Inspection on 17/07/07 for Greenhaven Resource Centre

This inspection was carried out on 17th July 2007.

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

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

Other inspections for this house

Greenhaven Resource Centre 30/05/06

Greenhaven Resource Centre 28/01/06

Greenhaven Resource Centre 01/09/05

Greenhaven Resource Centre 10/02/05

Greenhaven Resource Centre 18/08/04

Greenhaven Resource Centre 09/03/04

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

CARE HOMES FOR OLDER PEOPLE Greenhaven Resource Centre Grout Street West Bromwich West Midlands B70 0HD Lead Inspector Mrs Cathy Moore Key Unannounced Inspection 17th July 2007 07:00 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 DS0000035520.V338979.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. DS0000035520.V338979.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greenhaven Resource Centre Address Grout Street West Bromwich West Midlands B70 0HD 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 557 8088 0121 522 2354 Sandwell Metropolitan Borough Council Mrs Hilary Edith Kilbey Care Home 46 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (31) of places DS0000035520.V338979.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All requirements contained within the registration report of 6 & 7 December 2002 are met within the timescales contained within the action plan agreed between Sandwell Metropolitan Borough Council and the National Care Standards Commission. A maximum of 31 people in the category of OP to be accommodated on the ground floor, 5 of whom may be aged 57 years and over. A maximum of 15 people in the category DE(E) to be accommodated on the first floor, 2 of whom can be 57 years and over 30th May 2006 2. 3. Date of last inspection Brief Description of the Service: Greenhaven care home is owned and managed by Sandwell Local Authority. It provides residential services to a maximum of 46 older people. Five of the places are allocated for rehabilitation purposes, thirteen to older people who have a diagnosis of dementia. The home is situated in a residential area of Great Bridge West Bromwich. It is in easy reach of Great Bridge Town where bus links are available to neighbouring Dudley one side and West Bromwich the other. The home is located in a favourable position adjacent to Farley Park. A number of rooms have views over the park. The building is set out on two floors, with a lift providing access to all communal areas of the home. Access for wheelchair users is good. There are dining and lounge facilities on the ground floor with a number of smaller quiet lounges situated throughout the home. Living space includes two conservatories which offer a warm, bright place to sit or use for leisure purposes. The home has generous sized, attractive, safe garden areas which accommodate raised flower beds. Two flats cater for more independent living and represent part of the rehabilitation provision, these are not fully in used at the present time. The homes fees range from £0-£467 per week ( these may be subject to this financial years increase). DS0000035520.V338979.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced key inspection on one day between 07.00 and 18.40 hours. Prior to the inspection a questionnaire was sent to the manager for completion to gain information some of which has been included in this report. During the inspection I spoke to one relative, four staff and seven service users’. I spent most of the inspection time in communal areas to observe daily routines and staff service user interactions. I randomly looked at the premises which included; the lounge and dining areas, five bedrooms, bathrooms, toilets, laundry and gardens. I looked at four service users’ case files to assess admission processes and care planning. I looked at three staff files to assess recruitment processes, supervision and training. I looked at medication management and safety and randomly checked records concerning maintenance and servicing of equipment. I indirectly observed breakfast time on the first floor and lunch time on the ground floor. What the service does well: The home is owned and managed by Sandwell Council which gives access to a wide range of advice and support networks. The location of the home is favourable as it is situated in a pleasant residential area adjacent to a park. All bedrooms are single occupancy enhancing privacy and dignity. The home offers generous communal living space with both smoking and nonsmoking areas. Gardens are attractive and accessible. The home has a range of aids and adaptations to enhance service user safety, mobility and independence. The homes atmosphere is warm, friendly and positive. The home encourages service users’ to maintain contact with family and friends. It offers open, flexible, visiting times. Over half of the care staff team have achieved NVQ level 2 or above in care. Positive people made comments about the home I spoke to which included the following; “ I love working here”. “ I think it’s beautiful here, I really do. They look after me and are kind and good ”. “ I think the home is quite good”. “ It’s nice, I can’t fault it”. “ I am quite happy”. “ Oh I love it. It’s lovely here. They wait on you hand and foot”. “ It’s fantastic. I give it full marks or more”. “ Nothing is too much trouble”. DS0000035520.V338979.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The main concern that I identified during this inspection was medication systems and safety. There were a number of shortfalls which, could potentially place service users’ at risk that need to be addressed. Care plans need more attention to ensure that all risks passed on from other agencies are included. Care surrounding dementia and mental health issues needs to be more structured and expanded upon in the care plans. DS0000035520.V338979.R01.S.doc Version 5.2 Page 7 Training needs to be accessed in a number of areas examples being; medication and infection control. A second sink is needed in the laundry strictly for hand wash purposes. This was highlighted following the last inspection and has to date not been addressed. Staff must ensure that service users’ are weighed on admission to obtain a ‘ baseline’ measurement for future reference. Risk assessments must be carried out at least annually but always when changes occur. 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. DS0000035520.V338979.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 DS0000035520.V338979.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): 2, 3, 4, 6. Quality in this outcome area is good. Service users are issued with a terms and conditions document which, details their rights during their stay. The home however, is not ensuring that updated fees are changed for service users’ who have been at the home for some time. No service user moves into the home without having had their needs assessed and being given written assurance that their needs can be met. The home endeavours to maximise independence particularly concerning service users’ admitted for rehabilitation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No service user I spoke to told me that they did not like the home or indicate that the home was not meeting their needs. All were complimentary about the home and told me that it was for example; lovely, beautiful and that they were happy. DS0000035520.V338979.R01.S.doc Version 5.2 Page 10 Since the last inspection improvements have been made in all aspects of admission processes. One visitor told me that she and her daughter had been involved in choosing the home for their relative. One service user told me she had been to the home previously for a short stay and had liked it and returned. She told me another stay at the home was planned for September 2007. All files I looked at contained a terms and conditions document, which is good as that, tells service user what they can expect the service to provide. The home must be careful to ensure that the correct fee is entered on each service users’ terms and conditions document as it is increased annually. I saw records to evidence of assessment of need. I also saw a letter addressed to each service user confirming that the home can meet their needs. From observations it was clear that staff do try and encourage service users’ to do what they can for themselves particularly those at the home for rehabilitation. One service user told me; “ I do what I can. I am better now. I am going back home next week”. The manager told me that she has accessed training for some staff on rehabilitation techniques and is hoping to secure more in the near future. One staff member told me how positive it is having service users’ for rehabilitation as they get better whilst at the home and then are able to go back home. DS0000035520.V338979.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. Not all needs are set out in service users’ care plans. More attention needs to be paid to evidencing service user and relative involvement in care planning processes. Some fine tuning is needed to ensure that service user health care needs are fully met. Medication systems need improvement as at the present time there is potential risks. Service users’ are treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service user files I looked at contained a written care plan. The quality of these care plans varied for example; some were thorough and comprehensive, whilst others were not fully completed or did not cover needs in sufficient detail which could present risks to service users’ if staff are not fully instructed how to care for each individual. Written instructions were given by the funding DS0000035520.V338979.R01.S.doc Version 5.2 Page 12 authority for one new service concerning delicate skin. These instructions advised lifting this persons legs with a towel yet this was not mentioned in the care plan. One service user had been an in patient in hospital for some time where therapy was given which intimates severe depression yet signs and symptoms for depression were not included in the care plan. Similarly, I saw little instruction in care plans linked to dementia care. There was no evidence to confirm that service users’ or their relatives are being consulted about care plans or that they are being involved in their production. The manager told me that one team leader has recently been allocated to audit and improve care plans. She told me that staff had completed the old care plan formats then these new ones had been implemented which, has caused a few problems. I looked at four service user files. There was evidence of daily personal care and records of professional visits. One relative told me; “ He has improved so much since he came in here”. A service user told me; “ The nurse has been to see me today”. Another service user told me; “ I saw the doctor the other day”. There was however, some evidence lacking of chiropody, foot care and opticians assessments which needs to be addressed either service users’ are not being offered these services or record making is not adequate. It is positive that there was evidence of weight monitoring. However, in some cases where weight loss had been identified there was no audit trail or evidence of what had been done to prevent risks associated with weight loss. Two service user’ files told me that they had lost some weight yet there was no evidence of referral which could place these people at risk. I was disappointed to discover that one service user admitted for short stay had not been weighed to determine her baseline weight. The new care plans have brought with them new ways to risk assess which may bring about improvement in this area. I identified a shortfall in that records were made about one service user describing that her posture had changed. After this a record had been made stating that she had told staff that she had a fall. Whilst there was no evidence that she did have a fall there was no evidence to confirm that she had not .Change in body posture could potentially place this person at risk from falls, yet the staff had missed the opportunity to link this with possible referral to the doctor or the need for a new risk assessment to be carried out as a preventative measure. It is clear that staff have tried to improve medication systems since the last inspection. Staff example initial lists have been produced and photos are provided on all service user medication records for better identification to prevent errors. However, I identified a number of shortfalls, which must be addressed, to prevent risk and increase safety. Examples as follows; The medication records where staff initials are detailed are small making it DS0000035520.V338979.R01.S.doc Version 5.2 Page 13 impossible to count initials to allow effective audits. Medication totals are not always being carried over from the previous medication record causing confusion with one service users’ Nitrazepam as there were more left tablets than there should have been. Staff are not always recording how many tablets are being given when a variable dose is being prescribed for example; one or two again hampering any audit processes. Not all medication is being recorded when received into the home. A number of service users’ are ‘ self medicating’ yet there are no risk assessments in place to judge competence or safety. Not all staff have received accredited medication training. There was no care plan for a service user prescribed Lorazepam on an ‘ as required’ basis therefore; there were no instructions for staff telling them when this medication should be given . Temperature readings in the ground floor medication room were on some days 26oc, 27oc and 28oc when the maximum temperature for storing medication is 25oc. Similarly. The medication cupboard on the first floor is very warm yet there is no temperature monitoring taking place. The controlled drug cupboard is not of the approved standard and there was a lot of spillage on the wooden shelf from medication bottles in the controlled drug cupboard. Clear instructions for medication such as Risedronate were not available. This medication should be given 30 minutes before food or other medications and the person should not lie down for 30 minutes after taking. Without these instructions staff were in all probability administering this medication incorrectly placing the service user at risk. Similarly the label on the bottle of Li liquid said ‘ warning follow printed instructions given’. The only instructions on the medication record said; “ Take 2 x 5 spoonfuls at night”. Vital other instructions were not available again, potentially placing the service user at risk. I saw gaps on medication records where numerous prescribed topical preparations and nutrition drinks had not been signed for to confirm they had been given as prescribed. The new team leader told me that she had identified from an audit that she had done recently that there were problems with medication. The manager confirmed this. I was told that these issues would be resolved as a matter of priority. I observed staff and service users’ in different areas within the home. The staff were polite and friendly to the service users’. They ensured that toilet and bathroom doors were shut when in use. The nurse came to treat one service user I saw that this service user was taken to the bedroom to have this treatment in private. I saw records to confirm that the preferred form of address is determined for each service user. DS0000035520.V338979.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. Service users’ find that the lifestyle experienced in the home generally matches their expectations and preferences. Visiting times are open and flexible. Service users’ are very much encouraged to maintain contact with family and friends. Meals offered are nutritious, varied and interesting. This judgement has been made using available evidence including a visit to this service. EVIDENCE: I asked all service users’ about the daily routines. Not one told me that they were made to get up or go to bed against their will. All confirmed that they could get up and go to bed when they wanted to. Staff that I spoke to confirmed this further; “ They all have a choice. No way is anyone made to get up early or if they don’t want to”. “ Oh yes, everyone goes to bed and gets up when they want. One-lady stays in bed late, we just check her every fifteen minutes. She gets up when she wants”. I spent time on both floors within the home. In the morning I observed a lively ‘ parachute and ball’ session being carried out on the first floor. All but one of the service users’ in the lounge were participating and enjoying the session, DS0000035520.V338979.R01.S.doc Version 5.2 Page 15 there was much laughter. The one who did not join in had been poorly, however, I saw her watching what was going on. One service user seemed satisfied with the activities provided by the home she said; “ There is always something going on”. I felt that it was positive when early on in the morning a staff member asked the service users’ if they would like the television or radio on, rather than just putting these on. I looked at records confirming activity sessions. There were gaps when nothing was recorded. This shortfall would probably be bridged if a dedicated activities person were employed. I saw information on a notice board confirming that a trip was being arranged for a group of service users’ to go to the Black Country Museum on 25 July 2007. When I went downstairs I saw that a quiz session was being held with service users’. A number participated in this activity and seemed to enjoy it. The home has an open visiting policy. Service users’ I spoke with all told me that they have visitors regularly. I spoke with one visitor who told me that she could visit anytime and that she was made to feel welcome. Bedrooms I looked at held a range of possessions brought in by service users’ making the rooms personalised and homely. I saw evidence to confirm that long term service users’ are enabled to vote. A service user who told me confirmed this; “ Last time I used the postal voting service”. A night staff member told me that she had responsibility to ensure that menu boards were written on during the night so that as soon as service users’ got up they would know what meals were offered that day. When I walked around the home I saw that the menu boards were up to date and reflected meals given that day which is positive. I observed breakfast time on the first floor. A number of service users’ used the dining room, others used the table in the lounge area. The tables were nicely laid. Staff were on hand to give help. I saw one staff member sitting with a service user encouraging her to eat her breakfast. All service users’ were offered a range of cereals at breakfast time including porridge. I found it very positive to witness one staff member actually showing the service users’ toast and crumpets for them to choose which they would like rather than asking them, when their understanding may have been limited. I observed lunchtime on the ground floor. Most service users’ ate their meal in the dining room. This is a pleasant room. The tables were nicely laid with tablecloths. Sauces, condiments and a range of squash drinks were provided. The main meal was mixed grill or jacket potato and salad followed by stewed apple, apple pie and/ or ice cream. The meals were attractively served and smelt very nice. DS0000035520.V338979.R01.S.doc Version 5.2 Page 16 I was pleased to see that fresh fruit was available in lounge areas for service users’ to help them selves. The home has achieved a silver’ Five for life’ healthy eating award which is positive. I asked service users’ about the meals, their responses were as follows; “ I like the food. They ask us what we want and give us what we want”. “ Meals vary, good and bad. Mostly overall pretty good. We have a choice”. “ Meals are fairly good, much better than hospital”. “ The food is alright”. “ The food is wonderful. Good, solid, proper food”. “ The meals are good, I can not complain”. DS0000035520.V338979.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. The home has complaints information for service users’ and their relatives to access if they have the need. Complaints received by the home are dealt with appropriately. Processes are in place to protect service users. Training/ refresher training for staff concerning abuse awareness needs to be secured. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure which is available within to access. It was highlighted in the previous inspection report that alternative to written complaints procedures should be produced to aid the understanding of service users’ who have dementia or other diagnoses. The home has received one complaint- which was dealt with appropriately. The Commission received a complaint and intended to look into during this inspection. An identical letter of complaint was sent to Sandwell Tipton team in June 2006. However, the service user in question has not lived at the home for over twelve months. The file is no longer held by the home so it was not possible to address. One allegation has been made by one service user which was referred and addressed by Wednesbury Adult Team. There was no evidence one way or the other to uphold the allegation. DS0000035520.V338979.R01.S.doc Version 5.2 Page 18 Procedures are in place for staff to follow concerning allegations or incidents of abuse. The manager is aware that training in the subject of protection is needed but is having difficulty at the present time accessing this. I asked staff and service users if they had any concerns or if they had witnessed any shouting, rough handling or other. Their responses were as follows; “ No nothing, they have all been lovely”. “ No nothing, No one is unkind or rough”. “ No concerns, no shouting or anything”. “ No, no, no”. “ No definitely not”. “ No I’m not aware of anything. If there was I would report it straight away”. “ Oh, no. If there was anything I’d be straight down the office. If I did not get any satisfaction I would keep going higher until I did. If we notice anything, bruising or anything it is reported and documented, we find out the cause”. DS0000035520.V338979.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 26. Quality in this outcome area is good. Service users’ live in a safe and relatively well- maintained environment that meets their needs, is comfortable, clean and homely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Greenhaven is a large detached home that was purpose built and opened in the late 1970’s. Externally the home is sound. Window frames are all made of UPVC material. The home has attractive outdoor space with raised flower beds and easy access. I saw that garden furniture has been re-varnished since the last inspection which enhances it considerably. A lot of improvements have been made internally since the last inspection. Some carpets in corridors have been replaced and lounges have been redecorated. DS0000035520.V338979.R01.S.doc Version 5.2 Page 20 Generally, the home is well maintained is bright and homely. It has a number of different living spaces including conservatory areas and a choice of lounges in addition to dining rooms on each floor to give choice and privacy. It has smoking and non- smoking lounges for service user use. One service user told me; “ I am satisfied with the home, it is so big”. I looked at four bedrooms and found these to be of a good standard in terms of flooring and decoration. They were bright and homely. All service users’ I spoke to confirmed that they like their bedrooms. Two service users’ showed me their bedrooms themselves. Infection control has improved considerably since the last inspection as has general cleaning. The home looked a lot cleaner. Toilets and bathrooms are all provided with waste bins, liquid soap and paper towels. The manager told me that mechanical sluices have been purchased and are waiting to be installed. The home has not met a requirement made following the last inspection for a second sink to be installed in the laundry. During this inspection I saw that clothes were soaking in the sink. There is no dedicated sink for staff to wash their hands, which could present infection control problems. DS0000035520.V338979.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. Generally the numbers and skill mix of staff meets service user needs. Over 50 of the staff team have NVQ level 2 or above confirming that service users’ are in safe hands. Recruitment processes are adequate. Staff induction training is available as it should be. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels are provided as follows; Am 4 care ground floor 3 care first floor. Pm same Nights 1 senior and 2 carers. Team leaders are also provided on some shifts and the manager is on site during office hours. Cleaners, catering and laundry staff are also provided every day. The home has experienced some shortage of staff recently due to sickness. However, generally this is being managed by using casual carers or existing staff taking on additional hours. The manager confirmed that the usage of agency staff has decreased which is positive as this provides greater consistency of care. DS0000035520.V338979.R01.S.doc Version 5.2 Page 22 No one I spoke to told me that staffing shortages were a constant problem they said; “ Oh, yes there are enough staff”. “ Depends mostly ok”. “ Enough”. “ Not enough staff at times. This is when attention is not paid to covering “. “ Not always enough staff, but mostly enough”. I indirectly observed staff during the inspection. They were polite and respectful to the people in their care. Staff I spoke to confirmed that they enjoy their work. All service users’ spoken to complimented the staff. They said ; “ They are all good and lovely”. “ The staff are marvellous”. “ All helpful”. Information provided by the manager pre inspection confirmed that 23 of the 36 care staff have achieved NVQ level 2 or above which means that the home is meeting the required target of 50 of the care staff team having this qualification and that they have been assessed as being competent to do their work. I looked at four staff files to assess recruitment and supervision. These files held an application form, written references and evidence of Criminal Records Bureau and other required documents . There was however, a lack of official sources of identity for some staff. The manager is aware of this and is addressing it. The manager was able to provide me with staff induction files to look at to evidence that the required induction processes are in place. Training has been audited since the last inspection. The manager knows what training is required. I saw that an up to date training matrix has been produced and is on display in the manage’rs office. DS0000035520.V338979.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. Quality in this outcome area is good. The manager has been approved as a fit person to run and manage the home. Quality monitoring processes are in place and are of a good standard. Systems are in place to adequately safeguard service users’ money. More attention must be paid to staff supervision to ensure all receive to the required frequency. Generally, health and safety within the home is well promoted and managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the Commission as a fit person to run and be in charge of the home has approved the manager. DS0000035520.V338979.R01.S.doc Version 5.2 Page 24 The manager is interested in her work and is keen to make any needed improvements. The home has within the last 12 months been reaccredited with ISOQAR concerning its quality assurance system. A team leader has been allocated the task of undertaking a full audit of the home in terms of quality monitoring within the next few weeks. Systems are in place to gain the views of service users’ and relatives about services provided. The manager told me that a recent meeting has been held with district nurses and other agencies about services provided by the home and working relationships which was positive. The home has good processes in place to safeguard service user money. I witnessed staff on shift handovers checking the safe contents and signing to confirm that the contents were correct. Records of all money received and spent are made. Receipts are obtained and held to confirm all expenditure. I looked at staff files to assess staff supervision frequency. I found that one casual staff member has not had any supervision. The other two received supervision on 3.11.06 and 17.3.07 and 17.12.06 and 6.5.07. Supervision frequency does need to be increased to ensure that all staff have the required six supervision sessions in any twelve month period. I looked at records concerning health and safety.Evidence of fire training and drills for example, was available. Hot water temperature recordings were too high in some areas for example; the laundry, sluice and another unidentified area 65.7oc. Risk management needed to ensure service users’ do not have access to these areas. I identified that there are some gaps in mandatory training which the manager is aware of. She is finding it hard to access in-house training at the present time, but will continue to nominate staff for courses. I saw records to demonstrate in house checking of fire fighting equipment and emergency lighting. I saw service certificates for the following; fire extingishers, fire alarm system 6/07 , Lift and hoists 7/2/07 which shows that equipment is being maintained as it should to prevent accidents. I saw a letter to confirm 5 year fixed elecrical wiring not needed until 2008. Falls analysis is done monthly and reviwed every 3 months. Generally the number of falls in the last few months has decreased; 2007 Jan 24, Feb 27, March 25 April, 16, May 13, June 17 which is positive. I did not assess the kitchen on this occasion as it had been inspected by Environmental Health at the end of February 2007. I was assured however, that all of the required temperatures of fridges and freezers for example are being monitored as they should be. DS0000035520.V338979.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 3 x 3 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 3 x x x 3 x 2 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 3 x 3 x 3 2 x 3 DS0000035520.V338979.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 OP7 Regulation 15(1) Requirement The registered manager must ensure that care plans are completed thoroughly with the information required. Timescale of 30/11/06 not fully met. Care plans must include all needs, ( health, personal and medical) risks and goals, violence, aggression, abuse etc. The application of creams and lotions must be recorded at the time it is applied. Timescales of 24/02/06 and 10/06/06 not fully met. This requirement has been made to ensure that service users’ all receive their prescribed medication and that they are safe. The registered person and manager must ensure that a medication care plan is in place for ‘ As needed’ medications . These must give guidance and instruction to staff and highlight common side effects to be alerted to. DS0000035520.V338979.R01.S.doc Timescale for action 10/08/07 2 OP9 13(2) 16/08/07 3 OP9 13(2) 16/08/07 Version 5.2 Page 27 Timescale of 10/06/06 not met. This requirement has been made to ensure that service users’ all receive their prescribed medication properly and that they are safe. The registered person and manager must ensure that a documented risk assessment is carried out for any resident who self medicates. ( this applies to all routes of administration oral, topical, inhalant etc). Timescale of 05/06/07 not met. This requirement has been made to ensure that service users’ all receive their prescribed medication properly and that they are safe. The registered person and manager must take and record daily temperatures of the treatment rooms where medication is stored to ensure the temperature does not go above 25oc. Timescale of 10/06/06 not met. This requirement has been made to ensure that medication storage within the home is safe. The registered person and manager must ensure that all medications coming into the home are counted and recorded. (this to include nutrition drinks and creams). Timescale of 05/06/06 not met. This requirement has been made DS0000035520.V338979.R01.S.doc Version 5.2 Page 28 4 OP9 13(2) 16/08/07 5 OP9 13(2) 16/08/07 6 OP9 13(2) 16/08/07 7 OP9 13(2) to make sure that the management of medication within the home is safe. The registered person and manager must ensure that where a choice of dosage is prescribed examples being; ‘ one tablet or two-One or two spoonfuls’ that the amount actually administered is recorded. Timescale of 05/06/06 not met. 16/08/07 8 OP9 13(2) 9 OP9 13(2) This requirement has been made to make sure that the management of medication within the home is safe. Documented risk assessments 18/08/07 must be carried out for all service users who self medicate. Where this is insulin the district nurses must be asked to carry out this task. This requirement has been made to increase medication safety and prevent harm to service users’. All medication records must have 20/08/07 sufficient space to allow staff to initial but also allow audits and the counting of initials. All balances of medication must be carried over to the next medication record. This requirement has been made to increase medication safety in the home. Medication records must be amended to remove the preprinted ‘ none listed’ allergy section to allow staff to write in the space allergies or none. Clear instructions must be recorded on medication records for each medication an example DS0000035520.V338979.R01.S.doc 10 OP9 13(2) 20/08/07 11 OP9 13(2) 20/08/07 Version 5.2 Page 29 12 OP26 13(3) being Risedronate. The registered person and manager must ensure that a second sink strictly for ‘hand washing’ purposes is provided in the laundry. Timescale of 01/08/06 not met. 01/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP7 Good Practice Recommendations The registered person and manager should ensure that care plans are produced in formats appropriate to the individual residents i.e. large print / pictorial. The registered persons and manager should ensure that there is provision on the care plans for residents’/ or chosen others to sign and date to demonstrate that they are aware of their care plan and have been involved in its production. The registered person must ensure that all residents are weighed on admission and that this baseline weight is recorded. Risk assessments should be reviewed at least annually or when changes occur. The registered person and manager must ensure that where medication records are handwritten 2 staff sign to confirm that the information being transferred from bottles and packets is correct. An approved pharmaceutical guide no older than 12 months should be available at all times. The registered person and manager must determine from each resident their choice or otherwise in care provided by opposite gender staff. The outcome of this consultation must be recorded and acted on. The registered person and manager should ensure that a dedicated activities co-ordinator is appointed. Complaints procedures are produced in formats appropriate to the needs of the residents’. DS0000035520.V338979.R01.S.doc Version 5.2 Page 30 3 4 5 OP8 OP8 OP9 6 7 OP9 OP10 8 9 OP12 OP26 10 11 12 OP26 OP36 OP36 All staff should receive infection control training. The registered manager should ensure all staff receive supervision at least six times a year and this matter must be addressed by both parties, supervisor and supervisee. Night staff meetings should be considered to ensure better attendance. DS0000035520.V338979.R01.S.doc Version 5.2 Page 31 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: 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 DS0000035520.V338979.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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