Inspection on 29/07/08 for Highbury Nursing Home

This inspection was carried out on 29th July 2008.

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

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

Other inspections for this house

Highbury Nursing Home 08/08/07

Highbury Nursing Home 08/08/06

Highbury Nursing Home 01/02/06

Highbury Nursing Home 04/10/05

Highbury Nursing Home 17/03/05

Highbury Nursing Home 04/09/04

Highbury Nursing Home 03/08/04

Highbury Nursing Home 11/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Highbury Nursing Home 199/203 Alcester Road Moseley Birmingham West Midlands B13 8PX Lead Inspector Jill Brown Unannounced Inspection 08:10a 29 & 30th July 2008 th 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 DS0000024854.V370443.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. DS0000024854.V370443.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highbury Nursing Home Address 199/203 Alcester Road Moseley Birmingham West Midlands B13 8PX 0121 442 4885 0121 449 7855 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) Flintvaleltd@btconnect.com Flintvale Limited Manager post vacant Care Home 38 Category(ies) of Dementia (38), Old age, not falling within any registration, with number other category (38) of places DS0000024854.V370443.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 38 Old age, not falling within any other category (OP) 38 The maximum number of service users who can be accommodated is: 38 8th August 2007 2. Date of last inspection Brief Description of the Service: Highbury Nursing Home is purpose built and is located on the outskirts of Moseley Village, a suburb of Birmingham. The home provides residential and nursing care for up to 38 persons who are aged 65 years or above who may suffer from dementia. Bedroom accommodation includes both single and shared rooms, some of which have en-suite facilities. Bedrooms are situated on three floors; these are accessible via stairs or a shaft lift. The communal areas are situated on the ground floor and have recently been extended. All of the communal rooms are linked by well glazed partitions, which facilitates staff ability in observing residents and the nurses’ office is adjacently situated. The main lounge leads on to a smaller lounge, which leads onto the main dining area. There are two smaller rooms within close proximity one is used as a lounge and the other as an extra dining area. Communal toilets and bathrooms are within easy access of all areas of the home. The home has adequate quantities of specialist equipment and hoists to assist with the care needs of residents. During clement weather residents frequent a secluded and well laid out garden and patio area. A large unused grassed area is situated to the side of the garden and a generous sized car park is also located at the rear of the premises. DS0000024854.V370443.R01.S.doc Version 5.2 Page 5 The fee level was not available in the statement of purpose documents we looked at. We are aware there are additional charges for hairdressing, toiletries and chiropody. DS0000024854.V370443.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 visited the home without notice on a day in July 2008 and spent about 12 hours in the home over 2 days. During the inspection three people’s needs were case tracked. This case tracking involved looking at all the records and information about them, looking at their medication and their rooms and observing their care. This assists us to make a judgement about the care given. We also looked at parts of the care of a further two care plans. We received 9 comment cards about the service. Other documents about the running of this home were examined and parts of the building were looked at. We also took into account of information we had received from all sources about the home since the last key inspection. Services are required to complete an Annual Quality Assurance Assessment (AQAA) on a yearly basis; information from this was used in this report. We were aware from the AQAA and from contact with other agencies that there have been a number of complaints and adult protection issues and these for the most part have been resolved. During this inspection an expert by experience, Suzy Webster, accompanied us. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The expert by experience had the opportunity to speak to 9 people that live at the home and 2 relatives. A new manager Elizabeth Evans was appointed to this home in February 2008 and the owners have appointed John Ahern to monitor the home on their behalf recently. What the service does well: DS0000024854.V370443.R01.S.doc Version 5.2 Page 7 People living at the home have good access to health professionals such as GP, tissue viability nurses, dentists, opticians and so on. Every person spoken to or who commented on a survey said the food provided was good. The environment was clean and fresh and had facilities to give care to people with disabilities. All checks about the building such as fire safety, gas and electric certificates, checks on lifting equipment and so on had been undertaken as required. This means that the building is safe for the people living there. There was enough trained staff to give the care to people living in the home. What has improved since the last inspection? What they could do better: Although care plans have improved further work was needed on the recording of incidents for people that have challenging behaviour due to dementia. This will enable the home to look at the best way to provide the care Although staff had received training and care plans were in place the safe moving and handling of people from place was not always good. Where the manager had been informed of this action had been taken. DS0000024854.V370443.R01.S.doc Version 5.2 Page 8 We made an urgent requirement about the provision and fitment of bed rails as a number appeared unsafe. The manager has informed of action she has taken and this appears satisfactory. A number of night staff had not completed up to date training in key areas and this is important to ensure that people living in the home have staff that can meet their needs and maintain their safety. People living in the home were unaware of choices they can make about such things as getting up and going to bed and some cases felt unsure about raising issues with the home. The new management were aware of a need to change the atmosphere in the home and stated in the Annual Quality Assurance Assessment that they were committed to ‘changing the culture of the home to one where poor practice is not tolerated.’ We see this as the homes priority as this is key to all improvements in the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000024854.V370443.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 DS0000024854.V370443.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with sufficient written details about the home to assist them in making a decision about living in the home. There is a detailed assessment of the persons needs before admission and this helps to ensure that these needs are met. EVIDENCE: The home supplied us with a copy of the statement of purpose, which is combined with their service user guide. This document was stored on a computer so that large print copies are available if needed. The statement of purpose has been updated. A copy of the contract supplied to us had a section where the home could show how the fees were arrived at. For example how much health and or social services were paying towards the full cost. Some comment cards from people DS0000024854.V370443.R01.S.doc Version 5.2 Page 11 using the service indicated that they were unsure that they had received a contract. The contract did not state clearly which services such as chiropody incur extra payments. Detailed information was collected about people who may be admitted to the home. A form was used that prompts details about the person’s health, care needs, interests, family religion and ethnicity and helps the home to assess whether they can provide the care the person needs. The two assessments looked at had forms that were completed well. The information collected helped the home provide the care to the person. The preadmission forms showed where and when the assessment was undertaken and who had supplied the information as it was not always possible to get this information from the person. The home has a culturally and gender diverse staff group enough to meet the needs of the people in the home. People coming into the home and or their relatives were offered the chance to visit before deciding whether the home would suit them. DS0000024854.V370443.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most people living in the home have their care needs planned for and this assists with meeting their needs. Some people do not have all their needs planned for and these gaps could mean that people are not given help in the best way. Some health and safety risks are inadequately managed and this means that people could be at risk of injury. Medication is administered well but further checks about storage, discarding of medicines and communication between staff would improve this. People living in this service have differing views about the care they receive. EVIDENCE: There were care plans in place for all the people’s care that we case tracked. The care plans varied in the amount of information and instruction they gave DS0000024854.V370443.R01.S.doc Version 5.2 Page 13 to staff. Areas such as the person’s communication needs and the recently added people’s cultural needs were good and had enough detail for staff to give appropriate care. For example one communication care plan stated for a person ‘ wears glasses, minimise background distraction when talking to them, person’s speech can be jumbled and incoherent and look for their body language. They can grab objects when unsettled.’ Information about responding to people that have difficult behaviour was not specific enough. It did not show what may trigger behaviour or what action from staff may prevent or stop the behaviour. It was clear from daily records that not all incidents of challenging behaviour were being recorded. There were a number of requirements about care plans at the previous inspection these had been acted upon. Care plans were becoming more personalised and this means that people should be getting care that is specific to them. We looked at the records of people that had pressure areas. We saw that a number of people had been admitted with reddened areas and these were not graded as low-level pressure areas and some of these had developed into pressure sores. Grading reddened areas and putting together skin management plans may improve the outcomes for people. We found that people that were incontinent had assessments of this and plans were put into place to try and ensure that their needs were met. Comment cards said that sometimes people have to wait for care such as going to the toilet. Staff were collecting information about people’s life history and this was influencing their care and activities offered to them. This included information about diversity such as the person’s religion, ethnic origin, sexuality, cultural care and so on. We looked at the way people were moved from place to place. We found that care plans said what equipment should be used and how these moves were to be undertaken. This information was available to staff. The staff have received recent moving and handling training. However there have been some incidents where these instructions have not been adhered to. We have had a concern raised and the manager has informed us of 2 recent incidents where there have been issues with moving and handling. The manager took appropriate action with those incidents she was aware of. We looked at the rooms of people we case tracked and found that bed rails were in place. In some cases the use of bedrails was not appropriate or were not fitted properly and this could mean that people could become trapped. An urgent requirement was made. As a result of this we have been told that all of the people living in the home have had their need for bed rails reassessed. A large number of bed rails have been removed in some cases other more DS0000024854.V370443.R01.S.doc Version 5.2 Page 14 suitable arrangements have been made. Arrangements have also been made for the rails to be checked by an independent person. Bed rails are to be checked routinely. People living in the home have access to health professionals such as chiropodists, dentist, tissue viability nurses and so on this helps to maintain their health. Medication was stored in a secure way. The medication room was warm and above the temperature recommended for storing medications. There were appropriate policies and procedures that have been reviewed. The home’s pharmacist has recently checked the medication in the home. The records and medication were kept in an ordered fashion and people were given the medication they were prescribed with few errors. We had been told of one serious medication error prior to the inspection this has been investigated and appropriate action has been taken. One staff member was unaware of the change to the administration of medication to one person and there were not enough checks to ensure that changes were noticed. Medication that had been removed from the blister pack and refused by the person was not always being kept for return and not entered into the returns book. Further work about staff knowledge and communication about medication was needed. It is recommended that audits of staff competency with medication include these areas. The responses to questions about the care that residents receive were mixed. One comment card said ‘I don’t feel residents are always respected.’ Others felt that they had to wait for care. All the residents spoken to by the expert by experience said they were treated well. One resident stated that she could speak to staff at any time if they were busy they would explain that and always return to her as soon as possible. Another comment card said ‘I don’t like reporting them things because I have to live with them.’ This gives an indication of the difficulties the home has had and the changes the home is and has to make to improve the service for people living there. (see standards 12,14,16,18 31 & 33) DS0000024854.V370443.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People in this home are having activities on a regular basis and this improves the quality of their life. People living in this home do not always know about the choices they can make in their day to day routine and this can restrict what they do. People have good nutritional food and this improves their health and well being. EVIDENCE: The expert by experience stated ‘The manager of Highbury Nursing Home took up her post 6 months ago. It is very clear from talking to staff and people living in the home there have been many improvements in terms of activities offered to the residents. Since the last inspection in August 2007, an Activities Coordinator has been employed by the home for 20 hours a week. All of the people spoke very positively about her and the range of activities available during the time she is at the home. A worker from Age Concern attends the home once a week to do artwork. One person who used to enjoy art before moving to the home stated that doing this activity improves her life at the home and it is “lovely to see the colours again.” Other activities that take place DS0000024854.V370443.R01.S.doc Version 5.2 Page 16 at the home include; gardening, reminiscence work, gentle exercise, music, percussion and song.’ We found individual records of activities that people had been involved with. We also found that in addition that a few people had also been out for a meal at the local pub. The expert by experience commented that two of the people stated that the Activities Coordinator spends time just talking to them and that in itself is a welcomed activity. We found that although there was good support offered by the activities coordinator this had yet to be part of the longer waking hours of the people living in the home. There appeared to be no undue restrictions on relatives and visitors to the home and people were seen entering the home throughout the day and evening. Since the last inspection there have been concerns about the care people have received and the atmosphere in the home. More recently there have been changes in staffing and management and these concerns are being worked on. When the expert by experience asked about the choices given to people in regards to waking, resting and sleeping, she received very mixed responses. Some residents stated that they could go to bed at their time of choosing while others report that they have to wait their turn. Of all the residents she spoke to none of them knew if they could go to their rooms during the day to rest, one resident said she had never asked but if she did she was sure staff would assist her to her room if requested. One resident said he did not have any choice about when he got up in the morning and as an early riser throughout his life this made him feel unhappy. One woman stated she would like a choice for the time she went to bed because sometimes she would stay up later than others. She also said that she had never asked to vary her bedtime. Whilst the manager and staff spoken to were clear that people in the home have the choice this may not have always been the case. Management and staffing need to look at ways of ensuring that people living in the home also feel that they can make choices safely. All comment cards received said the food was good. People said when asked Do you like the meals? ‘very much so a good choice.’ ‘I like the meals’ ‘The food is very good.’ We received a sample of the 6 week menu. The food provided was a traditionally English nature. Hot food was available breakfast, lunch and teatime. The meals appeared nutritionally balanced. The people whose care was case tracked were found to be maintaining their weight mainly and the DS0000024854.V370443.R01.S.doc Version 5.2 Page 17 cook tried to ensure where necessary food was fortified for those residents who had eating difficulties. DS0000024854.V370443.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 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there are signs that the response to concerns and complaints is improving people living at the home have yet to be confident about raising concerns. EVIDENCE: There is a complaint procedure in place. A summary of this is part of the Statement of Purpose. This gives a quick guide to the complainant about making a complaint and other agencies they can contact. Comment cards suggest that people living in the home are aware how to make a complaint. Some people feel that they can raise concerns and staff will listen to them others feel they mostly can, two did not feel able to. The home keeps records of complaints and their action on these. We have received a number of complaints since the last inspection and some of these were referred to safeguarding procedures. There were concerns raised at the end of last year that resulted in investigations and increased monitoring by social services and health services. This increased monitoring has now ceased. DS0000024854.V370443.R01.S.doc Version 5.2 Page 19 More recent concerns have been referred, investigated and responded to appropriately, The home’s Annual Quality Assurance Assessment recognises that the home has had a problem in both providing a good service and responding to complaints in an open and learning way. The new manager Elizabeth Evans and the newly appointed Responsible Individual John Ahern are committed to ‘changing the culture of the home to one where poor practice is not tolerated.’ Staff records indicate that poor practice is being identified and action taken. The majority of the staff have received adult protection training and dementia care training this year as a result of these concerns. DS0000024854.V370443.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): 19,22 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a warm, comfortable and safe environment and this enhances their day-to-day life. EVIDENCE: There is level access to the home and the other 2 floors can be accessed by a passenger lift. Each floor has level access. There are a number of assisted shower and bathing facilities. This means that the home is suitable for wheelchair users. Parts of the building were seen at various times throughout the day and we found it to be clean and odour free. We commented on how much brighter the home was and were advised the corridor lighting had been added to and there is an intention to lighten doors and so on where this is possible. Some painting was being done to the lift doors during the inspection. DS0000024854.V370443.R01.S.doc Version 5.2 Page 21 The expert by experience said of the home ‘Individual rooms held personal belongings and treasured photographs which add to a sense of belonging however I did not feel this was reflected throughout the home. The communal areas felt somewhat clinical and some personal touches may have helped to provide a more homely feel e.g. pictures, memorabilia appropriate for the peoples’ histories.’ We found this to be true and further signs and other devices to help people with dementia know where they are in the building and to increase activity during the day. The home was generally clean and fresh. The home had an infectious outbreak in recent months, which had now cleared. It was noted that in shared rooms that bowls used for personal hygiene were not separated to dry or marked with each persons name and this should be done as a matter of good practice. The manager was aware of concerns about the work of the laundry and was monitoring this. DS0000024854.V370443.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): 27,28,29 &30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are adequate numbers of staff to provide the care that people living in the home need. Staff providing care at night do not always have the same level of training as day time staff and this could affect the service people living at the home receive. EVIDENCE: Review of the staff rota suggested that staff are allocated in sufficient numbers for each 24 hour period. There are two trained staff on duty during daytime hours as well as a minimum of five care staff and where possible 6 care staff in the morning. Night times there was 1 nurse and three carers available. All staff appeared to have adequate time off duty to be able to perform their duties, it was noted that on occasions staff were working longer hours but this was exceptional to cover annual leave or sickness. There were 54 of carers that have completed a National Vocational Qualification Level 2 (NVQ2) in care at the time of the inspection. DS0000024854.V370443.R01.S.doc Version 5.2 Page 23 We looked at the recruitment of staff and found that the home operates a safe means of recruiting staff. All of the relevant checks and two satisfactory references are obtained before a post was confirmed. The home has recently introduced an induction programme that includes all topics of the Skills for Care programme to give staff the basic knowledge and skills for working in the care sector. Staff had received training in Fire Safety, safeguarding, Food Hygiene, and other courses that cover the specialist needs of the current client group. Some staff had also had training in Dementia Care. However there were gaps in training for bank and night staff and there were no documents to show that these staff were competent in these areas. Staff files looked at showed that staff were receiving supervision but that not frequently enough to meet 6 times a year. Staff records showed that shortfalls in staff performance were being brought up with staff and where necessary formal action was being taken. DS0000024854.V370443.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of this home has changed and whilst there has been improvement in some areas there is a need for further work so people living in the home feel comfortable making choices and raising concerns. The maintenance and upkeep of the building, the management of residents money and the development of auditing systems ensure the safety of people living in the home. EVIDENCE: From thestatement of purpose and Annual Quality Assurance Assessment (AQAA) the manager Elizabeth Evans is a registered nurse and has been so for 30 years and has considerable experience as a home manager. She holds the Registered Manager’s Award. She has only been in place since February 2008 DS0000024854.V370443.R01.S.doc Version 5.2 Page 25 and since applied to be registered with the commission; this is now being processed. The owners have appointed a new person John Ahern to oversee the progress of the home. He was undertaking the required monthly visits and doing a report of his findings. The manager has also sent to us information about what they are doing about previous identified shortfalls. There was evidence the manager is working through the National Minimum Standards with staff to audit the service and manage improvements. The home has been through a difficult period since the last inspection with concerns coming to light about the care and attitudes in the home. The new management is seeking to address these issues however some work is required to enable people living in the home are comfortable raising concerns and are empowered to say how and when they want their care delivered. Records of meetings for staff, relatives and people living in the home show that this is beginning but it will take further to change the culture of the home. We were supplied with an AQAA however the full potential of this document as part of their quality assurance system and annual action plan had not been used. The system for recording and storing money was safe and there were appropriate receipts for any service or items the person had. The accounts matched the money held. There were systems in place to assist people living in the home whatever way their personal allowance came into the home. Some records of receipts were kept together such as chiropody and we have requested that these be kept with each individual record. Purchasing toiletries for each person separately may enhance people’s choice. A number of health and safety records were looked at to confirm that arrangements had been made for Fire safety, electrical wiring and equipment checks, gas safety and the safety of lifting equipment. These documents were all in place. DS0000024854.V370443.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X 2 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 DS0000024854.V370443.R01.S.doc Version 5.2 Page 27 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(1) Requirement People that have challenging behaviour must have a care plan that shows any triggers, any management plan and details of how and where to record any incidences. Timescale for action 30/09/08 2 OP8 13(4)(a) (c) This is to ensure that people with challenging behaviour have their safety appropriately managed and that appropriate steps are taken to prevent or minimise the effects of any incidences. You must assess all those 07/08/08 bedrails currently in use in the home and ascertain whether these are appropriate to meet the needs of the residents or whether alternative methods of maintaining residents’ safety could be adopted. Where bedrails are assessed as the only option to maintain residents safety then these must be fitted appropriately to prevent any possible entrapment. This is to ensure that people living in the home are safe when DS0000024854.V370443.R01.S.doc Version 5.2 Page 28 3 OP14 12(2)(3) 4 OP30 18(1)(c) (i); 13(6) they are resting in bed. Urgent requirement letter sent Appropriate response received 06/08/08 Steps must be taken to increase 31/10/08 the amount of choices that people living in the home can comfortably take about their care, health and welfare. Night staff must undertake 15/09/08 routine update training to ensure they remain safe to deliver care. You should advise us of the steps you intend to rectify this. 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 OP2 Good Practice Recommendations The home’s contract with people living in the home should contain information about what services may incur extra costs such as chiropody, hairdressing and so on. This is to ensure that people admitted or their representatives are clear what is excluded in the fees Tissue viability planning should begin for all people admitted to the home with reddened skin areas. This is to ensure that preventative planning takes place and hopefully reduce the numbers of pressure sores. Audits of medication should include individual staff competency for all staff undertaking the administration of medication, including knowledge base and communication. Record of the temperature in the medication room should be kept at the hottest time of day and steps taken to keep this room cooler if this continues to be over 25 degrees centigrade. Medications that have been refused must be kept securely and recorded on the returns book for appropriate disposal. Consideration should be given to increasing the ways that people living in the home can raise issues and the ways DS0000024854.V370443.R01.S.doc Version 5.2 Page 29 2 OP8 3 4 OP9 OP9 5 6 OP9 OP16 7 OP22 8 9 4. OP22 OP36 OP33 that they can be given information about any responses to those issues. Consideration should be given to installing signage on the doors of all communal rooms and individual’s bedroom doors. This would assist people in orientating and increase their independence. Consideration should be given to increasing the amount of homely, tactile and visual materials in the communal lounges. Supervision of staff should be planned so that each member of staff giving care has supervision no less than 6 times a year. Consideration should be given in developing a more robust quality assurance system. Further audits should be carried out and all audits included in the report. DS0000024854.V370443.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 DS0000024854.V370443.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. 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