Inspection on 18/12/08 for Hafod Nursing Home

This inspection was carried out on 18th December 2008.

CSCI found this care home to be providing an Adequate 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

Hafod Nursing Home 04/02/10

Hafod Nursing Home 27/10/09

Hafod Nursing Home 02/07/08

Hafod Nursing Home 07/08/07

Hafod Nursing Home 18/10/06

Hafod Nursing Home 08/11/05

Hafod Nursing Home 27/07/05

Hafod Nursing Home 18/10/04

Hafod Nursing Home 23/06/04

Hafod Nursing Home 09/02/04

Hafod Nursing Home 18/09/03

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Hafod Nursing Home 9 - 11 Anchorage Road Sutton Coldfield West Midlands B74 2PJ Lead Inspector Lisa Evitts Unannounced Inspection 18th December 2008 09:30 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 DS0000024844.V373513.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. DS0000024844.V373513.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hafod Nursing Home Address 9 - 11 Anchorage Road Sutton Coldfield West Midlands B74 2PJ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 354 9442 0121 354 2616 hafodltd@aol.com None Hafod Care Homes Manager post vacant Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29), Terminally ill over 65 years of age (29) of places DS0000024844.V373513.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That Mahnaz (Nazy) Mohtadi undertakes and obtains successfully the Registered Managers Award or equivalent by December 2005. This is currently under review and will be removed. 2nd July 2008 Date of last inspection Brief Description of the Service: Hafod Nursing Home provides general nursing care for up to 29 people. The Home is not registered to provide care for people who suffer with dementia. Four rooms are contracted by the Primary Care Trust for the provision of intermediate care and Social Care and Health fund four beds for interim care. The Home comprises of two converted houses within a residential area that have been adapted for it’s current use and is located close to Sutton Coldfield town centre. There is good access to local bus and rail links and it is within 5 10 minutes walking distance of the town centre. There is off road parking at the front of the building for six cars. There is a choice of seating and dining areas located on the ground floor. There is a mixture of single and shared rooms located on both floors and with the exception of one bedroom, all have en suite. There is a passenger lift for people to access both floors and a large well-established secure garden situated to the rear of the premises, which is suitable for wheelchair users. There is a no smoking policy within the Home however smoking is permitted within the garden area. Assisted bathing facilities are provided and aids/adaptations are provided for people with physical disabilities. There is a notice board on entering the home, which displays a range of information for people living in the home and their visitors. A service user guide was available but this did not include information about the current fee rates. This information can be requested from the home. Additional costs include dry cleaning, hairdressing, chiropody and newspapers. A copy of the previous inspection report was available in the reception area of the Home for anyone interested to refer to. DS0000024844.V373513.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the Home and their views of the service provided. This process considers the Care Home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. This is the second key inspection of the home this year and it is recommended that this report is read in conjunction with the previous report from inspection on 2nd July 2008. One inspector undertook this visit to the home over one day and was assisted throughout by the manager and registered nurses. There were 27 people living at the home on the day of our visit and the home did not know that We, the commission were visiting on that day. Information was gathered from speaking to and observing people who lived at the home. Three people were “case tracked” and this involves discovering their experiences of living at the home by meeting or observing them, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. We spoke to four people who live at the home and three members of staff. Staff files, training records and health and safety files were also reviewed. Prior to the visit in July we were sent an AQAA (Annual Quality Assurance Assessment) by the home. This tells us about what the home think they are doing well and where they need to improve. It also gives us some numerical information about staff and people living at the home. We also looked at reports the home had sent us about incidents that had happened in the home. No immediate requirements were made on the day of this visit, which means that there was nothing urgent for the home to put right to ensure people were safe. What the service does well: Any information of interest to people is available in a large print format so that people with poor eyesight can access this information. DS0000024844.V373513.R01.S.doc Version 5.2 Page 6 People have access to a range of Health and Social Care Professionals and people who come to the home on a temporary basis receive comprehensive input from the multidisciplinary team in preparation for their discharge from the Home in order to improve the quality of their lives. External people visit the home to provide activities and people are encouraged to go out of the home, as they are able so that they can do the things that interest them and that they enjoy. There is an open visiting policy and people are made welcome in the home, this means that people can continue with relationships that are important to them. People receive a choice of a wholesome and nutritious diet, which meets any dietary, cultural needs or preferences. People are able to bring personal items such as pictures, ornaments and small items of furniture into the home so that that their personal tastes and interest are reflected and a homely atmosphere is created. There is an ongoing programme of refurbishment and re-decoration in the home to enhance the living environment. The home has a range of aids and adaptations available to support people with mobility difficulties around the home. The home has a choice of bathing facilities so that people can choose how their personal care needs are met. The home has a robust recruitment procedure so that they only employ people suitable to work with vulnerable people. People told us: Its nice here, I like the company We have a young man come to waive things around and exercise our body I go to bed about 6:30. I can go when I like, its my choice 70-80 of food is good, there are somethings I dont like but its good solid food I havent got any complaints but would speak to the manager I have my own room My room is nice, a single room. I moved downstairs because I didnt like the lift Staff are quite nice, they come and help me when I need help On the whole the staff are good but there are one or two who think they know better The manager comes to talk to me, shes great DS0000024844.V373513.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: The service user guide should provide all information about the home so that people can make an informed decision about whether they would like to live there. DS0000024844.V373513.R01.S.doc Version 5.2 Page 8 The number of hours worked by staff and conditions of work permits should be reviewed so that people are being assisted by competent and safe staff who are working in accordance with their work permits. Staff should receive training relevant to their roles to ensure that they have the knowledge and skills to meet peoples needs and safeguard them from harm. The manager should submit an application to become registered so that people know who is responsible for 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. DS0000024844.V373513.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000024844.V373513.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People have some information about the home to enable them to make an informed decision about whether they would like to live there. Pre admission assessments ensure that people know their needs can be met prior to moving in. EVIDENCE: The home has produced a service users guide and statement of purpose, which are available in the reception area and in each bedroom. These documents provide information about the home so that people can make an informed decision about whether they want to live there. The documents are written in a large print so that people with visual impairments can access the information. Current fee rates for the home are not included and this is recommended so that people know how much they will have to pay to live there. DS0000024844.V373513.R01.S.doc Version 5.2 Page 11 The certificate of registration only had one page displayed and both pages should be displayed so that people can see the information. The certificate was old and did not give correct information about the home. We will issue a new certificate with updated details. Comprehensive pre admission assessments are undertaken prior to people coming to live at the home. This should ensure that peoples individual needs can be met when moving into the home. Intermediate care funded by the Primary Care Trust (PCT) can be provided at the Home for a period of up to approximately six weeks per person. The intermediate care team includes General Practitioners, an Occupational Therapist, Physiotherapist, Specialist Community Nurses and a Social Worker. Prior to coming to stay at the Home, the intermediate care team assess each person’s suitability to stay there. People receiving intermediate care are admitted directly from hospital and are often in need of rehabilitation care. Most of the specialist equipment required for people receiving intermediate care is funded and provided by the PCT. Interim care funded by Social Care and Health can be provided for people for a period of up to six weeks each. This gives people the opportunity to decide where they would like to live in the future. At the previous inspection a number of people had dementia. It is acceptable for the home to admit people with dementia as long as their nursing care needs are foremost, however staff should have training for this to help them understand and meet the needs of people with this illness. The manager confirmed that this training was still to be undertaken and stated that the home are considering making an application to us to enable them to admit people with a diagnosis of dementia. One person said Its nice here, I like the company DS0000024844.V373513.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New care plans provide staff with specific details to assist people to meet their needs in a way that they prefer. People may not always receive their medication as prescribed. EVIDENCE: Each person has a care plan written. This is an individualised plan about what the person is able to do independently and states what assistance is required from staff in order for the person to meet their needs. The staff were in the process of re writing the care plans so that they provided current information about peoples care needs and preferences. The manager stated that half of the files had been rewritten. We looked at the files for three people who live at the home, two of these were in the process of being re written, however staff were very enthusiastic about the new style care plans and were working to get all care plans completed in this format. It is recommended that the files are completed as soon as DS0000024844.V373513.R01.S.doc Version 5.2 Page 13 practically possible so that staff have clear guidelines to follow to assist all of the people who live in the home. The new format was reviewed and was found to be person centred and written in a way that gave staff clear instructions about how people liked and needed to have their needs met. Examples of this are Apply 50/50 cream to legs and feet and aqueous cream to rest of body, Wash face with warm water and dry and Dry hair with hair dryer. One person said I have a shower two or three times a week and you have someone with you. Staff were able to tell us about the people who lived at the home and what assistance they needed to meet their needs. They were also able to tell us about personal preferences so that peoples needs are met in a way they prefer. One person had really detailed plans for care of their diabetes including rotating injection sites, when to check blood sugars and when further action needs to be taken depending on results. This should mean that this persons diabetes is well managed. One person had a pressure sore (sore skin area) and care plans were detailed and incorporated instructions from the Tissue Viability Specialist nurse. There were photographs taken of how this person should lie in bed due to their sores and contractures to prevent further deterioration. These instructions mean that all staff will know what to do to help people meet their needs. This persons plan said that they should have their position changed every three hours. Turn charts were reviewed, they generally showed that this was being done but on some occasions it was not recorded as being done this often. Staff should ensure that changes in position are recorded to ensure that people are not at risk from sore skin developing. Risk assessments were written for sore skin, diabetes, nutrition and bed safety rails. People are weighed each month and this means that staff can monitor changes and take action as required. Moving and handling assessments were written and told staff what type of equipment they needed to use to move people safely. Each person has been assessed for his or her own hoist sling and these have been purchased by the home. People can keep their own General Practitioner on admission to the Home (if the GP is in agreement). People had access to other visiting Health and Social Care Professionals including Opticians, Tissue Viability Nurses, General Practitioner, Physiotherapist, Chiropodist and dentist. This means that people receive specialist advise about their healthcare needs. The management of medication was reviewed and consists of both boxed medicines and blister packs. The home keeps copies of prescriptions so that can check the medication is correct when it comes into the home. Controlled medications were stored and recorded as required. Fridge and room temperatures were recorded and were within acceptable limits to ensure that medicines are stored in line with their product licence. There were no gaps on DS0000024844.V373513.R01.S.doc Version 5.2 Page 14 the Medication Administration Records (MAR). Medication is signed in upon receipt to the home by two people to ensure that it is correct. Variable doses are recorded so that staff know how many tablets people have received. The majority of audits undertaken were correct with the exception of one antibiotic, which had been signed as given, but the audit showed one tablet had not been administered when signed. Five other audits had discrepancies and it was not clear from the audit why they were missing, some of the tablets had not been recorded properly on the carry forward system and this should be reviewed to ensure that people receive their medication as prescribed. People are given the choice if they want to self-administer their medication but no one had chosen to do this at the time of our visit. People appeared to be supported by staff to choose clothing appropriate for the time of year which reflected individual cultural, gender and personal preferences. The preferred gender of care staff providing personal care to people at the home was recorded within their individual care plans. This should mean that people are assisted by staff they prefer in order to respect their wishes and maintain their dignity. People are asked if they would like to have a key to their room and their choice is recorded. There are dividing curtains in shared rooms so that peoples privacy is maintained, however the manager stated that she wanted further curtains to ensure peoples dignity was maintained. There were good interactions seen between people living at the home and the staff. DS0000024844.V373513.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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to choose the activities that they participate in which promotes their individuality and independence. People are offered a choice of meals to meet their dietary, cultural needs or preferences. EVIDENCE: The home has a dedicated activities coordinator for 12 hours per week. Activities include bingo, games, hobby therapy and arts. There is a weekly visit from a donkey sanctuary and an external person comes to the home weekly to do exercises to music. There were photographs displayed of Halloween and bonfire parties and a Christmas party had been held at the home. Large print books and books on tape are sought from a local library although one person said I would like large print books or talking books but I never get them, this was discussed with the manager on the day of the visit. Other people told us: We have a young man come to waive things around and exercise our body I like bingo and throw the ball (basket ball) DS0000024844.V373513.R01.S.doc Version 5.2 Page 16 A hairdresser visits the home twice a week so that people can have their hair dressed, as they prefer. A lay preacher visits the home and performs a church service once a month; she will also visit the home upon request to enable people to meet their religious needs. A service was in progress on the day of the visit and many people were observed to participate in this. People were also reading newspapers, watching TV and knitting. People can go out as they choose and this encourages their independence and assists them to maintain links with the community. Staff had arranged for one person to visit their mothers grave as she had requested this and this person told us how happy this had made her. The home has an open visiting policy and this enables people to see their visitors as they choose, enhancing their quality of life. There were no rigid rules or routines at the home and people can choose how they want to spend their day. People can choose where they want to sit, have their meals and choose times of getting up and going to bed. One person said, I go to bed about 6:30. I can go when I like, its my choice There is a four weekly menu in place and this had recently been renewed for the winter following discussion with the people who live at the home. This means that people can have food that they like. There is a choice of cooked breakfast, cereals or fruit and a choice of two hot meals at lunchtime. For supper there is a choice of soup and sandwiches or a hot snack. Breakfast menus are laminated and are out on tables and there is a menu board in the dining room so people can choose what they want. Staff were observed to assist people in a discreet manner, tables were nicely presented and cold drinks and condiments were available for people if they chose them. The home can cater for religious and dietary needs and for preferences. Pureed meals were seen for people who have difficulty swallowing and these were served in separate portions so that people could taste the different flavours. One person asked a member of staff for a glass of sherry and this was brought to them. People told us: Food is nice you get a choice, I have a salad at night Food is very good 70-80 of food is good, there are somethings I dont like but its good solid food DS0000024844.V373513.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a comprehensive complaints procedure should people want to make a complaint. There are systems in place, which should safeguard people from harm. EVIDENCE: The complaints procedure is displayed in the home and is included in the service user guide so that people should know how to make a complaint if they need to. There were a number of thank you cards on display and there is a suggestions box and compliments book in reception so that people can voice their opinions about the home. The home had received three complaints since our last visit and these were recorded, along with actions taken and the outcomes. The complaints related to staff not answering call bells in a timely manner, talking on mobile phones and not being taken to bed until late. We have not received any complaints about the home. People told us: I havent got any complaints but would speak to the manager If there was anything serious I would talk to the manager but I havent needed to raise anything DS0000024844.V373513.R01.S.doc Version 5.2 Page 18 The home has an adult protection policy, which includes contact numbers so that staff would know who to call in the event of an allegation being made. The whistle blowing policy was displayed in the home and this should mean that staff would raise any concerns about peoples safety without fear of reprisals. Adults and Communities have undertaken investigations into three adult protections and the outcome of these is not yet known. Since our last visit to the home, staff have received training in the Protection Of Vulnerable Adults and the Mental Capacity Act and this should mean that staff have the knowledge to safeguard people from harm. One staff member spoken to was able to demonstrate a good knowledge of what to do to safeguard people in the event of an allegation being made. There is a safe recruitment process in place and peoples money can be held safely be the home. DS0000024844.V373513.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): 19,21,24, & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with a homely and clean living environment in which they can choose where to spend their day. EVIDENCE: The home is a detached two-storey building with off road parking for a small number of cars in a residential area. There was a welcoming and friendly atmosphere at the home, which was festively decorated for Christmas. The home was clean and odour free on the day of our visit. There are two main lounges for people to use and are decorated in homely styles. There is also a quieter room, which people can use, and some use this to meet with their visitors. There are two separate dining rooms one leading from the second lounge, people therefore have a choice of areas to sit to have their meals. At the last visit to the home there were comments about the size DS0000024844.V373513.R01.S.doc Version 5.2 Page 20 of the TV and the quality of the picture. A new digital flat screen TV had been purchased so that people could watch this. There is a mixture of single and shared bedrooms. Bedrooms contained people’s personal possessions that reflected their tastes and interests in order for them to feel comfortable in their surroundings. Bedroom doors are fitted with privacy locks, which can be overridden in the event of an emergency. People have the choice of holding their room key. There is a nurse call facility in each bedroom in order for people to summon assistance from staff when required or in the event of an emergency. There is an ongoing redecoration and refurbishment plan in place and the manager had identified the next two rooms to be redecorated and to have new carpets. New matching bed linen had been purchased to enhance the environment for people. People told us: I have my own room My room is nice, a single room. I moved downstairs because I didnt like the lift There is a range of aids to assist people with mobility problems such as mobile hoists, raised toilet seats and grab rails near to toilets. The home have wet rooms and bathrooms enabling people to a have choice of a bath or shower. There had been a recent visit from the Environmental Health Officers and a number of requirements had been made regarding equipment, cleaning and painting of the kitchen areas to ensure that food was prepared in a hygienic manner. The manager had addressed these areas of concern and responded to the Environmental Health Officer. There is a secure external garden, which is spacious. There is ramped access leading out to this area and is suitable for wheelchair users to enter the garden. There is a patio area and garden furniture for people to enjoy when the weather permits. The manager told us that they have planning permission for an extension to the home. DS0000024844.V373513.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported by staff who receive some training to ensure that they have the knowledge to meet individual needs. The recruitment procedure ensures that people are safeguarded from harm. EVIDENCE: The home has four care staff and two nurses on duty throughout the day and one nurse and two carers at night. The home had one night carer vacancy at the time of our visit. In addition to nursing and care staff the home also have housekeepers, administration and maintenance staff to meet all the needs of the people living at the home. The home uses little agency staff and this means that people know who will be helping them to meet their needs. 50 of care staff have a National Vocational Qualification (NVQ) level 2 in care and this should ensure that staff have the knowledge and skills to care for people individually and collectively. Four of the staff have also completed NVQ level 3. People told us: Staff are quite nice, they come and help me when I need help On the whole the staff are good but there are one or two who think they know better DS0000024844.V373513.R01.S.doc Version 5.2 Page 22 During the visit to the home staff were observed to interact well with both people living at the home and visitors. Staff were very welcoming and polite and were keen to learn about the inspection process. Three staff files were reviewed and contained recruitment checks to ensure the safety of the people living at the home. All staff are deemed to be safe to work with vulnerable people prior to commencing employment at the Home. The rotas showed that on some occasions staff were working sixty plus hours per week. This is an excessive number of hours and may mean that staff are too tired to provide a good level of care to people living at the home. One member of staff was working on a student visa and was working in excess of the 20 hours allowed during term time. It was recommended that the manager check the working conditions of the visa with immigration. It is also required that the number of hours staff work is reviewed. The manager told us that staff receive an induction into the home and this includes working with other staff so that they know what they are expected to do. Each person has an individual training record and copies of certificates are kept. The manager has devised a training matrix so that it is easy to see what staff need training and when refreshers are due. This should mean that staff receive training relevant to their role so that they can meet peoples needs. The matrix indicated staff have received training in fire, health and safety, infection control, first aid, manual handling, food hygiene, Protection Of Vulnerable Adults, and the Mental Capacity Act. Staff have not yet received training in Dementia care and this is recommended. DS0000024844.V373513.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home needs time to sustain the improvements made so that the home is run in the best interests of the people who live there. EVIDENCE: The manager had previously been the registered manager of the home but had left employment there for approximately nine months. At the time of the last visit to the home the manager had just returned and has made considerable improvements to the running of the home so that it is run in the best interests of the people who live there. It is recommended that the manager submit an application to us to become registered, as this will show a commitment to the home. DS0000024844.V373513.R01.S.doc Version 5.2 Page 24 The manager has many years of experience working within a managerial role and has completed the Registered Managers Award to gain knowledge to assist her to lead the staff team in a competent manner. It was clear that the manager had built up a good rapport with visiting health and social care professionals, visitors and the staff team. One person who lives at the home said, The manager comes to talk to me, shes great. A resident meeting had been held in November and the winter menu and entertainment had been discussed. There was evidence that peoples suggestions had been acted upon and that people have a say about how the home is run to meet their needs. Staff meetings have been held and minutes were available for these. These meetings give people an opportunity to discuss any ideas or concerns about the home. An external person had completed the first regulation 26 visit report in November. This is a report written by someone from the organisation about the quality of service provided by the home. The manager has implemented a number of daily, weekly, monthly and quarterly audits to monitor quality of the home. Resident and family questionnaires had been sent out to gain their views on the service provided. Information had been collated into bar graphs and actions had been taken to resolve any negative comments received. These audits should ensure that any concerns are identified and rectified so that the home is run in the best interests of the people who live there. The home is able to hold small amounts of money for people who live there. We looked at four peoples money and balances were correct. Each person has an individual record and two signatures are obtained for all transactions. Receipts are kept and are numbered to correspond with the transaction. This should ensure that peoples money is held safely. Health and safety and maintenance checks had been undertaken in the home to ensure that the equipment was in safe and full working order. Maintenance checks are completed on the fire system and equipment. Staff had received fire training in July 2008. There were no fire drill records completed for staff for over a year and this was brought to the mangers attention as staff should receive two drills per year to ensure that they know what to do in the event of a fire. The manager stated that a fire test is completed once a week and this is also used as a fire drill but had not been recorded. Some requirements had been made by Environmental Health Officers regarding equipment, cleaning and painting of the kitchen areas to ensure that food was prepared in a hygienic manner. The manager had addressed these areas of concern and responded to the Environmental Health Officer. DS0000024844.V373513.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 X X 2 DS0000024844.V373513.R01.S.doc Version 5.2 Page 26 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 OP27 Regulation 19(1)(a) Requirement The number of hours worked by staff should be reviewed so that people are supported by staff who are fit. Timescale for action 12/02/09 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 OP1 OP1 OP4 Good Practice Recommendations Fees should be included in the service user guide so that people have all the information about the home. Both pages of the registration certificates should be displayed so that people can see all the information about the home. Prospective people should be written to prior to admission by the home saying that their needs can be met so that people can be confident their needs will be met upon admission. (Previous recommendation, not assessed on this occasion) Implementation of the new care plans should be completed so that staff have guidelines to follow to meet the needs of all the people living at the home. The systems in place for medication should be reviewed so DS0000024844.V373513.R01.S.doc Version 5.2 Page 27 4. 5. OP7 OP9 6. 7. 8. 9. OP29 OP30 OP31 OP38 that audit trails can be followed to ensure people receive their medication as prescribed. A review of work permits should be undertaken to ensure that staff are working to the terms and conditions of the permit. Staff should receive training in Dementia care so that they have the knowledge and skills to meet the needs of individuals with this illness. The manager should submit a registration application so that people know who is responsible for the home. Staff should take part in fire drills so that they know how to safeguard people in the event of a fire occurring. DS0000024844.V373513.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 DS0000024844.V373513.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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