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Inspection on 08/09/08 for Havencroft Nursing Home

Also see our care home review for Havencroft Nursing Home for more information

This inspection was carried out on 8th September 2008.

CSCI found this care home to be providing an Adequate service.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

From reviewing the information we received prior to the inspection and visiting the home for the key inspection, we found that the service has failed to demonstrate any improvement since the last key inspection which was completed in February 2008. None of the requirements made at the last inspection were met.

What the care home could do better:

The service should ensure that they can demonstrate how they are meeting the needs of residents who are unable to communicate their needs to others. This will help to ensure that vulnerable people using the service receive greater protection and are reassured that their own individual needs are being met. The home would benefit from a redecoration program, including upgrade of furniture and furnishings to enhance the home`s appearance and comfort for people living there. We raised concerns about the people who were unable to express their opinions. We looked at three residents` care records and these failed to provide sufficient information to demonstrate how the home was meeting their health and psychological needs.Activities that meet the needs, expectations and preferences of people living at the home should be available so that they are able to experience a meaningful lifestyle.

CARE HOMES FOR OLDER PEOPLE Havencroft Nursing Home Lea End Lane Hopwood Birmingham West Midlands B48 7AS Lead Inspector Chris Potter Key Unannounced Inspection 8th September 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 DS0000004115.V371171.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. DS0000004115.V371171.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Havencroft Nursing Home Address Lea End Lane Hopwood Birmingham West Midlands B48 7AS 0121 445 2154 0121 445 2159 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) Regal Care Limited Lesley Ann Owen Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32), Physical disability (4), Physical disability of places over 65 years of age (32) DS0000004115.V371171.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 3rd January 2008 Brief Description of the Service: Havencroft Nursing Home is a large, Victorian building. It is located just off the main road in the village of Hopwood. Hopwood is close to the boundary of Birmingham easily accessible from junction two of the M42 motorway. A limited bus service which stops within walking distance of the home is available for visitors. Limited off road car parking is available outside the home for staff and visitors. The home is registered to provide nursing care for up to 32 people who require 24 hour nursing and personal care. The home is equipped with specialist equipment to assist the staff in meeting the health and personal care of the residents. This includes a range of pressure-relieving mattresses to help prevent the development of pressure ulcers, and mobile hoists to help people move from (for example) their bed to their wheelchair if they have limited or restricted mobility. Accommodation is provided on three floors in both single and shared rooms. A lift is available to assist people using the service to access all areas of the home. Communal areas are available with three lounges and a separate dining area, so that the residents have a choice of where they wish to spend their day. Specialist bathing facilities are provided on each floor so that people with limited mobility can receive support with their personal hygiene needs. A large garden is available for the people to use when the weather permits. A limited range of activities are provided for the people. The registered providers are Regal Care Limited, and the registered manager for the home is Lesley Owen, who is a first level registered nurse with many years experience working in both the National Health Service and the private sector. Information regarding the home can be obtained from the statement of purpose and the service users’ guide which are available from the home. Fees range from £470.00 - £520.00 per week depending on the individual’s care needs and the room provided. These fees were correct at the time of the inspection for more up to date information please contact the home directly. DS0000004115.V371171.R01.S.doc Version 5.2 Page 5 Additional charges are made for chiropody, hairdressing, television license where applicable, dentist and daily newspapers. Copies of the most recent CSCI inspection report are readily available within the Home and on request. DS0000004115.V371171.R01.S.doc Version 5.2 Page 6 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. We, the commission, undertook an unannounced inspection of this service over two part-days, which means that the home did not know we were coming. This was a key inspection – which is an inspection where we look at a wide range of areas. Before the inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the service for completion. The AQAA is a self-assessment and a dataset that each registered provider has to complete each year and send to us within agreed timescales. The document tells us about how providers of services are meeting outcomes for people who use the service and is an opportunity for them to share with us what aspects of the service they believe they are doing well. Some of the provider’s comments have been included within this inspection report. During the visit to the home care records, staff records and other records and documents were inspected. Surveys were sent out and received from residents (two), staff (three). We looked at some parts of the accommodation and interviewed some staff. Time was spent speaking privately with residents in their rooms as well as spending time out and about in the home observing what was happening and talking to residents and their relatives. Generally comments we received from people using the service who were able to talk to us were complimentary and included: “I would give the home ten out of ten” “all staff are excellent” “food is good” “staff are respectful and courteous” Comments received from staff and relatives included: “Not enough staff on duty especially in the mornings” “activities not enough going on” “always a rush to do things and don’t have the time to spend on the paperwork” “staff call in sick at short notice resulting in more pressure on the rest of the staff” “staff meetings would help to motivate the staff” What the service does well: DS0000004115.V371171.R01.S.doc Version 5.2 Page 7 We were told by relatives and residents that they had been provided with sufficient information about the home to assist them make an informed choice prior to moving in. Comments included: We are very pleased with our choice of home. All the staff are wonderful” “we moved house to be nearer to the home, we can’t fault it and feel that ---is really safe here.” “------- room is brilliant” “I have been in several homes and this is the best one in my opinion” The home has a thorough recruitment procedure in place so that only people suitable to work with vulnerable people are employed. People living at the home receive a well-balanced and varied diet that meets their nutritional and dietary needs The home is clean and tidy – thereby providing a hygienic place for people to live. Residents are able to bring some of their own personal possessions into the home so that they are able to create a homely environment. Comments included: “------ room is brilliant and they love it” What has improved since the last inspection? What they could do better: The service should ensure that they can demonstrate how they are meeting the needs of residents who are unable to communicate their needs to others. This will help to ensure that vulnerable people using the service receive greater protection and are reassured that their own individual needs are being met. The home would benefit from a redecoration program, including upgrade of furniture and furnishings to enhance the home’s appearance and comfort for people living there. We raised concerns about the people who were unable to express their opinions. We looked at three residents’ care records and these failed to provide sufficient information to demonstrate how the home was meeting their health and psychological needs. DS0000004115.V371171.R01.S.doc Version 5.2 Page 8 Activities that meet the needs, expectations and preferences of people living at the home should be available so that they are able to experience a meaningful lifestyle. 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. DS0000004115.V371171.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 DS0000004115.V371171.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): Standards 1, 2 and 3. Standard 6 is not applicable to this home as they do not provide intermediate care. Quality in this outcome area is adequate. People have enough information before moving in so that they know what the home provides, and what they can expect when they move in to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We saw copies of the home’s Statement of Purpose and Service User Guide in the reception area of the home. The Statement of Purpose was last updated in May 2007. The Service User Guide was updated in August 2008, and contains pictures to assist residents understand the contents. DS0000004115.V371171.R01.S.doc Version 5.2 Page 11 We received surveys and people told us during the inspection that they had been provided with sufficient information to assist them with their choice of home. Comments included: “We chose the home for ------ because they were unable to do this themselves. We are very pleased with our choice of home. All the staff are wonderful” “We moved house to be nearer to the home, we can’t fault it and feel that ---is really safe here.” “I have been in several homes and this is the best one in my opinion” We looked at three people’s pre-admission assessments which had been completed prior to the person moving into Havencroft. The manager told us she or the deputy manager usually complete pre - needs assessments. The pre–admission assessment assists in determining that they are able to meet the health and personal care needs of the individual. The assessments reviewed provided basic information about why the person was in need of nursing care, and basic information relating to their health and care needs. The assessments provided little information regarding the psychological needs of the person moving into the home. We talked to the relative of a recently admitted resident, and we were told that they had been provided with the information necessary to enable them to make an informed choice about the home. The surveys received prior to the inspection confirmed that residents had been assessed prior to moving into the home. There plans for further improvement over the next 12 months include facilitating more home visits and assessments for prospective new residents. DS0000004115.V371171.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): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate. The poor care planning arrangements do not ensure that staff have the information they need to meet people’s health and personal care needs consistently. The home supports people with their medication in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the care records for three people using the service, and were disappointed to find that the nurses are still failing to provide an accurate care plan. Without up-to-date comprehensive information, staff do not have the DS0000004115.V371171.R01.S.doc Version 5.2 Page 13 information they need to meet people’s health care needs consistently in a way they prefer. Examples of this included: The pre–admission assessment recorded that a resident was a diabetic on medication. No further information or instructions for the staff about how this should meet this person’s needs was available in the care plan. The medication record for this person confirmed that they were receiving medication for diabetes. The pre–admission assessment recorded that a resident has dementia. No further information about this person’s needs and behaviours or instructions for the staff about how she should be supported with her activities of daily living had been recorded. This person’s assessment records that she has problems with communication due to her dementia, but provides no guidance to staff as to how they can support her to communicate effectively. The nutritional risk assessment recorded for a resident equated to a high risk, and that they required supplements and their fluid intake monitored. The nurse told us it was difficult for the resident to take fluids. We asked how this was being monitored and she told us that there should be a fluid balance chart in place. This was not in place. The pre-admission assessment described this person as frail no weight monitoring had not been recorded. No details of food supplements being provided were recorded in the care record or prescribed on their medication administration record. Social care records for one person described the individual as being “withdrawn”. No further information or instructions for the staff about how this should be managed were recorded in the care record. The assessment for risk of skin damage from pressure equated to “high risk”. The care plan developed for pressure areas was some 24 hours after their admission and failed to provide sufficient information about the skin damaged area or the equipment being used to reduce further skin damage. The care records we looked at for a resident recorded that they had skin damage due to pressure; this was completed three days after they had been admitted to the home. The information failed to provide sufficient information about the area of skin damage, or photographic evidence, or the equipment in use to reduce further possible damage. The care plan also recorded two hourly turns, no evidence was available as to how this was being monitored. This places people at risk of developing sore skin. We saw the care records for another resident. Again, these failed to provide an accurate assessment of the skin damaged from pressure. The home had DS0000004115.V371171.R01.S.doc Version 5.2 Page 14 requested that the tissue viability nurse assess this person for their specialist advice. No photographic evidence or details of equipment being used to assist in reducing further skin damage had been recorded. We also read that a resident had suffered a recent urinary infection; this had not been developed into a care plan so that short-term health care needs were met. We found that the care plans were not person centred and provided very basic information for the staff delivering the care. Care plans provide little evidence that the individual has been consulted and are in agreement with the plan. We were told by the manager that they are still having problems with the nurses developing appropriate care plans. She is looking to change the format for these again. We were told by the nurses that they do not have sufficient time to complete the paperwork The care records do not necessarily affect the outcome of care provided for the individual, and the comments from residents and relatives were positive about the care provision. However, the care records should accurately reflect the care provision. Not doing so may result in a lack of consistent care provision for the person. We looked at how medication was being managed for the three residents we case tracked and found the system to be well organised. A copy of the original prescription was available to check that the details on the medication record was correct. The supplying pharmacist provides a regular audit of the medication management The medication administration records seen were well documented with no gaps on the record. The balance of medication was correct for those residents checked. We observed staff respecting residents’ privacy and dignity - for example, knocking on doors before entering private rooms, and speaking to them courteously. We were told by residents and relatives that all staff were respectful and courteous when addressing them. The Annual Quality Assurance Assessment completed by the manager stated that they access specialist services for the residents, hairdressers, dentist etc. States that they have tried to improve their care planning and staff training. Plans to improve for the next 12 months include using end of life pathways, and better continence and review. DS0000004115.V371171.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): Standards 12,13,14 and 15 Quality in this outcome area is adequate. The provision of social and recreational activities for residents does not meet their needs and expectations. People have nutritious meals and snacks, at a time and place to suit them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We were told by the manager that a part-time activity organiser is employed for eight hours per week. This person is currently on leave and one of the carers is temporarily covering for them. We were told by the manager that various entertainment had been booked until December. On the day of the inspection a fashion show had been organised and some residents were purchasing new clothes from this. Two relatives told us that they did not feel that the home provided sufficient activities for the residents. Comments included: DS0000004115.V371171.R01.S.doc Version 5.2 Page 16 “my ---- has been in the home since ----- and has not been out once, we feel that the home have failed to meet their statement of purpose and what was told us prior to admission” “the activities are down at the moment because ---- is not here” “ ---- tends not to join in” “no set budget for the activities” The manager told us that the home had recently lost their transport, and so were unable to take residents out at the moment. A resident told us that the television in the main lounge had a poor picture and he had made repeated requests for this to be addressed, and felt nothing had been done. On the second day of the inspection the manager reported that a television had been borrowed whilst the other one was being repaired or replaced. We were told by six residents that their choices about, for example, going to be and arising are respected and four staff confirmed this. The care records reviewed failed to include information about their individual choices and wishes. Staff do not have all the information they need to ensure they meet people’s needs in a way that they prefer. Comments from staff included: “residents do have a choice of what time they get up and go to bed” “some residents who require two for assistance have to wait at times, could do with additional staff in the mornings” We were told by residents and staff that the quality and choice of food was good. The chef confirmed that the menus have been reviewed since the last inspection, offering the residents a more varied choice. We reviewed the menu’s which are displayed on a weekly basis. Alternatives are available for the residents to choose from. The home caters for specialist diets including a vegetarian option. Mealtimes and meal options are flexible and varied. For example, breakfast is served between 8 and 9.30am, and provides an option to choose between a full cooked breakfast, a bacon sandwich, cereals and toast. We observed the lunch being served on the day of the inspection, and this appeared appetising. Staff were assisting residents appropriately where needed. The home received a four star (“Good”) rating from the Environmental Health Officer’s most recent inspection in January 2008. Comments about the food included; DS0000004115.V371171.R01.S.doc Version 5.2 Page 17 • • • • “The food is very good “We have a choice of meals if we don’t like what’s available there is always an alternative” “The meals always look nice and ----- never complains”, “would like more varied choice at tea-time” The Annual Quality Assurance Assessment completed by the manager stated that they intend to improve the quality of the service in the next 12 months. DS0000004115.V371171.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. People who use the service are able to express their concerns and have access to the home’s complaints procedure, but cannot be confident that their views will be listened to and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We have received no complaints about this service since the last key inspection in February 2008. We looked at the home’s complaints procedure and records were seen. The complaints policy is in need of review and update, the policy has not been updated since January 2006. Six residents and three relatives spoken to were aware of the home’s policy and who to report concerns to. Comments received included: “ I am aware of how to make a complaint, but have never needed to” “I have complained about the poor picture quality on the television and nothing is being done” DS0000004115.V371171.R01.S.doc Version 5.2 Page 19 We looked at the complaints received by the home since the last inspection since February 2008. Only one was recorded and given the details this should have been referred to the multi-agency team under safeguarding vulnerable adults procedures for consideration. The outcome for the investigation was recorded and appropriate action taken by the home. The resident complaint about the poor picture quality had not been included in the home’s complaints register. We were told by staff that they had received “safeguarding” training and were aware of the home’s whistle blowing policy. Staff also confirmed that they would have no hesitation in reporting any concerns to the manager. The Annual Quality Assurance Assessment completed by the manager stated that plans for improvements over the next 12 months includes: Continued ongoing of training, audits of complaints and policies and procedures. DS0000004115.V371171.R01.S.doc Version 5.2 Page 20 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): Standards 19 and 26 Quality in this outcome area is adequate. To provide a more homely and comfortable environment some further improvement is needed to ensure all areas of the home are pleasant, homely and are adapted to meet the needs of the people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Havencroft nursing home provides a mixture of 24 single and double bedrooms some offering en- suite facilities. The homes service users guide states that the residents are encouraged to bring personal items into the home to make the environment more personalised and assist them to settle into the home. DS0000004115.V371171.R01.S.doc Version 5.2 Page 21 The home is surrounded by extensive gardens which residents, who do not have mobility problems can use when the weather permits. The gardens do not provide level access which creates difficulties for people with mobility problems. A passenger lift is fitted to assist residents to access all areas of the home. A telephone line can be installed into the room at an additional charge to the resident so that they can keep in contact with their family and friends. We looked around the home and saw that some of the bedrooms are personalised for the person using the room, and this gives a homely atmosphere. The communal areas including lounges and dining areas are looking tired, wallpaper looking dirty, carpets stained and the furniture is well used. The manager told us that plans to upgrade these areas are included with the plans to extend the home. However, this does not provide people with a pleasant place to live. The footings have been put in since the last inspection, but the manager was unsure when building work will commence. Comments received from relatives and residents included: “homely atmosphere here” pleased with the standard of cleanliness in ---room” “ ----- room is brilliant” “I rate the home ten out of ten, it suits me” We observed that the home was generally free from offensive odours, which is commended given the size of the home and the dependency of the residents. The Annual Quality Assurance Assessment completed by the manager states for improvement that continued refurbishment is required. Upgrading is required to meet the new fire regulations. DS0000004115.V371171.R01.S.doc Version 5.2 Page 22 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): Standards 27,28,29 and 30 Quality in this outcome area is adequate. Generally, there is enough staff to provide the people who live at the home with the appropriate support needed, and staff get the relevant training and support from the manager so that they have the skills and competencies to meet residents’ needs. However, staff feel pressured and care records have not been completed which, in turn, compromises continuity and consistency of care delivery. The procedures for recruitment of staff are robust and offer further protection to the people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the home’s duty rotas, which confirmed that, despite staff comments that they need more staff, the home is providing sufficient staff proportionate to the number and needs of residents. Staff to resident ratios equated to 1:3 (i.e. two nurses and 5 carers for 22 residents). DS0000004115.V371171.R01.S.doc Version 5.2 Page 23 Nursing and care staff stated that the residents would benefit from an additional person in the mornings when it is busier. We were also told by staff that some people phone in sick regularly which places them under more pressure. Staff comments included;(We’re) “always in a rush to do the care plans… never have enough time”. “a carer is doing activities as well as care” “not enough staff on duty to take the residents out”. The conflict between staff ratios and staff comments would indicate that staffing problems relate to the effective management and deployment of staff within the home – thereby affecting care delivery. The manager showed us the training matrix which the deputy manager has completed to assist in ensuring that staff receive appropriate training and refresher courses. The staff told us that they receive regular training updates including moving and handling, adult abuse, medication, and dementia. The records we reviewed confirmed that the home employs more than 50 of care staff with an NVQ qualification level two or above in care. The provision of staff trained to a national level of competency helps to ensure that the home employs competent staff that are able to effectively meet the needs of vulnerable people. The home employs male and female staff from a diverse cultural background, and respects the preferences of the people using the service for male or female staff. We looked at the personnel record files belonging to three staff members and records showed that the home had carried out all the appropriate recruitment checks before the staff had started working at the home. Only staff that are suitable to work with vulnerable people are employed within the home. DS0000004115.V371171.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33, 35, 36 and 38 Quality in this outcome area is adequate. The residents have confidence in the care home. However, complaints, staff deployment and health care are not well managed which, in turn, adversely affects the quality of management within the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been no change with the management arrangements since the last key inspection in January 2008. We were told by residents and staff that the DS0000004115.V371171.R01.S.doc Version 5.2 Page 25 manager is supportive and approachable - making herself available for them at any time. We are provided with copies of the monthly monitoring audit known as Regulation 26 reports, which is an internal quality audit to improve the service for people living in the home. The home has a quality auditing system in place and surveys are distributed annually to the residents, relatives and professionals who use the service. The results are generally positive from the last survey completed. The only negative was about the laundry which the manager feels shall be resolved when the extension is completed. The manager is available when on duty for the residents and families who may wish to see her. Regular residents’ meetings are held and the minutes of these were shared with us at the inspection. Comments from the homes quality auditing system included: “love the home and staff, very happy here.” “would like a bigger room” We looked at the supervision records for three staff, and these confirmed that regular meetings have been held with the member of staff and the deputy manager, and staff get feedback on their performance. We were told by the staff interviewed that they would welcome more frequent staff meetings to discuss issues as a group as thy do not happen often enough. We were told by the manager that the home does not manage the resident’s finances. For all transactions the home sends an invoice to their nominated person who manages their finances. The Annual Quality Assurance Assessment completed by the manager stated the plans for improvements over the next 12 months, to provide residents, staff, relatives to be part of the home running, and identifies “internal audit” as an area in need of improvement. The Assessment also confirms that all health and safety checks have been completed. The requirement for the low surface glazing has not been addressed, the manager confirmed that this is to be completed when the building work commences. We looked at the fire records and these showed that the regular checks were being completed, so that in the event of a fire, people are protected by living in a home where smoke detection systems and evacuation procedures are regularly reviewed and tested. Comments made by staff under the section of this report entitled “Staffing” related to staff regularly ‘phoning in sick. The management of this problem is poor and compromises care delivery by placing additional strain on the staff group which, in turn, affects care delivery and the time available to record care. DS0000004115.V371171.R01.S.doc Version 5.2 Page 26 DS0000004115.V371171.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X N/A 3 X 3 DS0000004115.V371171.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (1) (2) (b) Requirement To ensure that the residents’ care needs can be fully met; the Care plans need to provide a detailed plan of care for every assessed need. This should be reviewed and updated to reflect any changes or at least monthly i.e. weight monitoring. To further protect the residents from accidental injury, safety protective glazing film must be applied to all areas of low-level glazing. Timescale for action 31/10/08 2. OP24 13 (4) 31/10/08 3. OP31 18(1)a To further protect residents, staff 31/10/08 absences and deployment need to be more effectively managed to promote consistent care delivery. DS0000004115.V371171.R01.S.doc Version 5.2 Page 29 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 OP12 OP38 Good Practice Recommendations To assist residents with more complex needs the home should review more suitable activities / therapies. It is recommended that the provider installs internet access for the staff to allow them to review latest information in keeping up to date, and also for the nurses to monitor clinical triggers. To further ensure the health and safety of the residents the risk assessments should be reviewed and more up to date documentation developed. It is recommended that nurses maintain their professional accountability by attending clinical training sessions, 3. OP8 4. OP30 DS0000004115.V371171.R01.S.doc Version 5.2 Page 30 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 DS0000004115.V371171.R01.S.doc Version 5.2 Page 31 - 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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