Inspection on 21/08/07 for Hall Steads

This inspection was carried out on 21st August 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hall Steads 17/08/06

Hall Steads 12/01/06

Hall Steads 30/08/05

Hall Steads 13/10/04

Hall Steads 20/04/04

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

CARE HOMES FOR OLDER PEOPLE Hall Steads Stacey Crescent Grimethorpe Barnsley South Yorkshire S72 7DP Lead Inspector Mrs Jayne White Key Unannounced Inspection 21st August 2007 07:30 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 DS0000006482.V337455.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. DS0000006482.V337455.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hall Steads Address Stacey Crescent Grimethorpe Barnsley South Yorkshire S72 7DP 01226 781525 01226 781308 firthj@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Limited Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Jennifer Jane Firth Care Home 90 Category(ies) of Dementia - over 65 years of age (30), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (30), Old age, not falling within any other category (60) DS0000006482.V337455.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons accommodated shall be aged over 60 years and above. Ferrymoor House is registered for dementia elderly (DE/E), mental disorder elderly (MD/E) - 30 places nursing (N) of which 5 can be personal care (PC). Willowgarth House is registered for personal care (PC). Ladywood House is registered for nursing care (N). Date of last inspection 17th August 2006 Brief Description of the Service: Hall Steads is a purpose built care home that accommodates up to 90 older people. The home is divided into 3 units, each accommodating up to 30 people. The Willowgarth unit provides personal care, Ladywood nursing care and Ferrymoor care for people with a mental disorder or dementia. BUPA Care Homes (CFHCare) Limited owns the home. The home is situated on the outskirts of Barnsley. It is a short distance from public transport, shops, the post office and local amenities. Extensive gardens surround the home. The home is single storey. All bedrooms are single. Each unit has its own lounge and dining area, plus a smoking room for people that live there. A kitchen is available on each unit, but a commercial kitchen provides the meals for each of the units. A commercial laundry carries out all the laundry for the units. Sufficient bathing facilities are available on each unit. There is a large car park. Information about the home is available from the reception and in welcome packs for new people. Inspection reports produced by CSCI were displayed on each unit. Fees at the home currently range between £334.50 and £442.00, plus a nursing care contribution where applicable. DS0000006482.V337455.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector visited between the hours of 7:30 and 17:45 without giving any notice. In June 2007 the service had to evacuate the Ladywood and Ferrymoor units because of flooding. As a result those units were being refurbished and people had still not returned home. As a consequence this inspection is only able to report on what was found on Willowgarth. Also taken into account was other information received by CSCI about the service since the last inspection. Before the inspection, surveys were sent to a range of people, asking them about the home. One came back from a person that lived at the home, two from representatives of people who lived at the home and one from a health and social care professional. The inspection process included inspecting parts of the building, reading some records and observing care practices. It also included discussions with eight people living at the home, three representatives, seven members of staff and the manager. The inspector wishes to thank the people living at the home, their representatives, staff and manager for their warm welcome, time and cooperation throughout the inspection process. What the service does well: Management and quality assurance was good. They made sure people received information they needed to choose a home, which would meet their needs. Generally, people were assisted to make some choices and decisions in their daily life and social activities. Contact with families was encouraged and visitors were welcomed. There was a complaints procedure that people had access to. People were protected from harm by the systems within the home. They maintained an environment that was comfortable with pleasant living areas. There was an experienced and stable staff team, with a good mix of carers and ancillary staff. Peoples’ monies were handled appropriately. DS0000006482.V337455.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Improve the daily record to explain what care has been given. This will demonstrate that people have had their care needs met, in accordance with their plan of care. Make sure medication is given in accordance with the prescribed dose, so that people have their medication as prescribed in order to maintain their health. Ensure accurate records of medication to demonstrate medication is administered as prescribed. Provide a more domestic type apron at meal times to enhance the dignity of people. Also, for staff assisting people to eat to sit at the same level as the person and at an appropriate angle. This will make the meal time a more pleasant experience for the person being assisted. Make sure laundry is returned to the correct person and doesn’t go missing. This assures people and their representatives their laundry is handled with care and respect. Make sure that menus available for people, reflect the correct day, choices on offer and that all those choices are offered. This will make sure people do not become confused about the day it is and the choices being offered that day. Review the number of staff on duty in the evening to increase the availability of staff to meet people’s needs in a timely manner. DS0000006482.V337455.R01.S.doc Version 5.2 Page 7 Implement quality assurance on staff training. This should include checking with staff the information they received on training programmes and observing they put it into practice. For example, the importance of fitting bed rails correctly, moving and handling people and assisting people to eat. This should improve the quality of care provided. Include laundry staff in the programme of training for infection control. This will make sure they are up to date with current prevention of infection control systems. 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. DS0000006482.V337455.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 DS0000006482.V337455.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): The outcome for standard 3 was inspected. The home did not provide an intermediate care service. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People received information they needed to choose a home, which would meet their needs. People had their needs assessed, so that the service would be able to determine whether they could meet those needs. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) said the service put a lot of energy into presenting vacant rooms. It said time is spent with potential customers to listen to what they want. The AQAA identified people are fully assessed prior to admission, to ensure the service can meet their needs. DS0000006482.V337455.R01.S.doc Version 5.2 Page 10 The files of three people were inspected. Each contained an admission assessment. This confirmed the launch of QUEST (BUPA’s new care record system) documentation was now in place. The survey returned by the person living at the home said they received plenty of information before they moved in. Surveys returned from representatives also confirmed they generally had received sufficient information about the care home. This enabled them to decide if the home was right for them. DS0000006482.V337455.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): The outcomes for standards 7, 8, 9 & 10 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. However, specific areas, identified in the evidence, need prompt attention and action by the manager. Generally, the health and personal care that people received was based on their individual needs. However, record keeping in respect of demonstrating those needs are met requires improvement, as does medication recording and administration. In general, the principles of respect, dignity and privacy were put into practice. EVIDENCE: A new care plan system QUEST had been implemented. Five individual care plans were inspected on a sample basis. These were reviewed regularly. The plans contained good information. There was sufficient detail on the plan for staff to be clear about the care to be provided. This enabled carers to have clear information about what they needed to do to meet a person’s health, personal and social care needs. Recording in the commentary against the plan, DS0000006482.V337455.R01.S.doc Version 5.2 Page 12 however, was sometimes of limited value for evaluation purposes. For example, the commentary was not always specific about the care carried out that shift, in accordance with the plan. Risk assessments were in place. Records of healthcare visits were maintained. These confirmed staff communicated with other healthcare professionals, so that the health care needs of people were maintained. Surveys from representatives said the people whom they represented usually had their needs met. Their comments included “Nursing needs are taken care of most of the time” and “I feel the home does well on personal health and needs and individual care”. The survey from the health and social care professional identified the care service always sought advice and acted upon it to manage and improve individual’s health care needs. They also identified that individual’s health care needs were always met by the service. Also that the service responded to the different needs of individuals. The organisation regularly reviews their policies and procedures. The CSCI were informed the policy for the safe handling and administration of medication had been reviewed on 19.02.07. It was noted however, that the policies and procedures were not consistently put into practice. The AQAA said that to improve the service in the last 12 months training had been delivered to staff in medication administration. Staff confirmed this. It also said medication audits had been carried out more thoroughly than previously. This month there had been a problem with the receipt of the medication administration records (MAR). This had resulted, in some cases, the receipt of medication not being recorded. Likewise, there was not a stock balance for medication that did not get used up the previous month. There were gaps in all medication records inspected and this made it unclear whether medication had been given. One person’s prescription for medication had been changed. The change had been recorded on the medication administration record. Examination of the actual medication, however, pointed towards the previous prescribed dosage still being given. This was because the medication was not in the blister pack and the record did not say it had been disposed of. This indicated care staff were not checking the medication administration record against the actual medication when administering the medication, to make sure what was being administered was correct. DS0000006482.V337455.R01.S.doc Version 5.2 Page 13 The manager was disappointed at feedback at the findings of the medication, given the improvements they had tried to make. She did say though that auditing of medication had lapsed in the last two months. The reason was because of the flood situation and the identified member of staff with the delegated responsibility not being on site as much. Inspection of the home’s medication storage identified there was a separate locked room for storing medication. The majority of medication was securely stored, but receipt of some recent medication had been placed on a work surface in the locked room. Observation of care practice confirmed staff were aware of the need to treat people with respect and dignity. There was clear and respectful communication between people and staff, for example, at mealtimes and when reassuring people who had forgotten they lived at the home. One person said, “they treat you like human beings, you’re not just another name” and “it’s personal service in a way”. At meal times people’s dignity could be improved by using a domestic type of apron, rather than disposable plastic aprons to protect people’s clothing from spillages. Also, two carers were observed assisting people to eat whilst standing at the side of them. This does not promote the person’s dignity. Representatives said, “patients’ clothes go astray too often” and “I think there is room for improvement on laundry service. Personal clothing goes missing. Sent to laundry, not being returned. All items have been labelled and still not found”. Discussions with staff identified there was a system in place for laundry. In practice, but this was not always working as inspection of drawers identified clothing was returned to the wrong people, despite them being labelled. People’s clothing is important as it is something they and their representative’s value and therefore should be treated with respect. Surveys from health and social care professionals said the care service always respected individual’s privacy and dignity. DS0000006482.V337455.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 12, 13, 14 & 15 were met. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Generally people were assisted to make some choices and decisions in their daily life and social activities, particularly where they were able to make their wishes clear. EVIDENCE: The AQAA stated that this service considered that increasing the variety of activities was something they could do better. It also said a lot more energy is being invested into activity staff as a company. Changing the individual care plan documentation had lead to a map of life being included, which included people’s dreams. The plan also ensured an individual plan was formulated of people’s leisure and social interests and pursuits. This was very comprehensive and gave a clear indication of what people would like to do. Discussion with an activity worker identified because of its recent implemetation she had not used this yet to influence her programme of group and individual activities. DS0000006482.V337455.R01.S.doc Version 5.2 Page 15 A number of people on Willowgarth were able to express their views about the opportunities they had for maintaining and developing their skills and interests. They were mainly positive about the range of activities, particularly highlighting the various outings and craft activities as something they enjoyed. The most recent outing had been a day trip to Cleethorpes, enjoyed by a number of people. A few people spoken with weren’t interested in the activities. One said, “I don’t join in the activities – they’re not for me. I get a newspaper. I visit my son and he visits me” and the other “I’d rather be on my own”. In a survey another said “I go out for a walk in the community on a daily basis”. Discussion with an activity worker confirmed that as well as group activities, they did carry out individual activities with people. They said this was particularly the case on Ferrymoor, where group activities were more difficult for people to become engaged in. During the day the majority of people were observed to spend their time in the lounges, with the TVs on or music playing. There were some people who were able and did walk around the home as they wished. The activity programme for the day involved wrapping gifts for a gala that was being held in the community. Two ladies and a gentleman were actively involved. Another gentlemen was observing and clearly enjoying the interaction between everyone. The activity worker and a member of care staff were involved in the action, encouraging the activity. One representative commented, “This home has a co-ordinator. She is very good. She helps the patients make birthday cards and Christmas cards for relatives. Special dates on the calendar are always celebrated by both patients and relatives, if they wish to attend”. Visitors were welcomed, but opportunities for private conversation were limited. There was seating outside the units, which was suitable for entertaining visitors in fine weather. The AQAA said in the last twelve months the service had invested a lot of energy into improving the presentation of meals, how dining room tables are dressed and ensuring menus are available on the table. The plan for the next 12 months is to constantly strive to improve the menu, considering peoples’ comments. Feedback from people about the food was generally good. People said, “on the whole the meals are good. There is some choice, particularly if you don’t like something, but sometimes you have to wait and see what’s left”, “meals are good really given the size of the place. There isn’t usually a choice. If you don’t like it, you leave it. You don’t get anything else”, “I don’t know why they’re asking us what we want, they don’t normally do – they just push it in front of you” and “they never tell you what the meal is”. DS0000006482.V337455.R01.S.doc Version 5.2 Page 16 There was a menu that identified a choice was available at each meal. This was available on the tables in the dining room. The problem was the menu on the table at the breakfast meal identified the day as Wednesday, when in fact it was Tuesday. This can be confusing for people, making them think they have got their days mixed up and cause anxiety. At lunch time the menu had been removed, but not replaced. This meant people did not know what the choices were until staff asked them what they would like. If they remembered what it had said at breakfast, what was being offered was different, which could be disappointing. Meals were served in an unhurried way, giving people time to eat. Staff were observed offering choice and regularly prompting people who were not eating. DS0000006482.V337455.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): The outcomes for standards 16 & 18 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There was a complaints procedure that people had access to. People living at the home were protected from abuse and had their rights protected. EVIDENCE: The complaints procedure was displayed so that people were aware of how to make a complaint and who would deal with it. The complaints record indicated complaints were logged. Complaints were recorded, investigated and responded to. This meant complainants could be assured their complaints would be taken seriously and acted upon. In survey responses people indicated that they were aware of how to complain and who to speak to. One representative said, “first I’d complain to the staff. If not put right I’d inform social worker or CSCI”. Two complaints had been received by CSCI. These had been referred to the provider to investigate. The provider had investigated the complaint and responded to the complainant. DS0000006482.V337455.R01.S.doc Version 5.2 Page 18 The AQAA confirmed there were policies/procedures/codes of practice in place to protect people from abuse. The systems in place to protect people from harm were working effectively. The service responds swiftly and looks into matters thoroughly when any issues have been raised, using appropriate procedures. DS0000006482.V337455.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): The outcomes for standards 19 & 26 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. On the whole, the environment was comfortable with pleasant living areas. EVIDENCE: This is a large site with three separate units. The one unit inspected had a well decorated lounge and dining area that were maintained in a comfortable and welcoming manner. They offered sufficient space for the number of people that used them. Furniture and fittings were of a good standard. Access around the home was good. People were able to personalise their rooms with pictures, photographs, ornaments and furniture. What detracted from the overall quality of the bedroom area was the sinks. Their design made it difficult for people who used wheelchairs to use them independently. DS0000006482.V337455.R01.S.doc Version 5.2 Page 20 There was a pleasant garden area for people and their families to use. Many of the bedrooms had patio doors that opened onto the grounds. People said families used the gardens during visits, because the children could play outside. This meant the children could enjoy the visit, as well as the people enjoying watching them play. The activity worker had taken some photographs of people using the garden and was going to enter them into a local competition. Some people were excited about this. The Ladywood and Ferrymoor units were being refurbished due to flood damage. There was a programme of updating in place and a rolling programme of routine maintenance. There were central laundry facilities sited away from food preparation areas and areas used by people who lived there. This meant the laundry process did not impose on the life of people living there. Clinical waste and infection control systems worked well. DS0000006482.V337455.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): The outcomes for standards 27, 28, 29 & 30 were inspected. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There was an experienced and stable staff team, with a good mix of carers and ancillary staff. On the whole, there were sufficient staff to support people and for the smooth running of the service. Staff had received training. This meant they were competent to meet peoples’ needs, but they did not always put this into practice. EVIDENCE: Generally, people spoke positively about the care they received, however, there were some staff they were not happy with, but could not quantify this. This information was given to the manager at feedback, to attempt to identify this in her quality assurance programme. Representatives said staff usually gave support or care as they’d agreed or expected and that staff had the right skills and experience to look after people properly. Their comments included, “sometimes care staff are a bit lax, especially when working short staffed. On the whole, most of them are very good. They tend to change care staff quite often”, “most of the staff have a DS0000006482.V337455.R01.S.doc Version 5.2 Page 22 good relationship, there’s always some you don’t like” and “some staff have the right skills and experience, some cannot be bothered”. Staffing rotas indicated that staffing levels were higher than usual, because of the reallocation of staff from the units where there had been flooding. However, it was noted that staffing reduced to two staff on an evening from 20:00. A number of people said they were still up at this time. Staff confirmed this. This meant that at this time availability of staff could be scarce. Ancillary staff were in adequate numbers. All areas were seen to be clean, meals provided on time and laundry returned to people in a timely fashion. Training opportunities were good. BUPA continually reviewed their policies and procedures, including training, to improve practice. This included implementing into their induction material reference to the potential hazards of bed rails and the necessity for these to be fitted safely. However, discussion with a member of staff identified they could not recall what the induction programme had involved without being prompted. This meant specific topics including bed rails may not have sufficient prominence in the induction programme. Other discussions with staff confirmed they had opportunities for training and this had included health and safety, moving and handling and fire. Most staff had received training on the prevention and management of infection control. This did not include staff working in the laundry. This would be advisable given that they were dealing with laundry that may be infected. Observation of staff practice, however, identified the training they had received was not always put into practice. This included moving and handling people and assisting people with their meals. Issues noted included moving people without footplates. This is poor practice and unsafe and can lead to injury of both the person being moved and the member of staff. In respect of assisting people to eat, this involved carers assisting people to eat whilst standing at the side of them. This does not promote the person’s dignity. The AQAA stated approximately 48 of staff were trained to NVQ Level 2 in Care, with approximately 11 working towards the qualification. Visiting health and social care professionals felt care staff had the right skills and experience to support individual’s social and health care needs. The home’s policy for recruitment was good. It included relevant recruitment information including an application form, two written references, making sure that any gaps in employment history were accounted for, a criminal records disclosure and where applicable a POVA (protection of vulnerable adults) first check. This demonstrated the recruitment process was sufficient to safeguard people from abuse. DS0000006482.V337455.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): The outcomes for standards 31, 33, 35 & 38 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Management and quality assurance was good. Peoples’ monies were handled appropriately. Generally the health, safety and welfare was managed well, but improvements were needed when moving people in wheelchairs. EVIDENCE: The manager was well qualified and had many years experience within the caring profession. This enabled her to contribute to the care of people and communicate a clear sense of leadership to staff. The manager had a good knowledge of the needs of people and she was committed to providing a good quality service. There was a relaxed and friendly atmosphere within the home. DS0000006482.V337455.R01.S.doc Version 5.2 Page 24 BUPA operates good quality monitoring systems as a matter of routine. People satisfaction surveys were carried out and an action plan developed from the results. The last survey results from December 2006 were available. Areas that had been developed as part of those results included systems to combat the odour in the units and menus and meals. In addition the organisation carries out regular monitoring of complaints, accidents and falls to pick up on any potential problems for improvement. Monthly visits by a regional manager were carried out. Finances held by the home on behalf of people were examined and found to be in good order. They included the date monies were deposited and returned, the purpose for which the money was used, a receipting mechanism and two signatures that confirmed the transaction. Health and safety routines and practices were generally found to be good. However, people were being moved in wheelchairs without footplates being in place. This is poor practice and unsafe and can lead to injury of both the person being moved and the member of staff. Systems for routine checks and maintenance seem to be well embedded practices. The AQAA confirmed electrical circuits, portable electrical equipment, fire detection and fighting equipment, emergency call equipment, heating system, soiled waste and gas appliances had been serviced or tested as recommended by the manufacturer. When the building was inspected fire exits were free from obstruction. The fire risk assessment was up to date. Hazardous substances were securely stored. Notifiable incidents were being reported to the CSCI. DS0000006482.V337455.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 DS0000006482.V337455.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 OP7 Regulation 15 Requirement The record in the commentary section of the individual plan of care must detail the specific action staff have undertaken to meet peoples’ care needs. That these meet peoples’ needs in accordance with the detail in the plan of care can then be established. Medication must be given in accordance with the prescribed dose, so that people have their medication as prescribed, in order to maintain their health. Records of medication must be accurate to demonstrate medication is being administered as prescribed. When assisting people to eat staff must sit at the same level and at an appropriate angle to the person. This will make the meal time a more pleasant experience for the person being assisted to eat their meal. Laundry must be returned to the correct person. This assures people their laundry is treated DS0000006482.V337455.R01.S.doc Timescale for action 31/10/07 2. OP9 13 (2) 31/10/07 3. OP10 OP28 OP30 12 (4) (a) 31/10/07 4. OP10 12 (4) (a) 31/10/07 Version 5.2 Page 27 5. OP15 12 (1) (a) 6. OP28 OP30 18 (1) (c) (i) 7. OP38 OP28 OP30 13 (5) with care and respect. Menus that are available for 31/10/07 people must reflect the correct day and that choices that are identified are offered. This will make sure people do not become confused about the day it is and the choices being offered that day. Staff working in the laundry 31/12/07 must receive training in infection control. This will make sure they are up to date with current prevention of infection control systems. People must be moved in 22/08/07 wheelchairs with footplates in place. This will ensure people are moved safely. 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. Refer to Standard OP10 OP27 Good Practice Recommendations Provide a more domestic type apron at meal times to enhance the dignity of people. The number of staff on duty in the evening should be reviewed to increase the availability of staff to meet people’s needs in a timely manner. DS0000006482.V337455.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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