Inspection on 18/05/06 for Halvergate House

This inspection was carried out on 18th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Halvergate House 03/06/08

Halvergate House 23/05/07

Halvergate House 30/11/06

Halvergate House 25/08/05

Halvergate House 02/06/05

Halvergate House 10/03/05

Halvergate House 13/10/04

Halvergate House 16/12/03

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

CARE HOMES FOR OLDER PEOPLE Halvergate House Nursing & Residential Home 58 Yarmouth Road North Walsham Norfolk NR28 9AU Lead Inspector Kim Patience Unannounced Inspection 18/19 May 2006 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 Halvergate House DS0000015642.V296579.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. Halvergate House DS0000015642.V296579.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Halvergate House Address Nursing & Residential Home 58 Yarmouth Road North Walsham Norfolk NR28 9AU 01692 500100 01692 407474 halvergate@eachltd.co.uk www.eachltd.co.uk East Anglia Care Homes 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) Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50), Physical disability (2) of places Halvergate House DS0000015642.V296579.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home operates only as a Care Home with Nursing. Fifty (50) Older People, not falling into any other category, may be accommodated. Two (2) people who are no younger than 45 years of age, are in need of nursing care due to their physical disabilities and are in need of respite care may be accommodated. The maximum number of persons accommodated should not exceed fifty (50). Registration of an appropriately qualified and experienced Manager (RGN). 25th August 2005 4. 5. Date of last inspection Brief Description of the Service: Halvergate House is a large period residence that has been adapted and extended over the years to provide accommodation to a maximum of 50 older people. The care home is located on the outskirts of North Walsham, standing within its own grounds with off road parking. Up to thirty-five people who have been assessed as requiring nursing care are accommodated and up to fifteen people who have been assessed as requiring residential care can also be accommodated. Qualified nurses are employed to give twenty-four hour cover in the nursing care part of the home. Care staff and additional ancillary staff including chefs and kitchen assistants make up the staff compliment available in the home. Halvergate House DS0000015642.V296579.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and held over two days taking approximately 12 hours. Day one of the inspection was conducted by two Regulation Inspectors. Feedback was not provided on completion of the inspection, but at a later date so that Mr Raghu, the provider and Frances Chatten, Regulation manager could be present. During the inspection, a tour of the building was completed and some resident’s rooms were entered. Residents care records were inspected, some residents were spoken with and observations of people engaged in their usual routines were made. A number of staff were spoken with and some formally interviewed. Staff records were inspected and observations of staff interaction with residents were made. Other records in relation to staff, residents and the running of the business were also inspected. During the inspection, the new manager, Jane Bunyan was present and helpful in facilitating the process. The staff on duty were also helpful in providing key information to support a thorough assessment of the standards. What the service does well: What has improved since the last inspection? What they could do better: The new manager has only been in post since April 2006. This new appointment follows a succession of managers over the last two years, Ms Bunyan being the sixth it is to be hoped that she will stay so that a period of stability can be created and meaningful improvements in the service can be effected. The lack of stability of management and leadership has without Halvergate House DS0000015642.V296579.R01.S.doc Version 5.2 Page 6 doubt contributed to the poor quality of the service. However, Mr Raghu has assured the Commission that he has been actively involved in ensuring that the home remains stable throughout the changes and he has appointed a quality assurance manager to assist. As yet there has been no significant sustained improvements. In addition, there appears to be a shift towards task-focused care, creating a clinical approach to peoples needs. The home needs to adopt an approach that looks to meeting people’s holistic needs in a place that they consider to be their home. Since the last inspection in August 2005, the Commission has made six unannounced inspections to monitor compliance with the regulations and one formal meeting has been held with Mr Raghu to provide an opportunity to state how the regulations will be met within agreed timescales. This inspection shows that only one of the seven requirements made at the last inspection has been met. The six outstanding requirements, some of which have been repeated from previous inspections, have been repeated in this report. In addition, other requirements have been made, due to the lack of sustained improvement. • requirement • The home must improve care plans to ensure they reflect peoples’ current health and care needs and they must demonstrate the involvement of residents and/or relatives /advocates. Repeat Care plans must provide clear information to staff about the needs of each individual and how they are to be met. Repeat requirement The home must improve their risk assessments to ensure that all risks are assessed and staff have clear information about steps that should be taken to minimise the risk to individuals. Repeat requirement The home must meet people’s social, emotional and psychological needs. Repeat requirement • • • The home must improve its medication arrangements to ensure that they protect the health, safety and welfare of residents. Non-compliance with this standard is of serious concern. Repeat requirement The home must ensure that offensive odours are identified and eliminated. The home must ensure they have adequate equipment that is in good working order. Repeat requirement Specialist equipment must be provided where the need has been identified. DS0000015642.V296579.R01.S.doc Version 5.2 Page 7 • • • Halvergate House • • The home must ensure that the staff are in sufficient numbers to meet peoples care needs within reasonable timescales. Repeat requirement The home must ensure that all staff are trained to fulfil their role competently. Repeat requirement The home must have a registered manager. Repeat requirement People falling outside of the category of registration must not be admitted to the home. Those already admitted must have their specialist care needs met. Repeat requirement Recruitment practice must be improved in order to ensure the protection of residents. Staff must be adequately supervised and supported. Regulation 26 reports must be completed and a copy made available to the Commission. The home should continue to seek a suitable way of displaying menus. The home should consider improving the pre admission information provided to prospective service users. The home should consider devising a care plan summary to improve accessibility to key information. Care records need to be organised in a way that up to date information is easily accessible. The home must promote peoples dignity at all times and consider introducing an alternative to the blue plastic aprons offered to residents when dining. The home should complete regular audits of resident’s financial transaction records to identify any errors. • • • • • • • • • • • The Commission is consider taking enforcement action to ensure compliance with the regulations and to ensure that an adequate standard of care is provided. 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. Halvergate House DS0000015642.V296579.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 Halvergate House DS0000015642.V296579.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 at least once during a 12-month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6 The quality outcome in this area is adequate as the home need to be more proactive in making information available to prospective residents and they are operating outside of their Conditions of Registration. People’s needs are appropriately assessed prior to admission. No intermediate care services are offered. EVIDENCE: The home has a pre-admissions process that includes an assessment of need prior to moving into the home. This is to ensure that the home has the capacity to meet those needs. The information trawled for is mainly about their physical needs. An information pack is given to all enquirers and contains a brochure providing details of the facilities and services offered. The information pack could be improved by including a copy of the service users guide, terms of residence and the complaints procedure and indicating to people how they can access inspection reports about the home. This would give people a greater opportunity to assess whether the home meets their individual requirements. See recommendations. Halvergate House DS0000015642.V296579.R01.S.doc Version 5.2 Page 10 Once the prospective resident has made a decision the home is suitable, the manager will conduct the pre-admission assessment and people are invited to visit the home to view the accommodation. It was identified at previous inspections that some people with a diagnosis of Dementia had been admitted. The home is not currently registered to accommodate people with these needs and is yet to demonstrate that they can provide adequate care for those people. See standards 7-11 for further details. Halvergate House DS0000015642.V296579.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 at least once during a 12-month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The quality outcome in this area is poor as the home continues to fail to assess holistic need and does not demonstrate that the residents are involved in the process. The medication arrangements are still in need of some improvement before it can be said that the home practices safe administration of medicines. Staff were seen to treat people with respect and offer choice where possible. EVIDENCE: Service user records were inspected and those service users selected were spoken with. At the last inspection many deficits were found in the service user plans. Whilst there have been some improvements, many concerns remain. Requirements in respect of resident’s plans have been made repeatedly for a period of two years. The home has not yet managed to raise the standard of record keeping and the delivery of care to an acceptable level. Halvergate House DS0000015642.V296579.R01.S.doc Version 5.2 Page 12 Some improvement was found in the overall standard of record keeping, staff are recording more detail in the daily records and care plans, however it is task focused and staff should adopt a more holistic approach to care. Care plans are kept in two parts, one is stored in the nurse’s station and one in the resident’s room, and both parts were inspected. The care plans written covered most elements of care, but again were task focused and clinical. There is little information about the individual’s social, emotional or psychological need and this aspect of care needs to be improved. This has been a continuing concern for the last two years. The plans still do not demonstrate that the residents and/or their relatives are actively involved in the process. See requirements. Care plans also need to be clear and provide up to date accurate information to staff. Case tracking showed that some care plans were not consistent with people’s current needs. Files are disorganised and it is difficult to find information. A care plan summary would be useful, providing key information to staff. See recommendations Care plans need to be reviewed more frequently, reviews were not up to date, however, improvement can be seen here. See requirements. Health needs were being addressed in some cases, evidence of GP visits and intervention of other professionals could be found. The deputy manager is doing some good work sourcing health care professionals to carryout assessments and for training purposes. Interviews with staff and observations made during the inspection showed that residents were not being bathed in accordance with their plans, this was said to be due to the lack of staff time. In addition, some residents were not having their personal care needs met until late in the morning. (See staffing standards 27-30) Further improvements are needed in respect of meeting people’s continence; assessments seen did not adequately cover this aspect of need. See requirements. Risk assessments were adequate, however, in some cases more than one risk assessment could be found for the same risk and it was not always possible to find the most recent one. See recommendations. There was a concern about one resident who has frequent falls, diagnosed as having dementia, care plans and risk assessment did not adequately reflect his needs and care was not being provided in accordance with those written. There was a lack of equipment to monitor activity and to ensure this persons safety. This was addressed in part during the inspection. Some risk assessments provide contradictory information i.e. moving and handling assessments providing conflicting information. See requirements Nurses will be attending compulsory care plan training delivered by an external training provider, so improvements are expected. Halvergate House DS0000015642.V296579.R01.S.doc Version 5.2 Page 13 Dependency assessments are in place and are being reviewed and audited on a monthly basis. These should be used to determine the correct staffing levels. (See standards 27-30) As found at the last inspection, staff were not available in sufficient numbers to ensure that people were provided with adequate care within a reasonable timescale. Repeat requirements are made in respect of staffing levels. The medication arrangements were inspected by the Pharmacist Inspector, and concerns remain. This is the third inspection of the medication arrangements this year and whilst the home has made some improvements, the arrangements are still not satisfactory and present risks to people’s health, safety and welfare. Requirements have been made in this respect and the home has been given a further 4 weeks to comply, at which point another inspection will be completed. The Commission will consider enforcement action if the home continues to fail to provide a safe system. See requirements The findings of the pharmacy inspection have been produced in a separate report, available on request. Good practice was observed in respect of privacy and dignity. Staff were seen to address people in a respectful caring manner and to close doors when carrying out personal care tasks. However, there was an issue about the Chiropodist who was observed to treat people in the communal lounges. This does not promote people’s privacy and dignity and can also be disturbing for other residents. Halvergate House DS0000015642.V296579.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 at least once during a 12-month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. The quality outcome in this area is poor, as the home still cannot demonstrate that people’s social, emotional and psychological needs are being met. Service users are encouraged to exercise choice and control, however, this is limited by the availability of staff. People are now provided with food that is wholesome and appealing served in pleasant surroundings. EVIDENCE: Previous inspections have highlighted concerns in respect of daily life and social activity. Those concerns still remain and no real improvement can be seen. Repeat requirements have been made in this respect over the last two years and the home have not yet managed to raise standards to an acceptable level. However, some improvement has been made to mealtimes. Care plans did not contain sufficient information about people’s social needs. Some care plans contained information about interests and hobbies, but this information was not acted on. For instance, one resident enjoyed knitting but there was no evidence to show that this interest was being promoted. The Commission received a complaint from a relative stating that the home will not take a resident out on nice days and that a member of staff said it was a luxury they cannot provide any longer. This is an activity that the individual Halvergate House DS0000015642.V296579.R01.S.doc Version 5.2 Page 15 enjoys very much and due to the lack of staff it can no longer be supported. See requirements No structured programme of activity is being provided, apart from extend classes once a week, and staff do not have time to engage with residents in a meaningful way. The manager is in the process of recruiting an activities coordinator, however if staffing levels were adequate activity could be incorporated in their day-to-day routines. See requirements Mealtime was observed and good practice was seen. Food appeared to be of a good standard and people were offered choices. There were two options available both served with fresh vegetables. Staff were observed to have a good approach with residents offering assistance where needed. One care assistant helping a resident to eat a meal did so in a nice gentle way. Following the meal, the cook was observed to visit residents to ask for their feedback on the food served. This is good practice and allows the home to assess the quality of the food from the resident’s perspective and make improvements if required. The home is also in the process of developing surveys to seek people’s views on the quality of the food. Nutritional needs assessments had been carried out and reviewed. Food was served in a way that met people’s individual needs, for instance, pureed food was served in individual portions and there was a vegetarian option. As on previous occasions, residents were seen using blue plastic aprons to protect their clothing during lunch, however, they were asked if they wanted one, some said no and others said yes. It is still the inspector’s view that a suitable alternative, more in keeping with dining and one that promotes dignity, could be found. See recommendations. On the day of inspection some residents were still getting up at lunchtime. The last person up on the day of inspection was brought to the dining room at 12.40pm. It was reported that on some days it is as late as 1.30pm. This indicates that staffing levels are insufficient. (See standards 27-30) It also raises questions about how people are provided with meaningful choices when staff are not available to assist at the time of their choosing. See requirements. Dining areas were nicely decorated and the tables were well laid out, creating a relaxed environment. During the inspection, visitors were seen to come and go without question. Residents spoke of relatives visiting at whatever time they wished to. Halvergate House DS0000015642.V296579.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12-month period. JUDGEMENT – we looked at outcomes for the following standard(s): The quality outcome in this area is poor as people still cannot be confident about how to make a complaint or that it will be fully investigated due to the lack of information about the complaints procedure and the homes failure to address complaints in accordance with the procedure. The home has systems in place to ensure that people are protected from abuse, however improvements can be made here. EVIDENCE: The home has a complaints policy and procedure, however, it is not well publicised and could not be seen on display on the day of inspection. Residents spoken with did not have a clear understanding of how to make a complaint if they wished to. It is required that the home ensures all residents have a copy of the complaints procedure and that a copy is displayed in the foyer so that visitors are also aware of how complaints can be made and will be dealt with. See requirements The Commission has had concerns about how complaints have been dealt with previously and it is hoped that the management have learnt from this experience and will improve the system to ensure that complaints are dealt with effectively and that complainants are satisfied with the outcome. The acting manager appears to have a good understanding of the correct procedure and is also much more visible in the home. On the day of inspection the manager was observed talking to relatives and staff about the home. Halvergate House DS0000015642.V296579.R01.S.doc Version 5.2 Page 17 The Commission has had several complaints and concerns raised over the last 12 months. One complaint has been ongoing for a period of two years and the Commission has been asked to carryout a thorough investigation of this complaint. The elements of the complaint relate to inadequate care planning and the homes failure to involve relatives in the process and inadequate staffing. Both of these areas are still of concern at this inspection and repeat requirements have been made. The complaint itself was not dealt with within the timeframes required and the report did not contain all the key components of a full investigation. See requirements. There have been no adult protection issues that the Commission are aware of since the last inspection. Staff have received training and new staff will be provided with training as part of their induction. Those interviewed had an understanding of adult protection procedures and were aware of the whistle blowing policy. It cannot be said that the home fully protects people from abuse due to the findings following an assessment of recruitment practice. See standards 27-30. Halvergate House DS0000015642.V296579.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12-month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,26 The quality outcome in this area is adequate as the home provides fair accommodation and facilities that are of a reasonable standard in parts and good in others. The home is kept clean and tidy by a team of domestic staff. However, some improvements could be made to eliminate odours. It cannot be said that the home provides specialist equipment to maximise people’s independence. EVIDENCE: Some improvements can be seen. Some areas have been redecorated and most re-carpeted, the plan of maintenance and renewal is ongoing. No odours were detected in the communal areas, as highlighted at previous inspections; however, two rooms entered have a strong odour that needs to be eliminated. See requirements. Communal areas were pleasant. Shared facilities were clean and tidy. Halvergate House DS0000015642.V296579.R01.S.doc Version 5.2 Page 19 Those resident’s rooms entered were pleasant and personalised, residents spoken with, were happy with their accommodation and the standard of cleanliness. Some equipment needs to be improved. The home has two wheelchairs that do not have footplates. Care Assistants were observed to move people without the footplates and this can be a hazard, although, they took great care to ensure that peoples feet were off the floor at all times. There is a general lack of wheelchairs, which is causing delays when people need to be moved from one area to another. Although the home is not registered for people with dementia, there are six people accommodated with diagnosed dementia. Therefore, in order to meet their needs, the home must source appropriate equipment and aids, signage, cues and prompts need to be placed to aid orientation, memory and recall. A requirement is made in respect of equipment. See requirements. The laundry procedures were inspected. The home employs assistants specifically to deal with the laundry. On the day of inspection one assistant was available for discussion about the procedures used. Systems were in place for infection control. Dirty laundry is collected in bags and taken to the laundry room, clean laundry is kept separately. The home has machines capable of washing at high temperatures and a tumble dryer. Once clothing is laundered it is ironed and placed in individual baskets to be taken back to peoples rooms. All items of clothing are named to reduce the chance of laundry going missing. There have been complaints about missing clothing and this was discussed with the manager. It was reported that the home employed a laundry assistant who did not follow the correct procedure and this caused the loss of some items of clothing. This person has since left and another has been employed to replace her. Discussions with the new laundry assistant showed that she had completed a basic induction, but had not been provided with any further training. It is recommended that training be provided in infection control. See recommendations. Halvergate House DS0000015642.V296579.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12-month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality outcome in this area is poor, as it still cannot be said that service users needs are being met due to the continued low staffing levels. Staff are now provided with regular training, however, an annual plan needs to be formalised. The home cannot fully demonstrate that people are protected by the recruitment procedures due to omissions in the pre-employment checks. EVIDENCE: The staffing levels continue to be of concern following repeated requirements to review and increase as necessary. The home has been given sufficient time to resolve the staffing issues and the Commission expects prompt action to be taken to ensure that peoples needs are adequately met. There has been a turnover of staff. However, newly appointed staff appear to have the right values and principles. They have completed an induction and shadowed by a more experienced member of staff for one week. The manager has introduced new routines to organise work and make more efficient use of staff time. However, this has only been in place for two weeks and therefore it is difficult to measure improvement arising from the change. It is hoped that in redefining roles and responsibilities and improving efficiency, the care does not become more task focused. This will not be positive; staff need to meet peoples holistic needs. Halvergate House DS0000015642.V296579.R01.S.doc Version 5.2 Page 21 Observations during the inspection confirmed that morning routines were too long, as mentioned in standards 12-15, some people were not out of bed until 12.40 and later on other occasions. Lunch is normally served at 12.30pm. No drinks were available or given to residents between breakfast and morning coffee (10.45am) staff were too busy engaged in getting people washed and dressed ready for the day. Staff are under pressure with heavy workloads. Resulting in some tasks being left or not completed to a satisfactory standard. Some people were not given baths due to lack of time and staff reported that they were never able to complete the bathing plan for the day. Staff do not have the opportunity to add quality to their work. i.e. activity, meaningful interaction, meeting need in accordance with care plans. Staff spoken with have a real desire to do a good job and for residents to be well cared for in every respect. However, they are prevented from achieving this due to the low numbers of staff. People’s holistic needs cannot be met. The number of care staff has been reduced and the number of nurses increased, but nurses have been given additional responsibilities and therefore do not have the hours to contribute to care. This results in there being less care hours available. The additional responsibilities for nurses include mentoring care assistants and supervision. Nurses administering medication are being called away to assist carers, this increases the risk of errors and the medication round is taking longer than it should. Following the third inspection of the medication arrangements there are still concerns about the safe administrations of medicines and staffing may be a contributory factor. See requirements. The home has only one care assistant in the residential unit in the afternoon now, resulting in unacceptable delays if people need two carers to assist with toileting or hoisting. Reports from various sources indicate that staffing levels are too low resulting in peoples care needs not being met within reasonable timescales. Accident records indicate that the majority of accidents have occurred between 2pm and 8am, this is a time when the staffing levels are lower and could indicate that people’s needs are not being adequately met. Based on the supporting evidence, the home is required to increase the staffing levels to ensure that resident’s health, safety and welfare are preserved. This requirement is repeated for the fourth consecutive time. See requirements. A training programme is yet to be developed for this year, but training has been provided and is planned. Staff think the training offered is good and are Halvergate House DS0000015642.V296579.R01.S.doc Version 5.2 Page 22 keen to do NVQ, which is being sourced by the manager. Requirements are made in respect of training. See requirements The files relating to new staff were inspected and it was found that recruitment practice needs to be improved. Some staff had commenced without two references. One had commenced without a Pova first check. Files need to be organised in accordance with the regulations. See requirements. Halvergate House DS0000015642.V296579.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 The quality outcome in this area is adequate as there is a system in place to ensure that the home is run in the best interests of the residents (but this needs developing further). The manager has not been in post long enough to have a significant impact on the management systems of the home but there are systems in place to protect residents’ finances, but some improvements could be made. However, staff are still not appropriately supervised. The home has systems in place to ensure that peoples health, safety and welfare is protected, however, low staffing levels continue to raise concerns about how the home would manage to evacuate safely in the event of a fire. EVIDENCE: Since the last inspection in August 2005 the home has had yet another change in manager. In April 2006, Jane Bunyan commenced as acting manager and has submitted an application for registration with the Commission. The requirement for the home to have a registered manager will be carried forward until such time that the process is complete. See requirements. Halvergate House DS0000015642.V296579.R01.S.doc Version 5.2 Page 24 The manager is a registered nurse and has been registered in her previous employment. There have been some positive changes since the manager started and a change in culture noticeable. However, the change is in its infancy and the manager will need to demonstrate that it is developed and sustained with positive outcomes. The home has a quality assurance system in place and employs a quality assurance manager to monitor the quality of the service and produce an annual report. Consultation processes are to be improved and new quality surveys are being compiled. This process will be assessed more thoroughly at the next inspection. The home has not produced any regulation 26 reports and these must be carried out monthly. See requirements. Service user finances were checked. The home holds a small amount of money for 26 residents. The money is held in separate named wallets and lock in a safe. The only person with access is the administrator. Financial transaction records are maintained and there is a clear record of money paid in and out. The records were crosschecked with the money held and in all but one case they were correct. One discrepancy was found, however, corrected during inspection and was an error due to calculations in the records. It is recommended that someone other than the administrator carry out an audit of financial transaction records. This could be incorporated in the regulation 26 visits. See recommendations Staff supervision has not commenced yet, but is to be introduced soon. The nurses on duty will take on the role but require some training to be able to do this effectively. See requirements. There were no obvious health and safety issues. However, the home could not produce a risk assessment in respect of the premises. This will be assessed more thoroughly at the next inspection. Fire safety risk assessments have been completed and fire alarms are tested weekly. The home has a plan of evacuation and fire safety procedures are on display around the building. However, in the afternoon the residential care unit has only one member of staff for 15 people. This raises concerns about what would happen in the event of a fire. See requirements in respect of staffing. In addition low staffing levels could create health and safety risks due to staff being under pressure to complete tasks speedily and this is a concern. The home maintains a record of accidents and copies were taken for analysis. The manager has introduced a system to audit the accidents, looking at what has occurred, who was involved and at which time of day. This is good practice as it helps to identify reoccurring themes. Halvergate House DS0000015642.V296579.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 1 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 2 X X 3 X X X 2 STAFFING Standard No Score 27 1 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 2 1 X 1 Halvergate House DS0000015642.V296579.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15(1)(2) Requirement Timescale for action 01/08/06 2. OP7 13(4c) 3 OP9 13(2) The registered person must ensure that care plans are written for all health and care needs and that they be reviewed in accordance with the standards. This is made for the second time. The registered person must 01/08/06 ensure that risk assessments are written and provide clear information to staff about the action to be taken to minimise risk. This is made for the second time The registered person must 16/06/06 ensure that all requirements made by the Pharmacist Inspector are complied with by the agreed timescales. This is made for the fourth consecutive time. 4. OP12 16(2)(m.n The registered person must 01/08/06 ) ensure that the social and recreational needs of each individual are recorded and arrangements are made for them to be met. This is made for the second time. DS0000015642.V296579.R01.S.doc Version 5.2 Page 27 Halvergate House 5. 6. OP26 OP22 16(2k) 23(2)(n) The registered person must ensure that odours are identified and eliminated. The registered person must ensure that the home has adequate equipment, in good working order, as may be required. This includes the need for specialist equipment. The registered person must ensure that at all times suitably qualified, competent and experienced persons are working in the care home in such numbers as are appropriate for the health and welfare of residents. This is made for the fourth consecutive time. The registered person must ensure that the home is managed by a person fit to do so. This refers to the need to recruit, train and register a manager. This has been a repeat requirement since October 2004. Under the ‘Care Standards Act 2000’, the registered provider must not admit service users not falling into the category of registration. This is an offence under the Act. The registered person must ensure that recruitment practice promotes the protection of residents and that pre employment checks are carried out prior to new staff commencing work. Staff files must also be organised in accordance with the regulations. The registered person must ensure that all staff are provided with supervision. DS0000015642.V296579.R01.S.doc 01/08/06 01/09/06 7. OP27 18(1) 01/07/06 8. OP31 9(1) 01/08/06 9. OP3 12(1)(a) 01/08/06 10. OP29 19 sch 2 01/08/06 11. OP36 18(2) 01/08/06 Halvergate House Version 5.2 Page 28 12. OP33 26 The registered person must provide the Commission with Regulation 26 reports on a monthly basis. 01/07/06 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 OP15 Good Practice Recommendations It is recommended that the registered person introduce a way of displaying the menu of the day to remind residents of what is on offer. It is recommended that the pre admission information pack contain a copy of the Service users guide, complaints procedure and terms of residence. It is recommended that the home introduces a care plan summary that provides clear information of peoples care needs and how they are to be met. It is recommended that risk assessments are reviewed and old risk assessments are removed to avoid confusion. It is recommended that the home finds a suitable alternative to blue plastic aprons to protect clothing during dining. It is recommended that the laundry staff are provided with training in infection control and health and safety. It is recommended that the home complete regular audits of the service user financial transaction records. 2. 3. 4. 5. 6. 7. OP1 OP7 OP7 OP10 OP30 OP35 Halvergate House DS0000015642.V296579.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Halvergate House DS0000015642.V296579.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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