Inspection on 13/05/08 for Hollybush

This inspection was carried out on 13th May 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.

Other inspections for this house

Hollybush 13/11/09

Hollybush 12/05/09

Hollybush 23/10/06

Hollybush 07/03/06

Hollybush 10/08/05

Hollybush 08/03/05

Hollybush 02/11/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hollybush 45 Glamis Road Newquay Cornwall TR7 2RY Lead Inspector Ian Wright Unannounced Inspection 13th May 2008 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 Hollybush DS0000008930.V364404.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. Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hollybush Address 45 Glamis Road Newquay Cornwall TR7 2RY 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) 01637 874148 01637 874148 Mr Neil Edward Brazier Mrs Nicola Carla Brazier Manager post vacant Care Home 14 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (14) of places Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users to include up to 14 adults of old age (OP) Service users to include up to 4 adults with Dementia (DE(E)) Total number of service users not to exceed a maximum of 14 Date of last inspection 23rd October 2006 Brief Description of the Service: Holly bush accommodates up to fourteen elderly people, up to four of who may have dementia. Holly bush is situated in a residential area on the outskirts of Newquay. The home is close to shops and in walking distance of the coast. Mr and Mrs Brazier are the registered providers. The majority of bedrooms are situated on the ground floor. Five bedrooms are situated on the first floor and are accessed via the stairs or a stair lift. All bedrooms have en suite facilities. There are assisted bathroom / shower facilities for people with mobility problems. There is a large lounge / dining room, which provides shared space for people who use the service to relax in. The home has a conservatory and people who use the service can use the garden. There is car parking available for people who use the service, staff and visitors. The ground floor is wheelchair accessible. A copy of the inspection report is available in the hallway. A copy can be requested from management if required, or via the CSCI website at www.csci.org.uk. The range of fees at the time of the inspection is £360 to £440 per week. There are additional charges e.g. for hairdressing, chiropody, and newspapers etc. Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection took place in nine hours in one day. All of key national minimum standards were inspected. The methodology used for this inspection was: • To case track five people who use the service. This included, where possible, meeting and discussing with the people who use the service their experiences, and inspecting their records. • Discussing with four staff their experiences working in the home. • Discussion with other people who use the service and their representatives. • Observing care practices. • Discussing care practices with management. • Inspecting records and the care environment. • Assessing ‘Adult Safeguarding’ (adult protection) procedures and practices in the home, as part of a CSCI national survey. Other evidence gathered since the previous inspection, such as notifications received from the home (e.g. regarding any incidents which occurred), was used to help form the judgements made in the report. What the service does well: What has improved since the last inspection? What they could do better: Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 6 This inspection has resulted in eight statutory requirements. Action regarding these legal requirements is necessary within the timescales set. In summary, requirements have been made regarding: • • • The medication system; particularly in regard to the management and storage of controlled drugs. Staff training, particularly in regard to ensuring training meets regulatory standards. Improving recruitment and personnel information obtained when staff are employed. An immediate requirement was issued regarding the registered providers carry out Protection of Vulnerable Adult ‘First’ checks on staff before they commence work in the home. Registering a manager for the home with CSCI. Ensuring receipts /appropriate evidence is provided for any expenditure carried out on behalf of people who use the service. Ensuring emergency lighting is tested according to fire authority requirements. Quality assurance systems so there are not shortfalls regarding the above matters. • • • • The commission will monitor the registered persons to ensure satisfactory improvements are achieved. 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. Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 7 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 Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 8 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): 2, 3 Quality in this outcome area is generally good. This judgement has been made using available evidence including a visit to this service. Information provided to people who use the service (e.g. regarding what service is offered, and individual assessment of need) is appropriate. This will help ensure people who use the service and their representatives, have satisfactory information regarding the rights and responsibilities, and what service they can expect. EVIDENCE: A copy of the home’s statement of terms and conditions of residency / contract was inspected. An individualised copy of this document was on people’s files inspected, and appears satisfactory. The manager confirmed that people who use the service (where appropriate) and their representatives, receive a copy of the service user guide so they are aware of their rights and responsibilities. The manager said she or other senior staff assess prospective people who use the service before they are admitted. She said, for example, some one will visit the person, and their representative(s) before admission is arranged. However Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 9 some of the pre admission assessments inspected were dated on the date of admission. Assessments should be completed at the time of the assessment, before a decision is made to admit the person to the home. Some people have moved to Holly bush, from previous homes outside the county. For these people, comprehensive assessments were obtained from either the statutory authorities (e.g. social services / health) or from other placements. The people were admitted on a month’s trial which enabled the person to be assessed while at the home. Copies of assessments were available for inspection in people’s files. Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 10 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 generally good. This judgement has been made using available evidence including a visit to this service. Health and personal care standards are generally satisfactory, although some improvement is required to the management of medication. People who use the service and their representatives said they were happy with the care provided. EVIDENCE: There is a copy of a care plan in each person’s file. Care plans are accessible to staff. Care plans inspected were last reviewed on either 3rd May 2008 or 4th April 2008. Most people who use the service, who the inspector spoke to, did not seem aware they had a care plan. However people who use the service said care is delivered to a good standard, and staff did their best to meet their needs. People who use the service said they were satisfied with the healthcare support they received. This includes visits from GP’s, district nurses, chiropodists, dentists and opticians. Some people said they had not been happy with the chiropody service, but the manager said this had now changed according to Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 11 people’s wishes. Medical interventions appear to be appropriately recorded in care files. The registered provider has a medication policy. Medication is administered via the monitored dosage system. The medication system was inspected and needs some improvement regarding the storage of controlled drugs. The controlled drugs are stored in a cash tin, within the medication cabinet. However the tin is not secured e.g. to the wall. Storage of controlled drugs should be in line with the Royal Pharmaceutical Society Guidelines. A copy of these can be found via their website at: http:/www.rpsgb.org/pdfs/handlingmedsocialcare.pdf The administration of controlled drugs is recorded in a note book. This may have had pages taken out. Controlled medication needs to be recorded in a controlled drugs book, which is bound and tamper proof. Books for this purpose are available from a pharmacist. The inspector noted that totals for the controlled medication for one person did not tally with what was recorded in the controlled medication book. The manager checked this, and there appeared to be a recording error from when the totals were transferred to a new page. The manager showed this error to the inspector, and it was agreed she would make the appropriate amendment. People who use the service said they felt staff worked with them in a manner, which respected their privacy and dignity. People who use the service were positive about their care. People who use the service said personal care was provided to a good standard. Staff were observed working with people, in a positive manner and appeared caring and kind. The registered provider has a satisfactory policy regarding anti discrimination. There are currently no people who use the service from ethnic minorities, although it is understood the registered provider would be happy to accommodate people who use the service from other cultures. The local population is predominantly Cornish, and from ‘White-UK’ background. The manager and some of the other staff are due to attend a training course regarding equality and diversity shortly. Issues regarding sexuality and gender seem to be suitably addressed. Staff appeared to work with people with physical disabilities in a positive manner, for example walking at the individual’s pace, and encouraging people to walk rather than use a wheel chair so people could keep up their mobility skills. However one person used a wheel chair did not have foot plates, and this should be avoided so the risk of physical injury is avoided. Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 12 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. Appropriate arrangements are in place so people who use the service can enjoy a lifestyle that meets their needs. Food provided is to a good standard so people enjoy a choice of good quality meals that meet nutritional needs. EVIDENCE: Routines were observed as flexible and appear to suit the needs of people using the service. The inspector observed staff working in an appropriate matter with people who use the service. The morning routine appeared to work in a manner which individualised the needs of people who use the service. People who use the service either spend time in the lounge or in their bedrooms. There are some organised activities, for example, there are keep fit sessions, sing songs and entertainers occasionally visit. A Methodist minister visits the home on a monthly basis. It was very warm on the day of the inspection, and many of the people who use the service were enjoying using the garden. Many of the people living at the home said the garden was regularly used, and is a much appreciated facility. People who use the service said they could receive visitors when they wished. Two visitors spoke very positively about the home. One person using the service attends a drop in centre for the elderly which she enjoys. Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 13 People who use the service all said they were encouraged to make choices and did not feel there were excessive or inappropriate restrictions placed upon them. People said they could get up and go to bed when they wished. People the inspector spoke to, said they did not feel pressurised regarding how they spent their time. Bedroom doors are not lockable, as should be the case as outlined in the national minimum standard. The manager said people who use the service could have a cash box to store valuables if they wish, or the providers can lock valuables away in the safe. A suitable door lock / key (i.e. with an overriding facility) should be offered to all existing people using the service, and people who subsequently move in to the home. The registered provider should note National Minimum Standard 24. If locks are fitted, and where appropriate people are provided with keys, this will ensure people who use the service can lock their bedroom door if they wish. This will improve their security and privacy. However, people who the inspector spoke to, said they felt their personal belongings were safe and secure in the home. People who use the service have their meals in the downstairs dining room, or in their bedrooms. The inspector shared lunch with people who use the service on the first day of the inspection. The meal was roast lamb, fresh vegetables, roast potatoes, followed by a choice of dessert. The meal was to a good standard. All People who use the service said they enjoyed the food provided, although some people said the vegetables could have been cooked for longer. A choice of a hot and cold evening tea is offered. Suitable records of menus and records of meals provided are maintained. Special diets (e.g. pureed meals) are provided if required. Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 14 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. A suitable complaints procedure is in place. The adult protection policy and recruitment checks, in relation to Protection of Vulnerable Adults ‘First’ checks, need improvement. Improvement in these areas should give people who use the service more confidence about adult protection processes at the home. EVIDENCE: There is a suitable complaints procedure. The registered provider or Commission for Social Care Inspection have not received any complaints regarding this service. People who use the service generally said they had no concerns, complaints and allegations about the service. They said they would feel confident approaching staff or management if they had any problems. The inspector spoke to one person who said they were not happy. The manager did appear to have insight into the person’s situation, and was ensuring the person received support from external professionals. Subsequently, staff are recording concerns and accusations raised. The commission however recommends to the registered provider that there was regular liaison with social services / health staff regarding the person’s concerns and accusations. This will ensure a third party can monitor these. Subsequently appropriate advice, mediation and safeguarding can occur. Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 15 It is recommended an appropriate risk assessment is completed and regularly reviewed regarding concerns and accusations made. The action plan from this should protect the person , and also staff involved. The use of advocacy services should be considered for the person concerned. The registered provider has an adult safeguarding (protection) policy. This was inspected as part of the CSCI thematic ‘probe’ which was completed as part of this inspection. The policy does need some development to make it more robust. The policy also needs to be clearer regarding what people living and working in the home should do if there is an allegation: 1. Firstly, any accusations must be reported to Cornwall County Council’s Department of Adult Social Care. The registered provider has a duty to ensure such matters are always reported- even if the alleged victim of abuse wishes confidentiality to be maintained. The current policy states this may not happen if the person concerned does not wish it to be reported. The person subsequently needs to be informed of the registered provider’s duty if an allegation is made. If the person does wish the matter not to be raised, the social services department should be informed of the person’s wishes. This will ensure if there is a need for an investigation this can be carried out sensitively. 2. The Department of Adult Social Care are the coordinating agency for any investigation. The manager, registered provider or other persons should not investigate any allegations, beyond basic information gathering, unless delegated by social services to do so. 3. The policy states any allegations should be reported to CSCI. Although CSCI should be informed of incidents reportable under regulation 37 [Care Homes Regulations 2001] (as such an allegation is), the Department of Adult Care is the coordinating agency regarding the investigation of such matters. 4. The policy should state how people using the service, and their representatives, will be informed of what to do if they have any allegations of abuse or poor practice. 5. The policy should state what pre employment checks and training staff will receive. This should detail how staff will be informed (e.g. on induction) of correct protocols they should follow if there is an allegation. 6. Contact addresses and phone numbers should be in the policy and readily available to staff, people who use the service and their representatives. The two staff, the inspector spoke to seemed generally aware what to do if there was an allegation. For example people said they would either report any allegation to management, CSCI or social services. Personnel files showed most staff had received training regarding adult safeguarding (whistleblowing) from the county council. Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 16 The manager said there had been no allegations of abuse, and they had not had to refer any ex members of staff for inclusion on to the Protection of Vulnerable Adults Register. The inspector was concerned regarding recruitment checks completed on new staff, for example in relation to Protection of Vulnerable Adults ‘First’ checks (POVA First) completed. This is detailed in the ‘Staffing’ section of this report. Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 17 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, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Hollybush provides a pleasant, homely environment for the people who live there. EVIDENCE: The building was inspected. The building appears to be well maintained, clean, pleasantly decorated and homely. There is a very pleasant garden, which people who use the service can use. The garden has had a decking area built in the last year. This has helped the people who use the service considerably to use the garden. People said they really appreciate the garden. There is a large lounge / dining room which is homely and comfortable. Bedrooms are individualised and comfortable. Some of the downstairs bedrooms have uneven floors. Care needs to be taken that people who have mobility difficulties, and are of risk of falls are , where possible, not accommodated in these rooms. A carpet was loose in the downstairs hallway. This was reported to the manager who said she would ensure it was refixed to the floor. Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 18 A stair lift is provided to assist people who use the service to go upstairs. There are bathing hoists on both of the baths. Bathroom and shower facilities are to a good standard and effort is made to make these spaces homely. Suitable kitchen and laundry facilities are provided. Cleaning staff are employed, and the home was clean and hygienic at the time of inspection. Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 19 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. Staffing levels appear satisfactory to meet current people’s needs. Improvements are required to staff recruitment checks-particularly in regard to Protection of Vulnerable Adult First checks (POVA First checks). Some improvement is required to staff training. These measures will ensure people who use the service are better protected from staff deemed unsuitable to work with vulnerable people, and they are supported from staff who are appropriately trained to meet their needs. EVIDENCE: The inspector observed a copy of the rota for the week of the inspection. On the day of the inspection the following staffing was provided: • 0800-1500hrs-two members of staff • 1500-2200hrs- two members of staff • 2200-0800hrs- one waking night staff. • One cook and one domestic member of staff. The staffing levels appear satisfactory to meet the current needs of people currently living at the home. The manager was working ‘on shift’ on the day of the inspection, and the registered providers were on holiday. People who use the service were positive Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 20 regarding staff attitudes. Staff were observed working in a positive manner with people who use the service. The registered provider has a suitable approach to providing National Vocational Qualifications for care staff. Due to staff turnover the manager said currently 30 of staff have an NVQ 2 or 3, although two other staff are currently working towards this qualification. Staff recruitment records need improvement. Current staff have completed an application form. However this should be improved, as required by the regulations, for staff employed in future: 1. There needs to be an employment history- Currently prospective employees only need to provide two references. An employment history will give the provider a record of where applicants have worked before they worked at the home. Subsequently, the registered provider will have the opportunity to investigate any gaps in people’s employment history, and why previous employers have not been given as referees. 2. A statement by the person applying for the job as to their mental /physical health. The current information is too brief and does not enable the provider to ascertain whether applicants are deemed suitable to work in a care home. The records of six staff employed were assessed in detail. All of this sample of staff had two references, completed the current application form, and had a Criminal Record Bureau check completed. However, there is a lack of evidence that the registered provider is completing Protection of Vulnerable Adults ‘First’ checks, regarding new staff, before they commence work at the home. The inspector assessed all staff files regarding these checks being completed. For example there were no copies of these checks being completed on any staff file. The registered provider assured the commission previously that no staff were ever employed until a full Criminal Record Bureau check / Protection of Vulnerable Adults check was received. They said that therefore it was not necessary to complete a POVA First check. However: • Assessment of several staff files show that staff appear to have commenced employment at the home before the date when the Criminal Records Bureau / POVA check was received by the registered provider. • A member of staff was working at the home on the day of the inspection. This person said they were currently on induction and being supervised by senior staff. However only one reference was on file for the person, and the manager said no POVA First check had been completed. These matters are of significant concern to the Commission, particularly in respect of the previous assurances given by the registered provider. It is an offence to employ somebody who is on the Protection of Vulnerable Adults Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 21 Register, and to do so could put people who use the service at significant risk of abuse. Subsequently an Immediate Requirement was made regarding appropriate checks being performed in regard to the employment of staff. The commission has confirmed this in writing to the registered provider. A statutory requirement was made regarding this matter at the previous key inspection on 23rd October 2006. This has not been complied with and therefore is renotified. Failure to comply with the immediate requirement, could in future, result in enforcement action being taken against the registered provider. The inspector spoke to staff regarding staff induction arrangements, and these appeared satisfactory. There is evidence of staff induction on staff files (e.g. a staff induction checklist). This is adequate, and provides scope for expansion regarding issues which should be covered during a new member of staff’s first weeks of service. The registered provider’s approach to equal opportunities and anti discrimination is to a satisfactory standard. Staff training records were inspected for a sample of six staff. Staff training generally has developed since the last key inspection. For example most staff have received training regarding fire awareness, food hygiene, manual handling, infection control, dementia and adult safeguarding. Some of the senior staff have trained as fire wardens with the county council and subsequently deliver the fire training. Similarly some of the senior staff provide manual handling training. Dementia, food hygiene and infection control training is delivered via written training packages. Staff have received adult safeguarding training from the county council. However, CSCI are concerned about the following issues regarding staff training: 1. Most of the training is delivered internally. The content, particularly in relation to questionnaires used to test individuals, did not appear particularly rigorous to ascertain people had attained appropriate levels of skills and knowledge. From what was seen it is not clear whether training being provided takes into account current legal requirements and best practice. 2. If senior staff are to provide appropriate levels of mentoring and tuition, it is essential they receive regular updates to develop their skills and knowledge. This is particularly the case regarding staff acting as manual handling trainers and fire wardens, as well as those who mark the questionnaires completed to award certificates regarding ‘dementia awareness’, ‘food hygiene’ etc. 3. Training needs to be externally validated. For example certificates for the training is obtained from the training provider rather than issued by the home. Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 22 4. In regard to infection control and food hygiene training it is important these training packages comply, for example, with Health Protection Agency, and Food Standards Agency Guidance. (These agencies or the Environmental Health Officer may provide advice regarding these matters). CSCI are particularly concerned regarding First Aid training delivered by the registered provider. For example it is not clear whether the training provided ensures staff have the appropriate skills to be an ‘appointed person’, and to have the right skills to assist people using the service in an emergency. If it does not, people using the service could be put at significant risk. It is essential that CSCI guidance regarding First Aid training is followed. Full details of this are available on the CSCI Professional website. A copy of the registered provider’s risk assessment regarding this matter must be submitted to the commission (with an action plan as appropriate) within the timescale set. Appropriate levels of First Aid cover, must be provided by the registered provider, at all times, as a matter of urgency. Confirmation from the registered provider is required regarding this. Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Action is required to improve staff recruitment, adult safeguarding issues, staff training and to minimise health and safety risks. This will ensure people using the service can be assured they live in a safe environment and receive support from appropriately recruited and trained staff. EVIDENCE: The registered provider has owned the home for several years. A manager is employed to manage the home on a day-to-day basis. The registered providers spend at least two days a week at the home. The commission wrote to the registered providers in September 2007. This stated that the registered providers need to submit an application to have a registered manager at the home in accordance with the Care Homes Regulations 2001. The manager confirmed at the end of this inspection that Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 24 she had obtained an application form to apply to be registered, and has also obtained a Criminal Records Bureau check application form for the application. She confirmed the registered provider’s intention to register her with the commission as the manager. It was agreed the manager would submit her application for registration to the commission as soon as possible, but within three months of the inspection. It is clear the manager, and the staff team of the home work hard to provide care for the people living in the home. The manager appears committed to the home and the people who live there. The registered persons however need to ensure improvement regarding recruitment checks, particularly in relation to Protection of Vulnerable Adults checks-as outlined in the ‘staffing’ section of the report. It is particularly of concern the registered providers gave the commission previous assurance that staff did not start working at the home unless appropriate checks were completed. The Commission for Social Care Inspection does need appropriate assurance (e.g. from the Immediate Requirement issued) that such a breach in the regulations will not reoccur. This will give us more assurance, in this area, that the home is managed with appropriate competence and skill. The registered provider has a quality assurance policy. However this did not appear to be available for inspection on this occasion. A survey of people who use the service has been completed and this resulted in positive feedback from people who use the service. Thank you cards have also been maintained on file. ‘Residents meetings’ took place in April 2007, September 2007 and March 2008. This seems a positive initiative to assist people who use the service express themselves about the service. Staff meetings have also occurred in March and October 2007. Some further monitoring needs to take place by the registered provider to ensure some of the regulatory issues highlighted in the report are checked, and either maintained or improved. Management subsequently need to consider refining their systems to ensure there are improvements in some areas (e.g. management of medication, recruitment checks, staff training and health and safety). How management do this should be included in the organisation’s quality assurance policy. The commission will be requesting a CSCI Improvement Plan as a consequence of this inspection regarding the requirements issued. Some small amounts of cash are looked after on behalf of people who use the service, and records are kept regarding these. However, it was not possible for the inspector to audit expenditure as receipts are not obtained. Subsequently the registered provider needs to ensure receipts are obtained, or if this is not possible in some cases, at least a petty cash voucher completed and signed by the registered provider. Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 25 Other monies of people using the service are either maintained via individual solicitors or people’s relatives via Power of Attorney arrangements. Otherwise people who use the service or their representatives are responsible for their finances, and fees are paid via bank transfer. Suitable insurance for the building and people using it appears to be in place. The registered persons have a health and safety policy. The home has a fire risk assessment. Emergency call points for the fire system appear to be tested appropriately. However emergency lighting- essential if there is a fire- need to be checked at frequencies agreed by the fire authority. This appears to have been regularly checked until 31.3.08, but no checks have been recorded since then. According to records the fire system was last serviced in October 2007. Health and safety risk assessments have been completed. There is a risk assessment regarding the prevention of legionella. As the registered provider was away on the date of the inspection, it is not clear whether appropriate checks are completed to minimise this risk. In the last key inspection report a recommendation was made regarding this and we have repeated it in this report. The stair lift was serviced in November 2007. The bath hoist was serviced in November 2007. The boiler was serviced in April 2008. A new gas cooker was also installed in April 2008, and a gas engineer should check this annually. The electrical circuit was tested in July 2006, and an electrical hardwire certificate has been obtained to state this was satisfactory. The registered provider tested portable electrical appliances in December 2007. It is satisfactory that the provider completes these tests, as long as the Environmental Health Officer is satisfied as to their competence regarding the tests performed. Some concerns have been raised in the ‘staffing’ section of the report regarding some aspects of health and safety training provided. Hollybush DS0000008930.V364404.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 X 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 27 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 OP9 Regulation 13(2) Requirement Timescale for action 01/09/08 2. OP29 OP18 OP31 7, 10, 12, 13, 19 The management and storage of controlled drugs needs to be improved with reference Royal Pharmaceutical Society Guidelines and Care Homes Regulations 2001. Issues outlined in the report need to be addressed. People who use the service can then be assured their drugs are appropriately stored and managed in a secure manner. The registered provider must 13/05/08 ensure suitable checks are performed on all new staff working in the home as outlined in the regulations (for example POVA First check, CRB /POVA check, two written references). Guidance issued by CSCI, and other statutory authorities must be followed. This will help ensure people who use the service are protected from people who are unsuitable to work with the vulnerable. Immediate Requirement (Previous requirement and timescale regarding POVA checks of 01/12/06 not met. DS0000008930.V364404.R01.S.doc Version 5.2 Hollybush Page 28 3. OP30 OP38 10(3),12, 13(5)(6) 16(2)(j) 18, 23(4)(5) 4. OP30 OP38 12, 13(4), 18, 19 5. OP31 7, 8, 9, 6. OP31 OP33 7, 9, 12, 13, 24 Second Notification) Staff must receive training required by law. Matters of concern outlined in the ‘staffing’ section of the report must be addressed. This will help ensure people who use the service receive appropriate care and support from staff, who have suitable knowledge and skills. It will also help ensure risks to people’s health and safety are minimised. The registered provider must ensure staff receive appropriate levels of first aid training, and there is always sufficient first aiders on duty at all times: 1. A risk assessment- in line with CSCI guidance- must be submitted to the Commission within the timescale (with an action plan as appropriate). 2. Confirmation of satisfactory levels of first aid cover, at all times, must be provided to CSCI. These measures will help to ensure people who use the service receive appropriate first aid support in an emergency situation, and help to minimise any risk to their health and safety. A registered manager must be appointed to manage the home on a day to day basis. An application must be submitted within the timescale. This will ensure suitable arrangements for the management of the home are in place according to the Care Homes Regulations 2001. Further develop the quality assurance system to monitor standards regarding medication, staff recruitment, staff training, DS0000008930.V364404.R01.S.doc 01/09/08 01/07/08 01/09/08 01/09/08 Hollybush Version 5.2 Page 29 7. OP35 13(6), 20 8. OP38 12, 13(4), 23 health and safety. Measures taken should be included in the quality assurance policy. This will help minimise risks to staff and people who use the service. Receipts must be provided for 01/07/08 expenditure carried out on behalf of people using the service. This will help to ensure there is suitable evidence that any expenditure on behalf of people who use the service is legitimate, and any risk of financial abuse of people’s monies is minimised. Make arrangements for 01/07/08 emergency lighting to be tested at intervals recommended by the fire authority. This will help minimise health and safety risks to staff and people who use the service. 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 OP10 Good Practice Recommendations Existing people who use the service should be offered a suitable lock and key for their bedroom door. People subsequently admitted to the service should also be offered this facility. This will ensure people who use the service can lock their bedroom door if they wish to improve security and privacy. The registered provider should develop a risk assessment, and protocols with other agencies regarding how allegations are dealt with, regarding a particular person who uses the service. Develop the staff application form so it includes all information required under the Care Homes Regulations 2001. The registered provider is advised to send a copy of the DS0000008930.V364404.R01.S.doc Version 5.2 Page 30 2. OP18 3. 4. Hollybush OP29 OP38 Legionella risk assessment to the Environmental Health Department (Health and safety) for advice whether any regular checks need to be completed by the provider or a qualified contractor. Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Hollybush DS0000008930.V364404.R01.S.doc Version 5.2 Page 32 - 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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