Inspection on 15/02/06 for Greyfriars

This inspection was carried out on 15th February 2006.

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

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

Other inspections for this house

Greyfriars 28/06/07

Greyfriars 11/05/06

Greyfriars 29/07/05

Greyfriars 01/03/05

Greyfriars 30/06/04

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

CARE HOMES FOR OLDER PEOPLE Greyfriars 26 Clarence Gardens Shanklin Isle Of Wight PO37 6HA Lead Inspector Annie Kentfield Unannounced Inspection 15th February 2006 14:00 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 Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 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. Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Greyfriars Address 26 Clarence Gardens Shanklin Isle Of Wight PO37 6HA 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) 01983 864361 Mr David Cable Mrs Ann Cable Mrs Ann Cable Care Home 9 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (9) of places Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th July 2005 Brief Description of the Service: Greyfriars is a small residential care home in a domestic setting offering care to nine frail older residents and is registered to admit two residents with dementia. Situated is a residential area of Shanklin, the home is managed by the registered owner who lives close by. All of the residents are accommodated in single rooms on the ground floor or first floor. Access to the first floor is via a stair lift. There is a patio and small garden to the front of the house that is used by the residents in the warmer months of the year. Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of the home in this inspection year and was arranged a few days in advance to take place when the manager was in the home. The inspection covered a tour of the premises, discussion with some of the residents and staff, and inspection of some of the home’s records. At the time of the inspection there were eight residents in the home and the manager, two members of staff and a student, were on duty. Comment cards were left for residents and visitors to complete and return if they wished to. What the service does well: What has improved since the last inspection? What they could do better: 1. Requirements from the previous inspection have either not been met or have only been partially met. 2. Staff recruitment procedures – these do not meet current regulatory requirements that require thorough checks on all staff to protect vulnerable residents. This requirement has not been met over three inspections and a letter of serious concern has been sent to the registered manager. Failure to meet this requirement has the potential to place residents at risk and failure to comply with the Care Homes Regulations 2001 may result in enforcement action being considered. 3. Fire Safety – this requirement has been partly met. The registered manager has consulted with the Fire Safety Officer about fitting approved self-closing mechanisms to internal fire doors, but the work Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 6 has not yet been carried out. Doors must be kept closed and not wedged open, as this is a fire safety risk. 4. Staff training – The registered manager must demonstrate that staff in the home are trained and competent to meet the needs of the residents. Although staff are trained and supervised by the manager on a day-today basis, there are no training records or sufficient evidence of accredited training for staff in safe working practice 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. Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 7 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 Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 (other standards were assessed at the previous inspection) Residents have a written contract or statement of terms and conditions with the home. EVIDENCE: Records show that residents have a written contract that is signed by the resident or their representative. However, the contract must include details of the cost of the care and the room (number) to be occupied. In discussion, the manager agreed to amend the contract to meet this. Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 and 11 (other standards were assessed at the previous inspection) Medication is securely stored and there are policies and procedures in place for staff that dispense medication. It is recommended that the staff training plan should include accredited training in the safe administration of medicines. It is the policy of the owner/manager that residents can continue to live in the home as long as the home is able to meet their care needs. EVIDENCE: The manager oversees all medication received into the home and only senior staff that have been trained and assessed as competent by the manager are responsible for dispensing medicines. Although a member of staff confirmed that they had received training from the manager, it is recommended as good practice that all staff who dispense medicines should receive accredited training in the safe administration of medicines that includes: basic knowledge of how medicines are used and how to recognise and deal with problems in use, and the principles behind all aspects of the home’s policy on medicines handling and records. Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 10 All medication is kept in a locked cupboard in the office and records were signed and up to date. The manager and senior staff monitor the health of the residents on a daily basis and any concerns are referred to the relevant GP. The manager is a registered nurse and uses her skills and experience to ensure that residents’ health care needs are always met. The manager explained that she is in daily contact with all of the residents and it is the home’s philosophy that residents will live in the home for life as long as the home can continue meet the residents’ care needs. Residents’ wishes in the event of illness or death are recorded where appropriate or in discussion with a residents’ family or representative. Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 (other standards were assessed at the previous inspection) The daily routines in the home are flexible and informal and activities are offered to suit the needs and abilities of the residents. EVIDENCE: Staff in the home are encouraged to spend time with the residents wherever possible, usually in the afternoons. The inspector spoke to some of the residents who were in the lounge and some residents who prefer to spend time in their own rooms. Residents said they liked being in the home because it was small and homely and they felt comfortable. Visitors are always welcome and some of the visitors like to bring their dog to visit the residents. From discussion with some of the residents it was evident that the routines in the home suit their expectations and preferences. Residents have the opportunity for occasional music sessions, bingo and religious worship and birthdays and special events are always celebrated. Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 - 18 Although the manager is very aware of the need to ensure that residents are protected from harm, the home’s recruitment procedures are not thorough enough to ensure that residents are protected at all times. EVIDENCE: The manager explained that steps are taken to make sure the home is secure and safe for residents. As the manager is in daily contact with the residents she is aware of any concerns that may arise and these are addressed at the time. All of the residents are registered on the electoral role. There are policies and procedures for staff to read about awareness of adult protection issues although it has been some time since staff updated their training in adult protection awareness and procedures. Residents do not have their own telephone but can use the home phone if they wish to. This was discussed at the last inspection and the manager has since made arrangements for some of the residents to have access to the phone on a pre-arranged basis, as they choose. The home’s recruitment procedures do not meet current regulatory requirements and there are staff employed in the home without sufficient background checks and Criminal Record Bureau checks. This has been a requirement over several inspections and a letter of serious concern has been Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 13 sent to the manager. The manager has confirmed by letter that this requirement will be addressed within the timescale specified. Failure to carry out the required checks on new and existing staff has the potential to put vulnerable residents at risk. Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 (all of these standards were assessed at the previous inspection) The home is clean and tidy and comfortably furnished to meet the needs of the residents. Residents who need assistance with mobility can only access the first floor bedrooms and bathrooms with assistance from staff using the stair lift. It is recommended that all shared toilets and bathrooms have hand-washing facilities that meet standards for the control of infection. EVIDENCE: The home has a pleasant sitting room and a separate dining room with room enough for all of the residents to take their meals there. All of the residents have their own room and these are individually furnished and decorated. There are two bedrooms on the ground floor and one of these was being redecorated at the time of the inspection. There is a bathroom with an assisted bath on the ground floor. During the inspection it was noted that one upstairs Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 15 toilet had soap and a towel; good hygiene practice recommends that liquid soap and paper towels be installed in any shared facilities as part of infection control. Fire safety requirements from the last inspection have not been fully met, however, the manager explained that there are plans to redecorate and recarpet the ground floor of the home and the self-closing mechanisms will be fitted to ground floor doors when the decorating is completed and the new carpet laid which may involve re-hanging the doors. Although this was accepted it was noted that one resident had their door wedged open and this is a fire safety risk. Doors must be kept shut unless fitted with mechanisms that shut automatically in the event of a fire. The requirement to ensure that the upstairs fire exit door is kept clear has been met. The manager has sought advice from the local fire safety officer and their recommendations will be put into place when the refurbishment is completed. During the inspection it was noted that one bedroom door needs lifting in order to close properly and the manager said that this would be addressed as soon as possible. The inspector spoke to two residents who prefer to spend time in their own room and they expressed satisfaction with the accommodation provided. The home has a call alarm system for residents to ring for assistance if needed. Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30 (all of these standards were assessed at the previous inspection) Recruitment procedures are not thorough enough to protect the residents, or meet the current regulatory requirements. There must be a staff training plan that demonstrates that all the care staff are skilled and qualified to meet the needs of the residents, and to ensure safe working practice for the residents and staff. EVIDENCE: The home employs a large number of staff; most of them work on a part-time basis. Records show that some of those employed in the home have not been subject to thorough pre-employment checks or have Criminal Record Bureau checks, or have been checked against the POVA (Protection of Vulnerable Adults) list, before starting work in the home. This is a requirement that has not been met by the registered manager over several inspections. Current regulations require all employees in the home to provide a full job history, to provide two satisfactory written references (one of these should be the last employer) and to only start their employment when a satisfactory Criminal Record check and a POVA check is received. The Care Homes Regulations were amended in 2004 to ensure thorough checks are made on all staff that are employed to work with vulnerable adults. At present the home are not meeting these requirements and failing to comply with the regulations. Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 17 Since the last inspection there have been some improvements towards meeting the National Minimum Standard to have at least 50 of the care staff with the minimum of an NVQ level 2 in care qualification. However, at present only one member of staff has the minimum qualification, and two members of staff are enrolled to achieve this, and this is still well below the recommended 50 . The manager provides all staff training herself in health and safety and safe working practice. However, there is no record kept of staff training and staff supervision to demonstrate that staff have been assessed as competent and skilled. In discussion with the manager a requirement has been made that a staff training plan must be produced by the end of March 2006 that sets out how the home will meet the standards and requirements for staff to be trained and qualified. It is also recommended that the training plan should look at arranging accredited training by a recognised training provider to ensure that working practice in the home meets current standards of good practice. At present, the only person trained in First Aid is the manager. Some of the staff have done accredited training in Basic Food Hygiene although the manager confirms that the Food Safety Inspector has accepted that staff can be trained by the manager in food hygiene and risk analysis to an acceptable level because of the size of the home. The inspection spent some time discussing staff training with the registered manager and although it is evident that staff are experienced, the manager must demonstrate that staff are trained and competent to be able to meet the care needs of the residents and to employ safe working practice in the home. Also that staff are supervised on a regular basis and records kept. Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 and 38 (other standards were assessed at the previous inspection) The home has policies and procedures to ensure that residents’ financial interests are safeguarded. The manager needs to demonstrate that staff are trained in safe working practice that protects the health, safety and welfare of the residents. EVIDENCE: The home has a policy that the manager or any staff do not manage any residents’ finances or financial interests. Usually the family or representative of a resident will assist with finances and the residents are provided with an invoice of any expenditure on things like hairdressing or chiropody. The Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 19 manager is aware of any residents who may be at risk of possible abuse and would take steps to ensure that residents are referred for independent support. Fire safety checks on the alarm and emergency lighting are carried out weekly and the manager has just updated the home’s fire safety risk assessment. Previous fire safety requirements have already been discussed and found to be partly met and will be fully met when the current plans for refurbishment are completed. Staff training has been discussed in the previous section and the manager is required to provide a staff training plan to demonstrate that staff will receive accredited training in all aspects of safe working practice. Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 1 2 X X X X X X 2 STAFFING Standard No Score 27 X 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP18OP29 Regulation 19(1)(b) & Sch 2 Requirement Timescale for action 30/03/06 2. OP19OP38 23(4) 3. OP30 18 Two written references and details of previous employment must be obtained for all new staff. All new staff must have a current CRB check and POVA check in place before starting work in the home. (This was also a requirement at the inspection of 1st March 2005 and 29th July 2005, further failure to comply will result in enforcement action) Doors must not be wedged open, 15/02/06 as this is a fire safety risk. This was a requirement from 29th July 2005. The registered manager must 30/03/06 demonstrate that there is a staff training plan appropriate to the needs of the residents, including training in all aspects of health and safety and safe working practice. Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP2 OP9 OP26 Good Practice Recommendations The contract or terms and conditions should include the cost of care and the room number to be occupied. Staff who dispense medication should receive accredited training in the safe administration of medicines. Shared hand-washing facilities should meet current guidance on good practice for the control of infection (liquid soap and paper towels). Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Greyfriars DS0000012495.V251395.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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