inspection. Which was from a relative about a broken wardrobe. The complainant had been written to, to inform them that the bedroom was the next to be redecorated and the wardrobe would be replaced as well. The complaint from records seen was happy with this. However, as described in the last section of this report the Commission at the time of the inspection was concerned as the wardrobe door was seen to be broken. One referral has been made where concerns were identified about a resident transferred from another home. The majority of staff have received abuse awareness training from Sandwell Council which is positive as the training includes reference to the organisations abuse referring processes which they must follow. A number of policies and procedures aimed to protect vulnerable persons are in place however, some have needed updating for some time. Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 18 Relatives asked about protection gave the following answers. “ I have never seen staff shouting at residents or anything else”. “ I have not seen any problems with the staff they are polite and caring”. Glebefields Resource Centre DS0000035175.V309452.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,25,26. The overall outcome for this group of standards is judged to be adequate. The home has a number of redecoration needs where requirements have been made previously and have not been addressed. These areas are letting down the good work undertaken by staff and management. The homes’ layout, communal space availability and garden are excellent. Work and improvement is needed to enhance the safety of the home. Infection control processes need some fine tuning. EVIDENCE: Whilst it must be acknowledged that the home has since the last inspection has refurbished a room on the ground floor into a fully equipped hairdressing salon for the residents. The home has reclaimed an area in the home to use for day care purposes which has benefited the residents in terms of space and some redecorating work has been carried out it must be highlighted that the home has a high number of requirements concerning refurbishment / redecorating that have remained outstanding for some time. The outside of the Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 20 building is poor in terms of paintwork on rendering. Toilets, bathrooms, the dining room , hallways and landings are badly in need of redecorating. Communal space provision in the home is excellent. The home has a dining room, conservatory area, four lounges downstairs and two on the first floor. Safety key pads are in operation on doors to allow freedom and wandering in the building. The main entrance hallway by the office and corridor off have now become areas that residents have access to giving them more space. Radiators in areas accessible to residents are guarded with the exception of a room in the reclaimed area that will be used as the activity room and a first floor room that is being used as a kitchenette. These will need to be guarded to reduce risk to residents. It was observed that there is exposed pipe work in ground floor WC’ and the ventilation system in the ground floor WC is labelled as; ‘do not use’. These areas need attention to ensure safety and adequate ventilation. Infection control processes have improved over recent months. The laundry is well equipped. The manager has identified the need for better segregation of clean and dirty washing and is looking at ways to address this. There were no disposable bags in the laundry to reduce the need to deal with soiled laundry. A stock of these must be purchased. Liquid soap, paper towels, hand wash signs and protective clothing was available in high risk areas. No offensive odours were identified in areas viewed. Although a past requirement was made there was no evidence that regular infection control audits are being carried out as they should be. It is positive that the majority of staff have received infection control training. It is also positive that one staff member was observed encouraging and assisting residents to wash their hands after they had used the toilet. Glebefields Resource Centre DS0000035175.V309452.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The overall outcome for this group of standards is judged to be good. Staff numbers and skill mix are meeting service users needs. Service users are in safe hands. Fine tuning is needed in respect of recruitment practices to enhance safety. Generally, staff are trained and competent to do their jobs. EVIDENCE: Staffing is provided as follows; Am- three care staff PM- three care staff Night – two care staff. Additionally, at least one senior is rotered onto each day time shift. During the week the manager is on duty and on some shifts an additional senior staff member. Everyday cleaning, catering and laundry staff are provided. A full time handyperson is employed Monday to Friday. Generally it was felt that staffing provided is sufficient this confirmed individually by staff and management. There was positive feedback from both relatives and residents about the staff which included the following;” The staff are great. No problems with them”. “ The staff are polite and caring”. “ The staff are brilliant”. “ The carers are very good”. Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 22 At the present time the percentage of staff who have N.V.Q level 2 or above is 63 . This is an excellent achievement level. Recruitment processes have improved over the last year. A file was in place for each staff member which were well organised and contained the majority of required documents with the exception of a written application for one staff member and a second written reference for another. Generally, there was evidence of induction processes for new staff what was lacking was the confirmation that induction processes meet the Skills for Care standards. Glebefields Resource Centre DS0000035175.V309452.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35.36.38. The overall outcome for this group of standards is judged to be adequate. The manager is a fit person to run and manage the home. Improvement in some areas of quality assurance is needed. Improvements are needed to ensure that service users’ financial interests are safeguarded. Staff are appropriately supervised. Health and safety needs improvement in a number of areas. EVIDENCE: The manager has been approved by the Commission as a fit person to run and manage the home and has the required qualifications. A concern raised during the inspection( which was on a number of occasions witnessed by the inspector)was management time being depleted by having to answer the phone and face to face enquires for another service based within the building. Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 24 The home has been externally accredited to ISO 9002 status which is positive. It is positive that recent resident/relative satisfaction surveys have been carried out with the results displayed in the home front entrance hall. A past requirement to ensure that all staff have access to the homes policies and procedures is being addressed but has not been fully met to date. It was identified through viewing audits that these are not up to date. Regular auditing of processes etc must be re-instated. It was positive to see that seniors between shifts checked and signed for the whole safe content. The senior on duty then ensured safe, safety. Money belonging to three residents was checked against balances and was found to be correct. Shortfalls identified were that the hairdresser is not issuing individual receipts and that purchases of personal care items from the market for residents can not be verified, as an official receipt is not being obtained. It is positive that there was ample evidence on the staff files viewed to prove that they receive regular one to one supervision. Staff spoken to confirmed that this is the case. As stated in a previous section it was identified firstly through a complaint that a wardrobe door in one residents room was broken. On assessment of this the wardrobe door which is fairly big had come off its runner presenting as a risk to the resident a serious concern letter was issued by the Commission for this to be addressed. Flooring in both the kitchen and an area by the dining room door threshold was seen to be damaged which could potentially be an infection control and tripping hazard. It was difficult to determine if the staff have received the correct number of fire drills as recent ones are being recorded as the number of staff rather than individual names. The kitchen was briefly assessed apart from the flooring and a missing vent on the freezer it was satisfactory. The kitchen was assessed by Environmental Health in March 2006 who awarded a ‘gold award’ for food safety which is very good. Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 1 4 x x x x 2 2 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 2 3 x 2 Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 26 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 5(1)(2)12 (4)(b) Requirement The registered person and manager must ensure that the service user guide is produced in an additional format examples being; pictures or symbols which may make it easier to understand by the service user group. (Timescales of 01.02.05. 01.10.05 and 01/02/06 not met). 2. OP2 5 The registered person and manager must ensure that; All resident contracts detail the correct fee for any given financial year. That references in the contracts to NCSC are changed to CSCI. 01/11/06 Timescale for action 01/11/06 3 OP8 12(1a)12 The registered person and DS0000035175.V309452.R01.S.doc 01/10/06 Version 5.2 Page 27 Glebefields Resource Centre (1b)17(2) manager must ensure that daily personal care delivery records(tick charts / form SS534/1) are completed diligently and consistently. (Timescales of 9.8.05 and 01/02/06 not fully met). 4 OP8 13(4)(c) 5 OP8 12(1)(a) 13(4)(c) 13(4)(c) 6 OP8 7 OP9 13(2) The registered person and manager must ensure that risk assessments are reviewed on the review date set. The registered person and manager must obtain and put into operation a recognised tissue viability scoring system. The registered person and manager must ensure that residents who have two or more falls are referred to the falls prevention team. The registered person and manager must ensure that the medication policy is reviewed . (Timescale of 01/02/06 not met). No date on policy to determine last time it was reviewed. 01/10/06 01/11/06 01/11/06 01/11/06 8 OP9 13(2) The registered person and manager must ensure that medication records clearly state; The name of the residents’ doctor. Any allergies. The residents’ date of birth. This to include medication records that are handwritten. (Timescale of 05/01/06 not fully met). 05/10/06 Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 28 9 OP9 13(2) 10 OP9 13(2) 11 OP9 13(2) The registered person and manager must ensure that where medication records are handwritten two staff sign to verify that the information written is correct. The registered person and manager must ensure that their medication provider provides accredited medication training for all staff who have a responsibility for medications. The registered person and manager must ensure that; All medications received into the home are counted properly. 01/10/06 01/12/06 01/10/06 12 OP9 13(2) 13 OP11 12(4)(b) That the continuation/discontinuation/freq uency of (PC’s) Fucidin is clarified with the doctor. The registered person and 01/10/06 manager must ensure that each medication record is signed immediately after medication has been administered. The registered person and 31/10/06 manager must review service users’ files to ensure that an account is made of individual wishes, preferences relating to dying, following death and funeral arrangements. This information must be clearly documented on the service users’ individual personal file. DS0000035175.V309452.R01.S.doc Version 5.2 Page 29 Glebefields Resource Centre Where possible other relevant people must be secured to obtain this information. (Timescales of 01.02.05. 01.09.05and 01/02/06 not fully met). 14 OP16 22(2) The registered person and manager must display a complaints procedure within the home which is large print and a pictorial format. (Timescales of 1.2.05, 9.9.05 and 01.02.06 not met). 15 OP18 13(6) The registered person and manager must ensure that the departments policy for staff who witness severe bad practice is read, signed and dated by all staff. This policy must however, be reviewed in accordance with Sandwell MBC adult protection procedures and Department of Health guidance. (Timescales of 1.2.05,1.9.05and 01.02.06 not fully met). 16 OP19 23(2)(b)2 3(2)(d) The registered person and manager must ensure that the exterior of the building is redecorated. Timescales in respect of this requirement have been made in previous reports the work however, to date has not been addressed/completed. This must now be addressed by the timescale set to prevent further action. Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 30 01/11/06 01/11/06 01/11/06 17 OP19 23(2)(b)2 3(2)(d) The registered person and manager must ensure that the remaining downstairs windows (dining room) are replaced. Timescales in respect of this requirement have been made in previous inspection reports the work however, to date has not been addressed/ completed. This must be addressed by the timescale set to prevent further action. 01/11/06 18 OP19 23(2)(d) The registered person and manager must ensure that bathrooms, toilets and landings are redecorated. Timescales in respect of this requirement have been made in previous inspection reports the work however, to date has not been addressed/ completed. This must be addressed by the timescales set to prevent further action. The registered person and manager must ensure that the dining room and ceiling are redecorated. Timescales in respect of this requirement have been made in previous inspection reports the work however, to date has not been addressed/ completed. This must be addressed by the timescale set to prevent 01/12/06 19 OP19 23(2)(d) 01/12/06 Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 31 further action. 20 OP21 23(3)(j) The registered person must provide appropriate showering facilities. (Timescales of 1.10.05 and 01/03/06 not met). The registered person and manager must ensure that the radiator in the hairdressing room- first floor- is suitably guarded. ( Now the kitchenette). (Timescales of 15.9.05 and 01/02/06 not met). This must be addressed by timescale set as there are health and safety implications. 01/11/06 21 OP25 13(4)(a) (c) 01/11/06 22 OP25 13(4)( c) The registered person must ensure that; All exposed pipe work in toilets and bathrooms are guarded. 31/10/06 23 OP26 13(3) The ventilation system in the ground floor female WC is mended or replaced. The registered person and 01/10/06 manager must undertake an infection control audit of the premises, processes, policies and procedures. (Timescales of 25.1.05,15.9.05 and 01/02/06not met). No evidence available to demonstrate audits being carried out. Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 32 24 OP26 13(3) 25 OP29 19(2)Sch 2&4 The registered person and manager must ensure that red disposable bags are purchased and used in the laundry for soiled clothing etc. The registered person and manager must ensure that the home holds on site all records required as detailed in Schedules 2 and 4. (Timescales of 1.2.05, 1.9.05 and 15/01/06 not fully met. met). One reference only for one staff member no application for another. 01/10/06 15/10/06 26 OP30 18(1)(a) 27 OP31 18(1)(a) 28 OP33 24 The registered person and manager must ensure that the training section provide a letter to confirm that induction staff receive complies with the new Skills for Care Induction Standards. The registered person and manager must ensure that senior staff and management time is not depleted by having to answer phone calls or deal with face to face reception queries for other services based in the building. The registered person and manager must ensure that all policies and procedures are readily available to staff and that these can be accessed quickly in an emergency. (Timescales of 1.2.05,1.9.05 and1.02.06 not fully met). 01/11/06 19/10/06 01/11/06 29 OP33 24 30 OP33 12(5)(a) The registered person and manager must ensure that quality assurance audits are fully re-instated. The registered person must DS0000035175.V309452.R01.S.doc 10/10/06 10/10/06 Page 33 Glebefields Resource Centre Version 5.2 31 OP35 13(6) Sch 4 (9) ensure that a date for the follow up meeting to the meeting held on 21/07/06 ( staff/management concerns)is arranged and held. The registered person and 10/10/06 manager must ensure that; The hairdresser issues individual receipts to each resident for her services. An official receipt is obtain for any expenditure concerning resident money. 32 OP38 23(4) The registered person and manager must ensure that all staff receive fire training. Each staff member must receive fire drill training twice in any 12 month period. (Timescales of 1.9.05 and 01/02/06 not fully met). File drill training records must include the full name of each participant and their signature to verify attendance. 01/11/06 33 OP38 13(4)( c) 34 OP38 13(4)( c) The registered person and manager must inform (NP) and her son of the action to be taken and why, then remove the wardrobe door to prevent any risk. A serious concern letter was issued by the Commission in which this requirement was included. The registered person and manager must replace the wardrobe. A serious concern letter was issued by the Commission in which this requirement was included. DS0000035175.V309452.R01.S.doc 29/09/06 01/10/06 Glebefields Resource Centre Version 5.2 Page 34 35 OP38 13(4)( c) The registered person must make safe the vinyl floor by the threshold leading into the dining room. 10/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Glebefields Resource Centre DS0000035175.V309452.R01.S.doc Version 5.2 Page 36 - 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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