Inspection on 22/05/08 for Grey Ferrers Nursing Home

This inspection was carried out on 22nd May 2008.

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

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 11/12/07

Grey Ferrers Nursing Home 02/07/07

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Grey Ferrers Nursing Home Priestly Road Blackmore Drive Leicester Leicestershire LE3 1LQ Lead Inspector Louise Bushell Unannounced Inspection 22nd May 2008 11:00 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 Grey Ferrers Nursing Home DS0000001907.V365089.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.V365089.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) Ltd 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.V365089.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. Th 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.V365089.R01.S.doc Version 5.2 Page 5 Date of last inspection 11th December 2007 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 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 over 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 £433 to £733 per week. 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.V365089.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. 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 four people and tracking the care they received through looking at their care records, discussion where possible with the people who use the service, the care staff and observation of care practices. Because people with dementia are not always able to tell us about their experience of the service, we used a formal method of observation called the Short Observational Framework for Inspection (SOFI). This involved spending a period of two hours within the communal lounge of one of the dementia units observing up to five people. The observation period gave an indication as to how the service supports the personhood and individuality of people living with dementia. The visit was unannounced and planning for the visit included assessment of the notifications of significant events, which had been received from the service to the Commission for Social Care Inspection. We looked at the last Inspection Report and information on safeguarding and complaints since the last inspection and we looked at the feedback received from questionnaires circulated to relatives, staff and people who use the service. During the visit information was gathered from the relatives satisfaction survey and resident customer satisfaction survey which was conducted by Grey Ferrers in December 2007. Two safeguarding concerns had come to the attention of the Commission for Social Care Inspection (CSCI) since the last inspection visit, the nature of the concerns were in relation to care practices, medication systems, record keeping and staffing levels. The local authority was investigating the safeguarding concerns and the Registered Manager had set up Action Plans to address all of the concerns to ensure improvements to practice. Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 7 The visit took place between 11:00am and 18:40pm. This enabled the two inspectors to directly and indirectly observe the care practices and the day to operations of the service. A selected tour of the building was conducted during which the inspectors spoke with people who use the service, staff and visitors and the registered manager Pamela Brown. What the service does well: What has improved since the last inspection? A new care plan format has been devised and is now in place at the service. This focuses on the increased involvement from relatives, friends and or advocates where the person using the service requires or requests this. The format enables staff to quickly refer to the relevant section and act appropriately on residents needs. A named nurse and key worker system is now in place and being continuously developed in each unit. The Introduction of the menu manager and the night bite menu is now in place. This offers the person using the service more choice, variety and easier accessibility to food items and drinks as required. The service has improved the daily site cover report completed by the unit managers of each of the four units at the end of each shift every day. This covers the staffing arrangements, medication checks and audits as well and appointments, health and safety issues and any other significant issues. This is then reported back to the Registered Manager to ensure that a smooth line of open communication occurs between all. Meetings for the person using the service are now being completed and minutes are available. Relative meetings are now taking place. Two activity coordinators are now recruited on site to support in the provision of activities. Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 8 An air conditioning unit is being erected in the laundry area. What they could do better: The information and guidance on the Control of Substances Hazardous to Health (COSHH) needs to be reviewed and up to date information made available to all staff. Information on the ‘after life’ wishes of people using the service needs to be obtained and recorded within the individual care plans. The statement of purpose requires revising and reviewing. This should include the findings from the last Commission for Social Care Inspection report and the experiences expressed by people that use the service. The terms and conditions of contract for funded people should be implemented to ensure that the rights of the individual are respected at all times. Records of all concerns and complaints (verbal and written) that come to the attention of the unit team leaders and the registered manager must be retained. The record must include the actions taken to investigate the concerns/complaints and the outcome of the investigation. The registered provider should implement works to improve the internal redecoration and refurbishment at the earliest opportunity to ensure that the environment is maintained to a good standard. Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 9 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.V365089.R01.S.doc Version 5.2 Page 10 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.V365089.R01.S.doc Version 5.2 Page 11 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 1,2 & 3 (Standard 6 is not applicable in this service) Quality in this outcome area is good. Pre and post admission assessments are completed with sufficient information to ensure that the needs of the people who use the service are being met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has developed a welcome pack for people that use the service. The pack is available to each person and or family member / representative when they move into the service. The information pack includes photographs, the home’s statement of purpose and any other additional information that a person may need in order for them to feel welcomed and settled. The guide details what the person can expect and gives a clear account of the specialist services provided, quality of the accommodation, qualifications and experience of staff and how to make a complaint. Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 12 The statement of purpose details specific information individual to the service. It sets out the objectives and philosophy of the service supported by the information guide. All people are provided with a copy of the guide. When requested the service can provide a copy of the statement of purpose and guide in a format which will meet the capacity of the resident. The statement of purpose is to be revised and reviewed to include the findings from the last Commission for Social Care Inspection report and should also contain the experiences of those people who use the service. Admissions are not made to the home until a full needs assessment has been undertaken. The assessment is always undertaken by a qualified Registered Mental Health Nurse or a Registered General Nurse. Feedback from people consulted with, confirmed that they were provided with information about the home and that they had the opportunity to visit for a trial period or a day visit to see what the home was like. People also commented on the support they received from the staff and management team, during their transition to the home. There was evidence that the service receives a summary of the assessment and a copy of the care plan prior to admission if funded through the care management process. The manager and the staff at the service commented that admissions to the home only take place if the service is confident that staff have the skills, ability and qualifications to meet the assessed needs of the prospective person. Privately funded people are provided with a statement of terms and conditions or a contract. This sets out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the individual. Terms and conditions are reviewed when there is a change in need. Those people who are funded through social services have a contract held. However the service should develop the terms and conditions or a contract between the service and the person so they are provided with, and have the same rights as those privately funded. The manager stated this is an area that is currently being developed with the service as a corporate provider. Grey Ferrers does not offer intermediate care facilities for residents who want to receive rehabilitation before returning home. Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 13 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, 10 & 11 Quality in this outcome area is good. The health care needs of people using the service are set out in individual care plans, and tailored for the individual. This ensures that the care provided is individualised and that the social, medical, physical and psychological needs of the person using the service are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has now fully introduced a new care plan format that sets out the specific provision of care for each individual. The plans focused on the rights of the person, and recognised the importance of the equality and diversity needs of the person, to include personal preferences and choices. Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 14 Feedback from the most recent relatives and customer satisfaction survey stated that over all, 93 people using the service felt that they were treated like individuals. Comments received from a number of people that use the service confirmed that they are happy with the care that they receive, a total of 94 confirmed in the satisfaction survey that they rated the quality of care they receive as excellent / good. One relative provided comments that detailed that they did not feel that the service responded well to needs and changing needs. This has been managed through the complaints and safeguarding procedure. The personal healthcare needs including specialist health, nursing and dietary requirements were recorded in each persons care plan. There were assessments in place to assist in identifying changes in the health requirements. On the day of the visit, the staff were observed to respond to the needs of people using the service respecting their individuality and preferences. The delivery of personal care was individual and flexible. Findings from the Resident / Relative Customer Satisfaction survey determined that 100 of the responses at either an excellent or good level know the needs of the person using the service. People were supported and helped to be independent and can take responsibility for their personal care needs, and comments received on the day of the visit indicated that the people who use the service feel that their needs are being met. One relative spoken with said how “the staff do an excellent job under very difficult circumstances” and expressed satisfaction with the care provided for their relative living at the home. The people using the service have access to healthcare and remedial services. The health care needs of those unable to leave the service are managed by visits from local health care services and fully registered staff on site. Generally people using the service have the aids and equipment they need and these are well maintained to support them and staff in daily living. One person who required additional adapted seating had to wait an unsatisfactory length of time. This is now on order for the person. This is also being managed through the complaints procedure. Staff have access to training in health care matters and are encouraged and given time. The service trains internal managers to facilitate the mandatory Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 15 training for all staff, ensuring that staff numbers of those trained remain at a high level. The home has a medication policy supported by procedures and practice guidance, which staff understand and follow. The medication administration records (MAR) sheets were well managed and to ensure that compliance is fully met daily checks are carried out during each staff handover period. Where appropriate people using the service are given the support they need to manage their own medication. Individuals who did not manage their own medication through choice or lack of capacity, had risk assessments in place and the staff held the responsibility for the administration of their medication. There were systems in place for the receipt, administration, safekeeping, and disposal of medication and controlled drugs. One safeguarding concern raised in relation to medication had been addressed through the complaints procedure. Staff work to clear and robust practices when caring for individuals who have degenerative conditions and terminal illnesses. Good practice examples were indirectly observed on the day of the inspection. Staff were seen to be sensitive to the needs of the person and the family, providing information as required. A sample of care plans contained clear information about the individual’s wishes, choices and decisions as their health deteriorates. A number of care plans however did not detail the after life wishes of people using the service, although support was available for the family and the other people using the service during the bereavement process. The staff understand and are sensitive to the particular religious and cultural needs of the individual or their family. Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 16 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. The limited range of social and recreational activities affect the wellbeing of the people that use the service. Food choices are appealing and varied for all, ensuing that the nutritional well being of the people who use the service is met. These judgements have been made using available evidence including a visit to this service. EVIDENCE: Staff are aware of the need to support the people who use the service to develop their skills, including social, emotional, communication, and independent living skills. Feedback from staff indicated that they would like to see an increase in the provision of activities, and feedback in the Residents Customer Satisfaction Survey and the Relative Customer satisfaction survey indicated that the people Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 17 using the service would like to engage in more activities, with 20 finding that the choice of activities and events to be poor. In response to whether the extent of the activities and events are interesting, 40 stated that this was poor. With a further 50 stating that the number of events and activities was poor. In response to this the registered manager has employed two activities coordinators. There were limited opportunities for people using the service to take part in activities both within the home and in the community. Where possible, the staff gather information on community-based events and try to make individual arrangements for people to attend. The service was in the process of organising a Gala day for the summer. A number of people using the service commented that were looking forward to this event. Within each of the units there was activity plans on display so people who use the service were able to see what is being provided and scheduled dates, there was evidence to suggest that efforts were being made to increase the facilitation of activities for all. “Resident and relatives” meetings had been recently introduced to increase the involvement of the people who use the service. The minutes of a recent meeting were viewed and those present had questioned whether the management look at the minutes to address concerns that are being raised. The staff were seen to make relatives welcome, one relative said they visited their spouse on a daily basis to provide help with meal times. This visitor stated that this was the one area were they felt they could do something practical to help their spouse. Observations within one of the dementia care units, over the lunchtime period evidenced that there was five care staff and two registered nurses to provide care for twenty-eight people. The dependency levels of the people residing within this unit was very high in terms of the full assistance required when eating and drinking, moving and handling and personal care. Staff were observed to work as team ensure the basic needs of the people were met, due to the high physical dependencies of people who resided within the dementia care unit, the level of social engagement and quality time was compromised due to the high demands placed upon staff at this busy time of the day. Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 18 The findings from the observation period (SOFI) indicated that the quality of the interactions between the staff and residents was in the main good with a few neutral interactions. Good interactions were when staff took the time to listen and respond to people, reading body language and non-verbal cues and engaging 1-1 with the people using the service. Neutral interactions observed were such as staff acknowledging the persons in their care, whilst managing to keep any engagement to a minimum, simple exchanges of information between the person using the service and not prompting conversation. No poor interactions were observed. Information and findings gathered from the Relative and Resident Customer Survey found that in relation to tastiness of the food, 60 of the people use the service and 93 of the relatives found this to be excellent or good. In relation to the variety of dishes available, the people who use the service found that 60 thought this was excellent or good. Over all 73 of the people who use the service rated this as good. The Introduction of the menu manager and the night bite menu is now in place. This offers the person using the service more choice, variety and easier accessibility to food items and drinks as required. It identifies and enable all persons using the service to make informed choices and decisions about the food and drinks they consume. Care plans detailed meal choices, likes and dislikes and preferences, including cultural needs where applicable. Staff were observed to be assisting residents to eat. Staff said that they ensure that the people who need to have a soft diet are supplied with it and they assist them as required. Staff were indirectly observed supporting the people who use the service with patience and respect. During the tour of the building the rooms of people using the service were sample checked and in the main people are encouraged to personalise their rooms. In discussion with people using the service they expressed their satisfaction of the services received In general, both people who use the service and relatives stated that visitors are always welcomed to the home and no one reported any restrictions. The visitors spoken to were satisfied with the care provided. A number of concerns in relation to the provision of activities were raised and these have been managed through the complaints procedure. Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. The complaints procedure for the service is comprehensive, however some records and feedback gathered, determines that people who use the service may not all have their complaints dealt with adequately to achieve an expectable resolution. Safeguarding procedures are in place ensuring that the people who see the service are protected from harm. EVIDENCE: Feedback from a number of people who use the service and relatives, determined that they know how to make a complaint but others do not. Staff are aware of the complaints procedure but may not realise the importance of listening to, and then acting on concerns on behalf of the person. Written complaints from individuals are recorded, however the records were on occasion incomplete, with timescales, outcomes and actions not being properly recorded. Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 20 The service would benefit from introducing a verbal complaints log, supporting in the management of an open approach to the management of complaints. There is a comprehensive complaints procedure in place with suggestions of additional external agencies to contact as the complainant may wish. The complaints procedure should be reviewed. There are policies and procedures for safeguarding people who use the service and these are specific to the home. A number of staff confirmed that they have received training in safeguarding and protection of vulnerable people. When asked staff were able to discuss openly the processes they may take. Links with external agencies were good, and referrals were managed adequately. A high level of staff have had training around safeguarding adults. In general the people who use the service stated that they are satisfied with the care in the home and feel safe. Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 21 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, 20, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. In general the people using the service are provided with a pleasant environment, however internally the furniture and fabric of the building look in need redecoration and refurbishment. EVIDENCE: The physical environment is appropriate to the specific needs of the people who live there, is satisfactorily maintained and provides in most instances the specialist aids and equipment to meet the needs of people using the service. The home is a pleasant, safe place to live, the layout of the building allows people to live in smaller units and encourages a personal feel to each unit. The Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 22 design of the building supports and enables persons with physical disabilities in terms of access. A number of the communal areas are beginning to appear worn and tired. The service would benefit from early redecoration and refurbishment. A number of walls were seen to be marked and requiring re plastering in areas and redecorating. A number of specialist seating chairs appeared worn, frayed and discoloured although regularly laundered. People who use the service confirmed that they are offered with choices about rooms when the moved in if more than one was available. The people who use the service are encouraged to personalise their bedrooms. All the home’s fixtures and fittings meet the needs of individuals and can be changed if their needs change. The environment promotes the privacy, dignity and autonomy of residents. The findings from the Residents Customer satisfaction Survey confirmed that overall 80 of the people who use the service confirmed that they would rate the building and the grounds at an excellent / good level. Overall 94 of the relatives / visitors confirmed that they would rate the building and the grounds at an excellent / good level. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in private. The bathrooms and toilets are fitted with appropriate aids and adaptations to meet the needs of the people who use the service, and are in sufficient numbers and of good quality. The manager stated that the laundry facilities were in the process of being fitted with air conditioning units. The home was well lit, clean and tidy and free from offensive odours. There was an infection control policy in place and in discussion with the staff and observation of care practice demonstrated that the infection control practices were being followed. There was restricted access to high risk areas such as the main kitchen and the laundry areas to reduce the risk of cross infection, it was noted that within the laundry the Control of Substances Hazardous to Heath (COSHH) data sheets were in need of review, in discussion with the staff it was established that some of the chemicals listed were no longer in use. Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 23 One complaint / safeguarding referral had been addressed through the complaints procedure in relation to a person having acquired an infectious skin disease. The registered manager had recently taken action by enlisting the advice of the Public Health Agency and the infection had been successfully eradicated. During the visit the staff were seen to wear protection equipment such as gloves and aprons and hand sanitising gels were available at the entrance of each unit. Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 24 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 good. This judgement has been made using available evidence including a visit to this service. The service is adequately staffed in sufficient numbers to support and meet the needs of the people using the service. Sound recruitment procedures are in place so that the people who use the service are protected from harm. EVIDENCE: Feedback from a number of relatives / visitors determines that people’s perception was that staffing numbers were not sufficient to ensure that staff are always able to respond quickly to residents needs. As part of the inspection process the staff rota was reviewed to ensure that adequate staffing numbers were being allocated to the duty rota. Following the last inspection the service has introduced and improved the daily site cover report completed by the unit managers of each of the four units at the end of each shift every day. This covers the staffing arrangements, medication checks and audits as well and appointments, health and safety issues and any other significant issues. This is then reported back to the Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 25 Registered Manager to ensure that a smooth line of open communication occurs between all. On the day of the inspection interviews were taking place to recruit for care and nursing staff. Feedback from people that use the service and the staff confirmed that staffing numbers are more stable now and that there are now staff available as more have been recruited. There is a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the home recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. Accurate job descriptions and specifications clearly define the roles and responsibilities of staff. People who use the service report that staff working with them are skilled in their role and are consistently able to meet their needs. The service has a number of bank staff employed this ensures that agency staff are used as a last resort. The unit managers are surplus to the staffing levels and where required, ‘step in’ to ensure adequate numbers. Three staff files were inspected and contained all statutory information – Safeguarding of Vulnerable Adults checks that had been received before staff members had commenced employment information such as references, work histories, identification etc. were seen to be in place. Following discussions with the staff and the manager of the service the increase of staff commencing and completing the National Vocational Qualification in Care Level 2 continues. 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 for two shifts and then work with a mentor during their induction period. All staff are required to complete the induction programme during their first 12 weeks of employment and unit managers are responsible for supervising the completion of this. Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 26 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 good. This judgement has been made using available evidence including a visit to this service. The manager of the service is suitably qualified to ensure that the service is run smoothly meeting the needs of the people who use the service. Clear policies and procedures are in place for the staff to adhere to ensuring that care, health, safety and welfare of the people who use the service is protected. EVIDENCE: The Registered Manager has the required qualifications and experience and is competent to run the home. The Registered Manager and the unit managers have a clear understanding of the key principles and focus of the service, based on organisational values and priorities. They work to continuously improve services. Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 27 With the introduction of the new care planning format and training around its completion and implementation within the units, there is a focus on person centred thinking, with the people who use the service becoming increasingly more involved. The Registered Manager and unit managers lead and support a stable staff team who have been recruited and trained satisfactory levels. The manager is aware of the continued need to ensure that staff hold a National Vocational Qualification In Care Level 2. The manager promotes equal opportunities, has good people skills and understands the importance of person centred care and effective outcomes for people who use the service. The service has sound policies and procedures, which are corporately and internally reviewed and updated, in line with current thinking and practice. The manager ensures staff follow the policies and procedures of the home. The staff team are positive in translating policy into practice and showed good knowledge of care principles, health and safety and safeguarding issues. The service must ensure that adequate and up to date information and guidance is available for the control of substances hazardous to health. There was some evidence on staff records that staff have supervision but this is not always carried out on a one to one basis where staff have the opportunity to discuss their personal development. There is a need for all staff to be offered guidance about the role of supervision and for this to be documented with staff having one to one sessions periodically. Discussion with a member of staff determined that the staff member did not fully understand the process and role of supervision. It was commented that the staff member felt that supervision only took place “if you have done something wrong”. The management of the service were informed of this. Other staff confirmed that supervision does occur. Staff meetings take place regularly and minutes of the meetings are available on each unit. The home works to a clear health and safety policy. Safeguarding is given high priority and the home provides a range of policies and guidance to underpin good practice. Recent in house training has occurred regarding safeguarding issues. Staff confirmed that this was productive and showed a sound working knowledge of action to take in such an event. Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 X 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 3 2 3 2 Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 29 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 OP38 Regulation 13 (4) (c) Requirement Control of Substances Hazardous to Health (COSHH) must be suitably managed and up to date safety data sheets available in such incidences of misuse or accidents, ensuing that the safety of all is maintained. Timescale for action 24/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations The Statement of Purpose should be reviewed and contain the findings from the last Commission for Social Care Inspection, and experiences of people that use the service. The results from the quality assurance surveys should be included in the Statement of Purpose. This will assure residents and relatives that their comments are listened to and enable perspective residents to gain an insight into living in this home. Terms and Conditions of contract for those people who are funded through social services should be reflective of DS0000001907.V365089.R01.S.doc Version 5.2 Page 30 2 OP2 Grey Ferrers Nursing Home 3 OP8 4 OP11 5 6 OP12 OP16 7 OP30 8 OP33 9 OP36 those who are privately funded, ensuring equal rights for all. People who require additional and or alternative aids and adaptations should be supported to obtain these in a timely manner to ensure that their continued care needs are being met. People using the service should be supported as required to discuss their wishes concerning terminal care and after life to ensure that the service fully respects and dignifies the needs of the person. People using the service should be satisfied with the activities being provided. The service should implement a verbal complaints log to ensure that all complaints are logged and appropriate remedial action can be taken without delay. The complaints policy to be reviewed. Progress should continue to ensure that 50 of care staff are qualified to National Vocational Qualification Level 2. This is to ensure that the staff have the necessary skills and knowledge to care for people using the service. Resident meetings should continue to 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. 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. A system should be implemented to ensure that COSHH safety data sheets are reviewed and revised as required annually. Ongoing training should be provided to all staff to ensure they complete the required mandatory training and service specific training to enable them to fulfil their roles and responsibilities and meet individual needs. 10 11 OP38 OP38 Grey Ferrers Nursing Home DS0000001907.V365089.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Eastern Regional Office CPC1 Capital Business Park Fulbourn Cambridge CB21 5XE 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. 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