Inspection on 13/03/07 for Hadleigh House Care Home

This inspection was carried out on 13th March 2007.

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

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

Other inspections for this house

Hadleigh House Care Home 20/01/09

Hadleigh House Care Home 13/10/08

Hadleigh House Care Home 05/02/08

Hadleigh House Care Home 14/02/06

Hadleigh House Care Home 04/10/05

Hadleigh House Care Home 18/11/04

Hadleigh House Care Home 16/07/04

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

CARE HOMES FOR OLDER PEOPLE Hadleigh House Care Home 350 Pelham Road Immingham North East Lincs DN40 1PU Lead Inspector Mrs Jane Lyons Unannounced Inspection 13th March 2007 09:00 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 DS0000002861.V324783.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. DS0000002861.V324783.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hadleigh House Care Home Address 350 Pelham Road Immingham North East Lincs DN40 1PU 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) 01469 572514 Mr Michael Thomas Bailey Allison Smith Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places DS0000002861.V324783.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th March 2007 Brief Description of the Service: Hadleigh House provides comfortable, homely accommodation for up to 38 service users over the age of 65. The home is situated close to all amenities in Immingham. It has pleasant gardens; its own car park and is on a bus route. The home is a two-storey building with access to the first floor via stairs and a passenger lift, it is well maintained in terms of décor and furnishings. There are 32 single bedrooms and 3 shared, en-suite facilities are provided for the five new single bedrooms on the first floor. There are four bathrooms and a shower room with separate WC facilities provided on each floor. The home now provides 3 lounges and a pleasant dining room for residents to use. The rear garden has been landscaped and an attractive courtyard area provided, with seating and shade for service users and their visitors. Ample car parking space is provided. The home is owned by Mr M Bailey. The registered manager is Mrs A Smith. Weekly fees are: £329- £363. The home does not operate a system whereby the fees include a third party contribution. Additional charges are made for the following: toiletries, newspapers/magazines, hairdressing and chiropody. Information on the service is made available to prospective and current service users via the statement of purpose, service user guide and inspection report. Documents are made available prior to and following admission, copies are available in the residents’ lounge area. DS0000002861.V324783.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. • • This was the home’s second key inspection. The visit to the home lasted from 9 a.m. until 7 p.m. The inspector spent some time chatting to ten residents and four relatives. Five staff, a visiting district nurse, the manager and owner also talked to the inspector. Records about the care provided, and other records about the running of the home were looked at. Questionnaires about the home were sent to twenty of the residents, sixteen staff, twenty relatives and three healthcare professionals involved in supporting residents. Nine of the resident’s questionnaires, eleven relative, one health care professional and five of the staff ones were returned at the time this report was written. The inspector observed how staff and service users worked together throughout the day. People’s views about the home and what was found during the visit have been used to write the report and make judgements about the quality of care. Findings at this inspection identified that compliance had been achieved with 5 of the requirements detailed in the last inspection report although a number of new requirements have been made from this visit. • • • • • What the service does well: The home was welcoming and had a relaxed and homely atmosphere. Residents were observed to be very settled and comfortable in their surroundings. One relative’s survey detailed “the home is excellent; it is well run, kept clean and well decorated; the food is lovely” Residents really liked the food provided, are well fed and encouraged to eat a healthy diet. There were good visiting arrangements and visitors were made to feel welcome, discussions with a number of relatives confirmed this. DS0000002861.V324783.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Resident’s assessments and care plans must improve; individual resident’s assessments and plans were available however some records did not have enough information about all the needs of residents. This means the home was not able to show that all aspects of the health and personal care needs of resident’s are identified and planned for. The home must report all serious incidents to the Commission to ensure appropriate action has been taken to ensure resident’s safety and welfare. When residents have accidents such as falls, it is important that appropriate records are completed to ensure the correct action for the resident has been taken. More thorough audits of all accidents by the manager would better ensure that risks of accident re-occurrence have been addressed and the safety and welfare of the residents are better protected. Hot water temperatures in the home are checked regularly but when records show that the temperatures are too high work must be carried out to reduce them to safe limits, which will better ensure the residents safety. The manager has not always followed good practice when recruiting and selecting new staff by not ensuring all required checks on prospective employees are carried out before they start work in the home. This potentially places residents at risk of harm. DS0000002861.V324783.R01.S.doc Version 5.2 Page 7 The majority of the policies and procedures now require complete review and development to ensure that the staff have the required information to support all their current working practises which would better promote and protect the resident’s safety and welfare. Regular reviews of aspects of the home’s performance through a good programme of self review and consultations, which includes the views of residents, staff, relatives and others for example care managers must be carried out. This is needed to ensure continuous improvements are made and that residents and other parties have been able to influence the running of the home. 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. DS0000002861.V324783.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000002861.V324783.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 6. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are provided with sufficient information to help them decide if the home is right for them. The needs of service users are assessed prior to moving into the home and on admission, however the quality of the assessments potentially place residents at risk of not having all their needs identified and planned for. EVIDENCE: The admissions procedure does not fully guide staff on the actions to be taken to ensure prospective residents needs are assessed and planned for. Each DS0000002861.V324783.R01.S.doc Version 5.2 Page 10 service user has their own individual file and three files were looked at; two of these were for service users who had recently been admitted to the home. Copies of the Local Authority assessment and care plans had been obtained prior to admission for those residents referred through the local Social Services care management teams. The format of the home’s needs assessment covers all required areas; the standard of the completed assessments were found to be inconsistent; one of the records had been completed in detail however the other assessment was incomplete; neither document had been signed or dated. Staff confirmed that they were informed about new residents needs prior to admission. Service users told the inspector that the manager had visited them prior to admission. One relative survey detailed that they had visited the home prior to their loved one’s admission and met some of the staff which had been very useful. A number of surveys returned from service users identified that they had not received a contract however the three files checked during the visit contained a statement of the homes terms and conditions; the inspector advised the manager to carry out an audit to ensure all other residents had received this document or a contract, if privately funded. Residents spoken to could not remember if they received any information prior to moving in to the home; the manager confirmed that potential new residents were given copies of the statement of purpose and service user guides on assessment or when they come to look round the home. Discussions with the district nursing sister confirmed that issues she had raised previously around the manager accepting service users with identified nursing needs had settled; the manager now liaised with the service to ensure support in this area could be guaranteed. There was better evidence at this visit to demonstrate that care staff were accessing more service specific training; this will help ensure that they have the skills to enable them to deliver up to date care methods and have a better understanding of the varied conditions common to the elderly. The home does not provide intermediate care support. DS0000002861.V324783.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service user needs and choices are better provided through care planning and risk assessments, although they feel happy with the standards of care they receive some of the service user documentation remains inadequate and places them at risk of not receiving the care they need. EVIDENCE: Three residents were selected for case tracking, they had a range of individual plans in place which were supported by written risk assessments; however as identified in the previous inspection reports the quality and consistency of the information varied. Overall, improvements are being made to the care plan documentation however this is not being completed in a timely fashion; not all the senior care staff are competent in care plan writing which leaves much of DS0000002861.V324783.R01.S.doc Version 5.2 Page 12 the outstanding work to the deputy manager to complete. Senior care staff are scheduled to attend care planning training although this is later in the year. Two of the care files examined had the majority of care plans in place to support needs identified on assessment and developed to support changes in needs; however neither of the files had plans in place to support needs associated with confusion. Evaluation records were inconsistent for both files. There was good evidence that service users had been referred to relevant health care professionals and clear records of visits maintained. Significant improvements had been made to the daily record of care and records showed that staff were now completing records after each shift; only two gaps were identified in one file over two months and none in the other file. Improvements were also noted in the quality of the recording; daily entries gave more indication of the care given and were better linked to the plans. One of the care plans had a signed agreement in place the other did not. Risk assessment documentation was in place to support mobility, tissue viability, nutrition, falls and use of bed trails; the quality of the format for the moving/ handling assessment did not clearly identify the level of risk nor the equipment/ staff support required; the district nursing sister visiting the home agreed to provide a more detailed and user- friendly format for the home to use. The home utilises the traffic light system documentation to identify risks of pressure damage however one of the files examined contained a Waterlow risk assessment identifying high need yet the traffic light system identified low need which needed to be reviewed. Records of service users weights were better maintained and there was evidence that these were more closely monitored and referrals made to the G.P. or community dietician where necessary. The care file for the service user with mental health issues was case tracked again at this inspection visit; the care plan had not been updated since 2004 yet records and discussions with staff evidenced that the service users’ needs had changed. Problems around the service user placing herself on the floor of her bedroom and in the communal rooms had not abated; records evidenced that this continued to happen up to three times a day and required the support of three staff and the mobile hoist. Records of these incidents were inconsistently recorded with staff sometimes using daily records, incident forms and occasionally accident records. Other behavioural changes such as reluctance/ refusal to take meals, get out of bed, dress or accept personal care were also detailed in the daily records; however the service user was now displaying aggressive behaviours towards the staff. There were no care plans in place to support the service user’s challenging behaviour and tendency to put herself on the floor. Staff need to complete a risk assessment and clearly record all incidents on the correct document. DS0000002861.V324783.R01.S.doc Version 5.2 Page 13 Records showed that the Community Psychiatric Nurse had only visited the service user once since the previous inspection yet had confirmed in December to the manager that he would be visiting weekly. The manager was advised to make an urgent referral to the CPN and care management team to review current management of the service user’s needs and appropriate placement. This issue was followed up after the inspection; the manager confirmed that the CPN and psychiatrist had visited the service user and although medications had not been reviewed the service user’s behavioural problems had settled significantly and were being monitored closely. A multidisciplinary review meeting was scheduled to take place in the near future. Surveys indicated that health care professionals were satisfied that the staff at the home have a good knowledge of the service users’ needs, and follow specific, specialist instructions. Discussions with the district nursing sister during the visit confirmed that she was satisfied with the level of communication at the home, she considered that the nursing staff were always well supported by the staff during their visits and she was satisfied with the standards of care provided. All discussions with relatives and all surveys returned with the exception of one evidenced that the home informed them and kept them up to date with important issues. Improvements with the recording of accidents and specifically falls in the home is still required; the home also maintains incident records and staff need clarity around what incidents/ accidents need to be formally documented on the official accident documentation. Some resident’s files contained old care plans and risk assessments, the inspector advised that files could be improved by taking out all old or unnecessary paperwork and filing this. All residents were observed to be well presented and looked clean, appropriately dressed and comfortable. The manager confirmed that she monitors the standard of personal care closely. All residents and their relatives spoken to confirmed that they were very satisfied with the standards of care provided and that the staff were always very kind and helpful, with the exception of one service user who told the inspector that she felt one of the staff intentionally upset her at times. The resident’s daughter was present for the discussion and told the inspector she had no knowledge of the issue; the resident refused to tell the inspector or her daughter the name of the staff member however she later agreed to tell the manager and for the issue to be investigated. The medication policies and procedures have not yet been updated and reviewed; they do not reflect current good practice and do not provide staff DS0000002861.V324783.R01.S.doc Version 5.2 Page 14 with adequate information to manage all aspects of the system. The manager has responsibility for ordering the medication; she has arranged for the local pharmacy provider to visit the home to carry out an audit. Checks carried out on a sample of medication records identified satisfactory standards of recording and transcribing. None of the service users were currently prescribed any controlled medication or Temazepam. All medications were stored appropriately. One of the service users was self medicating inhaled medication which was supported by risk assessment however a number of service users held their GTN medication which also needs to be supported with a risk assessment. Care plan records identified that one service user had her medication administered in food; the manager confirmed that the G.P. had provided a letter to support this practice however it was not found on file, consent should also be sought from the service user/ representative and care management. Records evidenced that recently a medication error had taken place and a resident had received the wrong dose of insulin (staff provide the service user with the syringe which has the insulin dose drawn up by the district nurse and the service user administers this herself) appropriate action to inform health care professionals had been taken and the service user had not suffered any ill effects. The commission had not been informed of this incident. Records of the room and fridge temperature were maintained and satisfactory. The home had a current British National Formulary for reference purposes. DS0000002861.V324783.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The arrangements for providing activities, visiting, meals and supporting residents to make choices met with the expectations of the residents. EVIDENCE: Observation during the visit indicated the home operates very flexible routines these include the time the service users get up, go to bed, where they eat their meals and how they spend their time. Relative surveys indicated that they are able to visit their relative at any time and there is no restriction on visiting. Those relatives and friends visiting during the inspection confirmed that they are made to feel welcome and can visit at any time. DS0000002861.V324783.R01.S.doc Version 5.2 Page 16 In discussion staff displayed a good knowledge of individual resident’s needs, likes/ dislikes, family support and records contained information about people’s religious observances. The home has continued to make significant improvements in supporting resident’s social and recreational needs. The activity co-ordinator has assessed all the residents and completed profiles and social plans. She has developed a new weekly activity programme, monthly outside entertainment programme and provides one- to – one sessions for the more dependent service users. New activities include gentle exercise programmes, games with a beach ball and skittles; some craft sessions for Easter are planned. During the visit residents were enjoying a quiz in one of the lounges; residents spoken to said that they enjoyed all the sessions provided and how much they liked the coordinator. Records of participation and satisfaction are maintained. Discussions with the co-ordinator confirmed her knowledge of individual service users social needs and her satisfaction with her role. She told the inspector that staff helped out with the activity programme when they could but they were often very busy. All the comments received from surveys and during the visit confirmed that the home provided a high standard of meals which the residents really enjoyed Comments included “the food is always excellent” and “sometimes I have lunch at the home with my mother and the meals are always delicious”. The meal served during the visit looked tasty and well presented. The majority of residents use the dining room and the mealtime was seen to be a relaxed and social occasion with the staff interacting well with the residents; individual support was provided patiently and discreetly. Menu boards in the corridor display the daily choices. Specialist diets were currently provided for residents with diabetic needs. Resident’s weights are monitored regularly and any concerns are referred to community health services for support. The home did not have anybody from black or ethnic minority groups and none of the resident’s selected for case tracking had any specialist dietary requirements other than those for insulin and diet controlled diabetics. DS0000002861.V324783.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Improvements had been made to the recording of complaints received by the home and residents were confident that their concerns would be listened to and acted upon. Current recruitment practices are potentially placing residents at risk of harm. EVIDENCE: There was evidence that the management of complaints in the home had improved. The manager has now developed a clearer complaints procedure, which was displayed in the hall corridor. The home had received one complaint since the previous inspection in December from a service user regarding the staffing levels. Records showed that action had been taken and staffing levels increased in the evenings and that the complainant had received feedback. Evidence from resident and relative surveys confirmed that they knew who to complaint to and would feel able to raise concerns with the staff and management. One relative spoken to told the inspector that she had in the past raised issues with the manager who had dealt with the concerns very well and resolved the problems; she would have no hesitation in discussing further DS0000002861.V324783.R01.S.doc Version 5.2 Page 18 issues if they arose with the staff and management but was very satisfied with the level of care and facilities provided to her relative. The home has policies and procedures to cover adult protection and prevention of abuse and whistle blowing in place. New staff confirmed that abuse had been included in the induction training when they started at the home. When asked about abuse, what it was and what they would do if they saw a service user being abused, the staff answered correctly. Training records evidenced that 70 of the staff had received safeguarding adults training; the remaining staff are scheduled to attend courses over the next six months. In October 2006 an allegation was made against a male care assistant and the home responded appropriately. Examination of a sample of staff files showed the home was not always following good practice when appointing new staff. This is not acceptable practice as it potentially puts residents at risk of harm. Please refer to page 22 of this report. DS0000002861.V324783.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are provided with a warm and comfortable environment that is homely and welcoming. EVIDENCE: Hadleigh House provides a homely environment with furniture and décor of a good standard. There is evidence that maintenance, refurbishment and redecoration is ongoing. Resident’s rooms were personalised to the extent chosen by the individuals. The communal areas were all well utilised during the visit; service users commented on how happy and settled they were at the home. DS0000002861.V324783.R01.S.doc Version 5.2 Page 20 All areas of the home seen during the visit were clean and tidy; odour control has continued to be managed more effectively; there were no odour problems identified during the visit. The cleaning and care staff confirmed that all bedroom carpets were cleaned regularly. Staff told the inspector that they had a good supply of moving/ handling equipment which the manager regularly reviewed. There was evidence that paper towels had been provided in those resident’s rooms who were visited regularly by the G.P. or district nurse; the manager confirmed that supplies of paper towels were always available for use. DS0000002861.V324783.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides sufficient numbers of staff on each shift to meet the care needs of service users; the staff are trained and supervised to carry out their work. Recruitment practices do not afford sufficient protection for service users. EVIDENCE: Twenty-eight residents were living at the home at the time of the visit. The manager had now implemented the Residential Forum Guidance to calculate staffing hours; calculations made at the end of February showed that the home needed to provide 416 hours and was providing 420 hours. Statistics from the Pre Inspection Question showed that the home had admitted 50 service users and discharged 34 over the last twelve months which indicates the levels of respite care provision at the home; current dependency levels remain generally low however the manager must ensure the calculations are made weekly to support the frequent changes in occupancy and dependency. Staffing levels on the afternoon shifts were reviewed following the inspection visit in December and an extra care assistant is now rostered from 4p.m. until 9p.m., which staff reported, worked much better. Five care staff are on duty in DS0000002861.V324783.R01.S.doc Version 5.2 Page 22 the mornings, four in the afternoons and two waking staff on night duty. Examination of the rotas evidenced that there had not been any shortfalls of staff; holiday and sickness cover had been provided by the home’s staff. Turnover was moderate with eight staff having left the home in the last twelve months. Evidence from surveys and discussions with residents and relatives during the visit confirmed that they were satisfied that the care they received met their needs; they commented on how kind and supportive the staff were and that they generally answered the call bells promptly. Employment records for three staff appointed since the last inspection were examined. This showed that all workers had Protection of Vulnerable Adult register checks (Pova 1st) or Criminal Records Bureau check (CRB police check) in place prior to commencing employment. There was evidence that staff working with a POVA check were supervised when working with service users until the CRB check was in place. Two of the files did not contain any identification documentation. None of the staff files checked contained two written references; one file did not contain any references and two files contained only one. One of the new care workers had been employed without references from her previous employer. This is not acceptable practice as it potentially puts residents at risk of harm. Since the last key inspection visit in July 2006 the management have increased the percentage of staff qualified at level 2 NVQ from 25 to 34 and the manager told the inspector that the majority of the remaining care staff are completing the award or have signed up to start the course in the near future. Improvements have continued with the staff training programme; however staff spoken to were concerned that they were not paid to attend training and this would impact on their attendance in future. The provider has a responsibility under the NMS to provide staff with a minimum of three paid days training per year. The deputy manager has responsibility for staff training with good effect; she has developed a staff training matrix which identifies all training courses staff have attended and also a staff training programme up until September. Improvements have been made towards the provision of mandatory courses for staff; the majority of staff have accessed moving and handling training this year and the remaining staff have courses scheduled; sixteen staff accessed first aid courses in October 2006,ten staff accessed fire safety courses in June 06 and further courses are scheduled; basic food hygiene courses have been held and scheduled for the 2nd and 19th March. Staff have also accessed general courses in medications, care planning, safeguarding adults and dementia. DS0000002861.V324783.R01.S.doc Version 5.2 Page 23 The deputy manager has developed a staff information file on conditions such as dementia, Parkinson’s Disease, diabetes and strokes. Courses run by the local authority are scheduled for care planning, supervision, health / safety and risk assessment. The home is also participating in the local PCT training iniative where a nominated person from the home accesses relevant training for trainers courses and then disseminates the training inhouse. The community tissue viability nurse has arranged to visit the home in April to provide staff training. The home has implemented an induction programme which meets the Skills for Care Common Induction Standards; records for two recently employed staff were unavailable, as it was believed the workers had taken their packs home with them; because of this the inspector was unable to check the robustness of the induction process. No progress had been achieved regarding implementation of a formal programme of annual appraisals. These are needed to ensure the homes training plan and priorities accurately reflect the needs of the staff team and action must now be taken to address this. DS0000002861.V324783.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33,36,37 and 38. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and safety of the service users is not fully ensured and this has the potential to put them at risk, however some improvements have been made in some of the administration systems. EVIDENCE: Following the key inspection visit in July 2006 and subsequent quality rating for the home as “poor” the commission attempted to arrange a meeting with the registered provider to discuss how improvements in the management of the service could be made; this was finally achieved in January 2007. A random inspection had to take place in December 06 due to the absence of DS0000002861.V324783.R01.S.doc Version 5.2 Page 25 communication with the registered provider in order to confirm that management practices had improved and the safety and welfare of the service users were being protected. Findings at the random inspection visit in December evidenced improvements in staff moral, staff training, standards of care, odour control and activity provision. Following the key inspection in July 2006 the local authority had been notified of the quality rating; at this visit the commissioning officer for the NE Lincolnshire attended the home for a meeting with the provider to discuss how the authority could assist with improvements needed to the management of the service. The registered manager has been in post for fourteen months; it is her first manager’s position and she has had difficulty since her appointment in prioritising her management responsibilities with much of her time taken up with staffing issues and monitoring/ supporting the day-to-day work “on the floor”. Since the appointment of the deputy manager and the administrator/ activity co-ordinator there has been a significant improvement in some areas; the employment of another senior care assistant with experience has also meant that the manager can delegate some duties more effectively. The manager now needs to ensure that she fully protects her management time and prioritises her work effectively to fully develop all the management and administration systems and action all the requirements. The manager has completed her Registered Managers Award and has commenced the NVQ level 4 course in care. From examination of the training record analysis it was not clear what training the manager had accessed since her employment at the home; these records require updating. Residents spoken to said that the manager was friendly and kind. Staff confirmed that moral was good and commented that there was a good team approach to the care delivery at the home. Formal resident meetings and regular staff meetings are held. The manager has regular support form the registered provider, who spends at least two days per week at the home; arrangements have been made for the secretary of the local care homes association to visit the home monthly to carry out visits to support Regulation 26 and provide a report of his findings. No progress had been made to update the policies and procedures in the home to ensure they clearly reflected current practices in the home and that they had been updated to meet current legislation and good practice; this now needs to take place. Records evidenced that further improvements had been made to the supervision programme; senior care staff have been allocated teams of care staff who they are responsible for supervising. Care staff are now accessing the appropriate number of sessions. DS0000002861.V324783.R01.S.doc Version 5.2 Page 26 No progress had been made to implement a formal quality assurance system; the manager reported that the commissioning officer from the local authority had offered support to the home in this area. From case tracking there was evidence that staff were still not completing records on the appropriate documentation when accidents occurred in the home; a number of staff were completing the homes’ incident records and at times only recording accidents/ falls in the daily records. Staff need clarity around the appropriate use of the accident and incident forms. Audit records of accidents to identify management action which would further reduce risk had not improved and the inspector explained again how this could be recorded. The home is working with the community falls co-ordinator and has implemented falls risk assessments and records of falls; however the use of these forms has further confused staff around which documents to complete. At the previous inspection in December records identified that although the hot water temperatures at outlets accessible to service users were monitored monthly a number regularly exceeded 43 deg C (records for November evidenced that over 20 outlets recorded 45 deg C) Records revealed that the temperatures remained high in January and February; the plumber regulated the valves on the 15/02/07 however records for March show that one of the bath temperatures was 47deg C and the shower 46deg C. The manager confirmed that she would arrange for the plumber to revisit and further calibrate the thermostatic valves. At the previous inspection the inspector noted that a new keypad lock had been fitted to the front door. The manager confirmed that the lock was not connected to the fire alarm system; the home’s fire risk assessment and fire safety procedures had not been updated to detail the new lock however she had arranged for the local fire service to visit the home and provide advice. DS0000002861.V324783.R01.S.doc Version 5.2 Page 27 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 3 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 1 X X 3 2 2 DS0000002861.V324783.R01.S.doc Version 5.2 Page 28 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 OP33 Regulation 24 Requirement The registered person must ensure that the quality assurance programme is restarted and maintained. Previous timescales 30/06/06, 30/11/06 not met. Timescale extended. Timescale for action 30/06/07 2. OP38 13(4) 30/04/07 The registered person must ensure that accident management is reviewed to record all further action that staff take to further reduce risk e.g. falls. Previous timescale 31/03/06, 15/09/06 and 15/01/07 unmet 3. OP7 15 The registered person must ensure that service user care programmes are sufficiently detailed to identify all problems; they are updated to reflect current care needs. Previous DS0000002861.V324783.R01.S.doc 15/05/07 Version 5.2 Page 29 timescale 30/11/05, 30/09/06 and 15/02/07 unmet 4. OP8 12 and 13 The registered person must 15/05/07 review all current risk assessments. Where necessary risk assessments must be revised and updated. The registered person must ensure they are agreed to by the service users or their representative. Previous timescale of 30/09/06 and 31/01/07 unmet. The registered person must ensure all staff responsible for completing service user care programme documentation and risk assessments have the necessary skills and knowledge. Where required, staff must be provided with care programme training and risk assessment training relevant to the areas of risk being assessed. Previous timescale of 15/10/06 and 28/02/07 unmet. The registered person must ensure that hot water temperatures at outlets accessible to residents do not exceed 43 deg C. Previous timescale of 30/08/06 and 31/12/06 unmet. The registered person must ensure that all identification documents specified with Schedule 2 are held on file for all staff members employed. DS0000002861.V324783.R01.S.doc 5. OP7 18 01/06/07 6. OP38 13(4) 30/04/07 7. OP29 19 15/05/07 Version 5.2 Page 30 Previous timescale of 30/08/06 and 31/01/07 unmet. 8. OP38 23(4) The registered person must ensure that the front door lock is detailed in the home’s fire risk assessment and fire safety procedures. Previous timescale of 31/12/06 not met. The registered person must ensure that all assessments carried out prior and following admission are sufficiently detailed to identify the service users current needs. All assessments need to be signed and dated. The registered person must ensure that staff are provided with guidance to ensure that they are competent in completing appropriate incident/ accident forms. The registered person must ensure all required records as detailed in Regulation 19 and Schedule 2 of the Care Homes Regulations are obtained before workers start working in the home. This must include two written references, one of which must be from the most recent employer. The registered person must review all the homes policies and procedures to ensure they are comprehensive, comply with current legislation and demonstrate current good practice. The registered person must ensure that the home reports all notifiable incidents to the CSCI. The registered person must ensure that the registered DS0000002861.V324783.R01.S.doc 15/05/07 9. OP3 14 15/05/07 10. OP38 13 (4) 30/04/07 11. OP29 OP18 19 15/04/07 12. OP33 OP38 12 and 24 30/05/07 13. 14. OP37 OP31 37 9(2) 30/04/07 15/05/07 Page 31 Version 5.2 15. OP30 18(1) c managers’ training records demonstrate that she has undergone periodic training to update her knowledge, skills and competence. The registered person must ensure that all staff in the home are provided with three paid days training per year. 30/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP28 Good Practice Recommendations The registered person should ensure that 50 of the care staff have gained NVQ level 2. 2. OP2 3. 4. 5. OP9 OP9 OP31 The registered person should ensure that an audit of all service user files takes place to identify if all service users have been given a contract/ statement of terms and conditions from the home. The registered person should ensure that service users administering their own GTN medication have appropriate risk assessments in place. The registered person should ensure that agreement has been sought from the multidisciplinary team to support the practice of covert administration of medication. The registered manager needs to develop a time- table whereby she is able to allocate and protect her time to carry out the work needed to improve the management and administration systems. DS0000002861.V324783.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000002861.V324783.R01.S.doc Version 5.2 Page 33 - 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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