Inspection on 02/07/07 for Grey Ferrers Nursing Home

This inspection was carried out on 2nd 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Grey Ferrers Nursing Home 17/05/09

Grey Ferrers Nursing Home 22/05/08

Grey Ferrers Nursing Home 11/12/07

Grey Ferrers Nursing Home 05/07/06

Grey Ferrers Nursing Home 20/09/05

Grey Ferrers Nursing Home 28/04/05

Grey Ferrers Nursing Home 02/08/04

Grey Ferrers Nursing Home 06/05/04

Grey Ferrers Nursing Home 03/03/04

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

CARE HOMES FOR OLDER PEOPLE Grey Ferrers Nursing Home Priestly Road Blackmore Drive Leicester Leicestershire LE3 1LQ Lead Inspector Jo Wright and Keith Charlton Key Unannounced Inspection 09:30 2 , 4 and 9th July 2007 nd th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Grey Ferrers Nursing Home DS0000001907.V340353.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. Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grey Ferrers Nursing Home Address Priestly Road Blackmore Drive Leicester Leicestershire LE3 1LQ 0116 2470999 0116 2558364 brownpj@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Limited 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) Mrs Pamela Jane Brown Care Home 120 Category(ies) of Dementia - over 65 years of age (60), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (30) Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons who fall within category DE(E) may only be admitted into Stewarts Hey & Woodville House Unit located at Grey Ferrers Nursing Home Bradgate Unit located at Grey Ferrers Nursing Home may accommodate a total of 30 persons who fall within categories/combined categories OP and PD(E). Brandon House located at Grey Ferrers Nursing Home may accommodate a total of 30 persons who fall within categories/combined categories OP and PD(E). No person falling within either category OP or PD(E) may be admitted to Grey Ferrers Nursing Home when an overall total of 60 persons who fall within those categories are already accommodated within this home. The registered provider is able to admit into Grey Ferrers Nursing Home the person of category DE, named specifically in variation application number V43335 dated 18 February 2003, who is under 65 years of age. The registered provider is able to admit into Grey Ferrers Nursing Home the person of category MD(E), named specifically in variation application number V55305 dated 13 September 2003. The registered provider is able to admit into Grey Ferrers Nursing Home the person of category MD(E), named specifically in variation application number V55305 dated 13 September 2003. That Grey Ferrers Nursing Home is registered to admit one named Service User, named in application number V29612, under category PD. The maximum number of persons to be accommodated within Grey Ferrers Nursing Home is 120. To be able to admit the named person of category DE (under 65 years) named in variation V35650 dated 5th October 2006 into Grey Ferrers Nursing Home The registered provider is able to admit into Grey Ferrers Nursing Home one person under the category PD 50 - 65 years of age 5. 6. 7. 8. 9. 10. 11. Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 5 Date of last inspection 5th July 2006 Brief Description of the Service: Grey Ferrers is a 120-bedded care home providing personal and nursing care for older persons. Accommodation is provided within four separate units, these are known as Brandon, Bradgate, Stewards Hay and Woodville providing care for older persons with nursing, physical disability and dementia needs. Each unit is comprised of a large dining/ lounge area, a small quiet lounge, toilet, washing and bathing facilities and single room private accommodation. The home is located on the outskirts of Leicestershire and is easily accessed by public transport from the City of Leicester and from the County. The home provides nursing and residential care for service users whose care needs fall within the categories of Older Persons and or Physical Disability and Dementia over 65 years of age. The home is purpose built and is accessible to service users with disabilities. Accommodation is located on the ground floor. Each unit has a spacious lounge and adjacent dining area, which look out the gardens. All bedrooms are single occupancy and all are ensuite, many open directly onto the garden. The home is currently managed by a registered nurse and employs Registered General nurses, Registered Mental Health nurses and care staff. The home has ample parking and is close to a number of social amenities. The weekly fees range from £327 to £685 per week - the Registered Manager provided this information on the day of the inspection. There are additional costs for expenditure such as hairdressing, private chiropody, toiletries, newspapers, etc. The home provides information to residents and prospective residents in the form of a Statement of Purpose that describes the services it offers, with copies of the Service Users Guide and the last Inspection Report displayed in the reception area. Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting five residents and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. In addition, on one unit which specialises in dementia care, two hours were spent observing the care being given to a small group of people. The care of one of these people was looked at in depth when comparisons with observations were made with the records. This was an unannounced site visit. The Registered Manager was on duty. Planning for the site visit included checking on the notifications of significant events sent to the Commission for Social Care Inspection, the last Inspection Report and information regarding the four Vulnerable Adults Meetings held since the last inspection focusing on concerns raised. There have been six complaints made to the Commission for Social Care Inspection since the last inspection regarding care practices, medication systems, record keeping, staffing levels. As a result the Registered Manager has set up Action Plans to deal with these issues. The site visits took place between 09.30 and 16.00 on day one, between 09.25 and 16.20 on day two and 09.30 and 15.00 on day three. This included a selected tour of all the different parts of the home, inspection of records and indirect observation of care practices. The Inspectors spoke with nine residents, three staff members, and four visitors. What the service does well: Residents said that staff spoken to them in a friendly fashion, with respect, and they welcomed visitors to the units without restrictions. Premises and accommodation visited were generally well maintained and decorated. Garden areas provide pleasant areas for people to sit outside. Rooms visited were personalised. BUPA has a Regional Health and Safety Committee, which provides relevant information from around the world, which is a useful reminder to staff. Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: The Registered Provider needs to ensure that the welfare of residents is protected at all times regarding medical authorities being involved where necessary following injury. There must be a system whereby such instances of unexplained bruising are reported to the person in charge so that further investigation and referral if necessary is carried out and that the accident record should contain what follow up action was taken. Any unexplained bruising must be reported to the lead agencies. A record of daily living choices is recommended to be part of the Care Plan so that residents individual wishes are followed, e.g. what time they wish to get up. Medication systems need to be reviewed so that if medication does not arrive from the pharmacist this is then quickly followed up to ensure that residents are not left without their medication. Medication must be administered as proscribed and records not signed as medication being supplied if it has not been given to residents. Monthly Regulation 26 reports undertaken by the Company to establish how the home is operating need to be detailed to cover all requirements and issues of concern raised by Commission for Social Care Inspection / Social Services Department. No residents meetings are currently held. It is recommended that these meetings be set up. Relatives meetings are held to inform management as to how the home can promote the quality of life for residents though comments were made that ideas are not always acted upon or that the group receive proper responses to their concerns. The Registered Manager was recommended to attend such meetings. As the service accommodates a significant number of residents with mental heath needs, staff need be trained in dementia care. Staff must always be aware of residents care needs: Providing more signs to bedrooms would assist residents who have dementia, in that they can identify facilities clearly. Also to set up memory boxes for residents with dementia, which can be used for reminiscence and interest for them. Ensuring that the Activities Organisers Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 8 receive appropriate training would mean that residents with dementia have their needs met more effectively. The food provided to residents needs to be reviewed to ensure that there is a larger choice for residents with more diverse needs. 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. Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 (Standard 6.is not applicable in this service) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient Needs Assessment information ensures that needs of the people using the service are identified and met. EVIDENCE: Residents said that they could visit the home prior to their admission by way of a trial period, to give them a good idea of what services the home offered. They said they were asked about their needs so that staff could care for them properly. Relatives said that their relatives were visited in hospital by management staff that assessed their needs. Some residents said they were provided with a service users guide to the services the home offers. There was evidence of assessments undertaken by management available in the care files examined. This incorporates most of the issues contained in the National Minimum Standard to ensure staff can meet the individual needs of the new resident. Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 11 Grey Ferrers does not offer intermediate care facilities for residents who want to receive rehabilitation before returning home. Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Inconsistencies in care planning may result in residents needs not being met. Poor staff practice in relation to the implementation of medication systems leaves residents vulnerable of not having their health needs met. EVIDENCE: No residents or relatives asked knew they had a Care Plan or had been involved in this being set up. Although all residents whose files were looked at had plans of care in place, not all of these clearly set out the care that was required. This included referrals to health care professionals, the need for regular toileting, why position changes to deal with pressure sores appeared to be at lengthy intervals, mouth care, and dental needs not being quickly followed up as regards a dental check. Care plans are reviewed monthly and this was seen as recorded in the Plans. Risk assessments also form part of Plans to reduce the risk of harm from identified risks. During this site visit, residents on one dementia care unit were Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 13 observed for a period of two hours. The time spent observing residents daily life and staff care practices found that care staff routinely moved and transferred people using appropriate methods and equipment, and were mindful of privacy and dignity issues when delivering care. Staff were observed explaining to residents what they were going to do before they carried out the task. There was little detailed information recorded about people’s personal histories. Residents said that if there were a medical problem then staff would call a GP to see them. Relatives said that staff contacted them if their relative was not well. Accident records were viewed. There were instances where residents were observed to have unexplained bruising which had not been reported by care staff in a timely fashion to the unit manager and senior management. (See Section on Complaints and Protection). Residents said that staff and unit managers were friendly. Residents said that staff respected their privacy and knocked on doors before they entered. Staff who were observed were very friendly and respectful and carried out tasks at the residents pace. The visitors spoken with were impressed with the standard of care provided by the staff and said they were caring and friendly. The medication system was inspected. Management and staff confirmed that only qualified staff administer medication. It was found that a resident went without medication for three days as it was out of stock, which replicated a complaint from 2006. It was reported that there had been difficulties obtaining a prescription for this resident from the surgery prior to the medication running out. It was also found that medication had been signed as given on medication sheets when it was still in blister packs, as well as gaps on medication sheets when medication had been given and not signed for. In additional, when medication was not administered to a resident, a code of ‘O’ (meaning other) was recorded. However, the reason for non administration had not been recorded on the medication sheet. Grey Ferrers Nursing Home DS0000001907.V340353.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): Standards 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ wellbeing may be affected by the limited range of social and recreational activities. EVIDENCE: During this site visit, residents on one dementia unit were observed for a period of two hours. The time spent observing residents daily life and staff care practices found that care staff interacted very little with residents, other than when carrying out tasks. The majority of staff interaction observed was initiated by the activity organiser, and residents were clearly enjoying the time that she spent wit them. Residents said that there was a range of activities and that they are not forced to be involved in activities. There were comments that some residents would like more outings and activities and that activities are offered seven days a week. Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 15 Prompts such as memory boxes, containing valued items, which would assist with social interaction between staff and residents, especially those people with memory loss, were not in place. The activity organisers had not received any given training on providing suitable activities for residents with dementia, although one member of staff was observed talking with a resident and explaining what they doing, even though the resident was unable to communicate with them. There was limited information and signage in the dementia care units, e.g. colour coding/pictures on bedroom doors, to assist people to orientate themselves. Residents spoken with said that there were no rules that they knew of, e.g. no one reported that there were set going to bed and rising times, and all thought the atmosphere of their home was friendly and relaxed. However, there were some comments received that due to staff shortages residents were not always able to get up when they wanted. Personal choices were not always identified in individual care plans. Residents and staff spoke of being able to maintain their independence in other ways – washing, dressing, choosing clothing etc. During the observation carried on one of the dementia care units, residents were observed walking around the lounge area as they wished. Inspection of residents accommodation demonstrated that they were able to bring in to the home their personal possessions. Residents confirmed this. Both residents and relatives stated that visitors are always welcomed to the home and no one reported any restrictions. The visitors spoken to were impressed with the standard of care provided by the staff and said they were caring and friendly. There were generally positive views regarding the food though there were some concerns received regarding that residents thought some of the food was not their choice and that would prefer ‘English’ type food and not so much of other food - pasta, curries etc. Menus indicated at times that English food was not always offered. Vegetarian options were not always recorded so it was not possible to establish whether choices and variety were provided. Residents preferences in relation to food were not recorded in care plans. Three hot meals are offered each day, which is a good range of choice. Breakfast menus have improved – they are varied and offer a large range of choices. Staff were observed to be assisting residents to eat. Staff said that they ensure residents who need to have a soft diet are supplied with it and they assist residents as required. Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Despite concise complaints procedures being in place relatives do not always feel that they are listened to and their concerns acted upon. The lack of staff knowledge around safeguarding adults procedures may result in residents not being protected from harm. EVIDENCE: Residents said that they thought that if there was a problem then they would go to a unit manager to get it sorted out. However, relatives commented that they do not feel that issues they raise through relatives meetings are listened and acted upon as they do not receive proper responses. A Complaints Procedure was in place and made available. However, this procedure did not direct people to other agencies who they may raise their concerns with, such as the local social services department. The management of the service have received a number of complaints during the previous 12 months. These complaints were recorded in detail and had been dealt with by the management. Information provided by the Provider prior to this site visit stated that only twelve out of twenty two complaints received in the past year had been dealt Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 17 with within the twenty-eight day timescale, and that 2 complaints had not been concluded at the time the information was supplied. Since the last inspection, the Commission has been made aware of issues concerning the care and services provided at Grey Ferrers by relatives and social workers. As a consequence a random inspection was carried out in September 2006. Further issues have been raised since this time, and these have referred to the local authority through safeguarding adults’ procedures. Staff members spoken with were not aware of the full procedure regarding all outside Agencies to contact if the in house arrangement regarding protecting residents from abuse failed. In addition management at Grey Ferrers has made a number of referrals to the local authority safeguarding adults procedures in relation to staff practice and unexplained bruising. However as previously stated there were instances where residents were observed to have unexplained bruising which had not been reported by care staff in a timely fashion to the unit manager and senior management. Once reported, appropriate action had been taken. However, this suggests that not all staff are aware of the procedure in place for staff to report instances of potential concern to senior management to enable further investigation and referral to the appropriate authorities if necessary or that staff are not adhering to the procedures that are in place. Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable and safe environment that needs their needs. EVIDENCE: Residents said that they liked the facilities at Grey Ferrers, they appreciated that the home was kept clean by staff, and they could organise their bedrooms in the way they wanted. During a selective tour of the home it was observed that all areas were well decorated and furnished, clean, tidy and well maintained. Rooms had been personalised to accommodate personal possessions. There was only one unit, where the carpet was odouress and needed cleaning. The fact that this unit had asked for more intensive cleaning was evidence that Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 19 this had been identified as an issue. This unit also had damaged patches on some carpet areas so the carpet needed replacement. It was reported that there were plans to redecorate and replace furniture in 2007 and 2008, as money was made available. Relatives said that they had raised the issue of units needing fans to provide cool air in warm periods but there had been no action. It was reported that this issue was being addressed and air conditioning units were to be fitted. It was reported that residents/relatives would be informed of these developments in writing. It was noted that locks were not fitted to bedroom doors and residents were not routinely asked whether they would like a lock fitted. One resident commented they would like to have a lock fitted to their bedroom door. There are protected radiators to minimise any risk of burning to residents. Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Incomplete staff trainings means that residents are not always supported by staff with the necessary skills, knowledge and experience to fully met their needs. EVIDENCE: There were a number of comments made which indicated that peoples perception was that staffing numbers were not sufficient to ensure that staff are always able to respond quickly to residents needs. However, the rotas in the units confirmed that usually there were six Care Assistants plus a trained nurse from 8am to 2pm and five Care Assistants plus a trained nurse from 2pm to 8pm, with two Care Assistants plus a trained nurse from 8pm to 8am. There were comments that only bank staff and not agency staff can be used, which has the effect of there being less staff being available to be called on shift when there are shortages. Senior management disputed these comments, and it was reported that if necessary, agency staff would be obtained if bank staff were not available. Three staff files were inspected and contained all statutory information Protection of Vulnerable Adults checks that had been received before staff members had commenced employment with other information - references, work histories, identification etc. were seen to be in place. Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 21 Staff files contained evidence of training although not all care staff had received training on a range of essential care issues – e.g. food hygiene, health and safety, fire, first aid, moving and handling, infection control, dementia, residents health conditions – stroke, parkinsons disease, diabetes, hearing and sight impairment. Currently there are less than 10 of staff who have completed National Vocational Qualification training. However this has been recognised and it was reported that another fifteen staff are in process of doing this training with a plan to ensure that a similar number will be enrolled this year. It was reported that all staff receive mandatory fire safety training, moving and handling training and safeguarding adults training as part of their induction prior to going onto the units. New members of staff working supernumerary for2 shifts and then work with a mentor during their induction period. All staff are required to complete the induction booklet during their first 12 weeks of employment. Unit managers are responsible for supervising the completion of this. Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Ongoing staffing and management issues means that the service can not always be run in the best interest of the residents. EVIDENCE: Residents and relatives said that they thought the managers on the units were approachable and thoughtful as to the running of the service. However, comments were also made that senior management were not supportive and can be abrupt. The Regulation 26 reports seen during this site visit did not support that all requirements/issues of concern raised by Commission for Social Care Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 23 Inspection, Social Services Departments had been reviewed and action taken to rectify. No residents meetings are currently held. Relatives meetings are held to inform management as to how the home can promote the quality of life for residents though comments were made that ideas are not acted upon or that the group receive proper responses to their concerns. There was no evidence to support that Staff Meetings have been held. There is a BUPA Quality Assurance system in place and the one from 2006 was viewed. However relatives and other stakeholders, e.g. GPs, District Nurses, Social Workers etc were not included in this system and the results were not included in the Statement of Purpose, with a summary of findings and information as to action to be taken where needed. There was some evidence on staff records that staff have supervision but this is not carried out on a one to one basis where staff have the opportunity to discuss all relevant matter. Residents monies records were found to be properly kept, with running balances and receipts but only one recorded signature. There are Health and Safety folders with Risk Assessments for safe working practices in place though some detail was missing – e.g. one record asked that controls in place are listed but the record merely stated ‘’Its controlled’’. Additional health and safety information is provided for staff through the Regional health and safety Committee. Fire Precautions: System testing was on required schedules for fire drills, fire bell testing and emergency lighting. There was a fire risk assessment seen in one unit. As previously stated, not all staff had received all of the mandatory training. Staff members were asked about the fire procedure and one was not aware of the whole procedure. Safeguards were in place to prevent residents from scalding themselves with the hot water. The temperature of the hot water was checked and recorded regularly. Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement All people using the service must have an up to date, detailed care plan. This must direct staff on the delivery of care in line with the individuals assessed needs. This will ensure that people using the service receive person centred support that meets their needs. People using the service must receive their medication as prescribed. This will ensure that people receive the correct levels of medication. The reason for non administration of medication must be recorded on the medication sheet. This will ensure that there is a clear audit trail as to why medication has not been given. All staff must be fully aware of how to recognise abuse and how to instigate the safeguarding adults procedures, both internal and external to the service. This will ensure that people using the service are protected from harm. Timescale for action 31/08/07 2 OP9 13(2) 31/07/07 3 OP9 13(2) 31/07/07 4 OP18 13(6) 31/08/07 Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 26 5 OP18 13(6) 6 OP27 18(1) 7 OP33 21 8 OP36 18(2) 9 OP38 18(1) All staff must be made aware of the procedure in place for staff to report instances of potential concern to senior management to enable further investigation and referral to the appropriate authorities if necessary. Compliance with this procedure must be monitored. This will ensure that any potential incidents of abuse are identified and investigated appropriately in a timely fashion. The staff team must have the required skills and knowledge to deliver appropriate care to the people using the service. This will ensure that staff have a better understanding of the care the people using the service require. Systems must be in place to enable staff to comment on the conduct of the care home as far as it may affect the health and welfare of people using the service. This will provide two way dialogue between staff and management in order to improve the service provided. Staff practice must be supervised to ensure that the care they are providing is appropriate to meet the needs of the people using the service. Provide all staff with mandatory training with evidence to support that this had taken place. This will ensure that people using the service are cared for by staff with appropriate skills and knowledge. 31/07/07 31/10/07 30/09/07 31/08/08 31/10/07 Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations Information about a person’s personal history should be recorded in their files. This will provide staff with insight into the person’s life and enable them to see people as an individual with a valued history. Systems should be put in place to ensure that supplies of medication are available for people using the service at all times. This will ensure that people receive their medication as prescribed. Residents hobbies and interests should be recorded in their care files. This would enable staff to provide activities in accordance with individual’s preferences. Participation in activities should be recorded to support that their social needs are being met. Residents choices regarded preferred routines should be recorded in their care plans. This will assist staff to plan and in deliver care in a manner that meets residents preferences. The activity organisers should receive training specific to their role, taking into account the needs and preferences of people who use the service. This will enable the service provide a more person centred activity programme. Residents preferences in relation to food should be obtained and the menus reviewed accordingly. This will ensure that people are offered a choice of meal each day that takes into account their collective preferences. The complaints process should be reviewed to include information about other agencies that people can raise their concerns with. This will ensure that people have the required information to take their concerns to an external agency if they are dissatisfied with the internal response. 50 of care staff should be qualified to National Vocational Qualification Level 2, so that staff have the necessary skills and knowledge to care for people using the service. The Regulation 26 Monthly Report on the running of the service should contain sufficient detail to establish that requirements identified as needing action to protect the welfare interests of residents have been acted upon. DS0000001907.V340353.R01.S.doc Version 5.2 Page 28 2 OP9 3 OP12 4 OP12 5 OP12 6 OP15 7 OP16 8 OP28 9 OP31 Grey Ferrers Nursing Home 10 OP33 11 OP33 12 OP36 Resident meetings should be held to assist with monitoring and improving the quality if life for people using the service. Any issues raised at resident and/or relative meetings should be acted upon and feedback given to the group about the outcome. Relatives and other stake holders should be included in the quality assurance system and the results included in the Statement of Purpose. This will assure residents and relatives that the provider sees improving the quality of the service as a high priority. Staff should be provided with regular one to one supervision to ensure that the care they are providing is appropriate to meet the needs of the people using the service. Health and Safety Risk Assessments should ensure that all identified risks are controlled and detail how this will be achieved. This will ensure that people using the service are protected from any unnecessary risks. 13 OP38 Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Grey Ferrers Nursing Home DS0000001907.V340353.R01.S.doc Version 5.2 Page 30 - 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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