Inspection on 08/10/07 for Holywell Bay Care Home

This inspection was carried out on 8th October 2007.

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

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

Other inspections for this house

Holywell Bay Care Home 21/04/09

Holywell Bay Care Home 11/11/08

Holywell Bay Care Home 24/04/08

Holywell Bay Care Home 16/05/07

Holywell Bay Care Home 04/12/06

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

CARE HOMES FOR OLDER PEOPLE Holywell Bay Care Home Rhubarb Hill Holywell Bay Newquay Cornwall TR8 5PT Lead Inspector Ian Wright Unannounced Inspection 07:30 8 9 , 10 and 17th October 2007 th, th 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 Holywell Bay Care Home DS0000068129.V346016.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. Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holywell Bay Care Home Address Rhubarb Hill Holywell Bay Newquay Cornwall TR8 5PT 01637 830801 01637 831119 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) Newport Care Limited Post Vacant Care Home 45 Category(ies) of Dementia - over 65 years of age (45), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (45) Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 4 adults under the age of 65 years An application must be made to the CSCI by the home manager to become the registered manager within 6 months following the registration date. Date of last inspection Brief Description of the Service: Holywell Bay provides care and accommodation for up to 45 older people- all of whom may be diagnosed with dementia and/ or mental disorder. The registered provider is Newport Care Limited. A manager has been appointed but the Commission for Social Care Inspection has not yet received an application to determine fitness for registration. Holywell Bay care home is situated in the village of Holywell Bay, which is on the north coast of Cornwall near the town of Newquay. The home has pleasant views of the sand dunes, golf course and sea. The home is a large two-storey property which has been extended. There is a choice of communal areas for example a large dining area, which also has a seating area, a large lounge, a TV lounge, and a smoking room. There are also other rooms which the manager said the provider is planning to redecorate so they can be used. The home also has an enclosed garden which residents can use. At the time of the inspection fees were in the region of £500 per week. Additional charges are made for hairdressing, newspapers and personal items. A copy of this inspection report is available via the home’s management or the CSCI website. Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Key Inspection took place over twenty and a half hours over four days. All of the key standards were inspected. The methodology used for this inspection was: • To case track seven people who use the service. This included interviewing the people who use the service about their experiences and inspecting their records. • Interviewing seven staff about their experiences working in the home. • Informal discussion with staff and other people who use the service. • Observing care practices. • Discussing care practices with management. • Inspecting records and the care environment. Other evidence gathered since the previous inspection such as notifications received from the home (e.g. regarding any incidents which occurred) were 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: Although the manager and the registered provider have said they are committed to bringing about change, this inspection has resulted in twenty statutory requirements. The registered provider is required to take appropriate action, by law, within the timescales set. Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 6 In summary the registered provider must: • • • • • • • • • • • Improve documentation, policies and procedures (for example care planning, the service user guide, residents contracts, complaints and adult protection guidance.) Ensure medication is managed correctly. Improve the physical environment of the home including ensuring decorations and facilities are improved, and ensuring there are no offensive odours. Improve planned activities provided to people who use the service. Improve staffing levels. Improve recruitment and personnel information. Improve staff training. Ensure an application is submitted to the commission to ascertain if the manager is a fit person to be registered to manage the home. Improve quality assurance systems Ensure there is a monthly visit by the owners to the home to check standards. Ensure health and safety precautions meet legal standards. The commission will monitor progress regarding these legal requirements to ensure the registered provider complies with the regulations. The home is subject to the commission’s regional improvement strategy. Enforcement action will occur if satisfactory action is not taken within the timescales set. 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. Holywell Bay Care Home DS0000068129.V346016.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 Holywell Bay Care Home DS0000068129.V346016.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): 1, 2, 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered provider has developed a statement of purpose and a service user guide although these documents require some updating. Arrangements need to be made to ensure the service user guide is available to all people who use the service and their representatives. People who use the service are issued with a contract either via the social services department or the registered provider depending on who pays their fees. However all people who use the service who are funded privately must be issued with a suitable contract. All contracts-irrespective of the person’s funding source- must clearly specify information regarding nursing costs as outlined in the regulations. The provision of suitable information ensures people who use the service are aware of the services the registered provider offers. This information also helps ensure people who use the service are made aware of their rights and responsibilities. The registered provider’s assessment procedure is satisfactory. There is evidence that people who use the service are assessed before they are admitted to the home, however information obtained could be improved in some cases. Suitable assessment procedures ensure the registered provider Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 9 only accommodates people for whom the provider can suitably meet their needs. EVIDENCE: A copy of the statement of purpose was inspected and appears to provide satisfactory information regarding the service provided. A copy of the service user guide was inspected. A copy of the document is placed in the reception area, and is adequate. However the document needs to contain information regarding how people can make complaints if they are dissatisfied with the service. A copy of the complaints procedure is however on the notice board. The manager said, since she has been in post, people who use the service and their representatives, have been issued with a copy of the service user guide. She was not sure if people who had lived in the home for some time had this information. It is essential that all people who use the service and their representatives receive a service user guide as required by the regulations. A copy of either a social services contract (if the person is state funded) or the registered provider’s contract (if the person is privately funded) was contained in some of the residents’ files inspected. The manager presented the inspector with the company’s new contract. However this does not contain all of the information as required by the regulations. For example regulation 5a regarding nursing costs. Subsequently, where necessary contracts need to be reissued. These should not provide lesser security of residency or rights than the previous contract. Full information regarding what is required is contained in the revised Care Homes Regulations 5a (dated 01/09/06). The registered provider has a satisfactory policy regarding the assessment of potential residents. For example, one of the senior staff will visit the person before admission is arranged. Copies of pre admission assessments are contained on individual files. Assessment information contained in the files of people who use the service is generally satisfactory, but information needs to always be dated and signed. In some cases there is a copy of a social services or NHS assessment on files inspected. It is recommended this information is always obtained before admission is arranged. Holywell Bay Care Home DS0000068129.V346016.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 adequate. This judgement has been made using available evidence including a visit to this service. People who use the service have a care plan. However there needs to be improvement regarding the information contained in these and there must be improved evidence of review. Suitable care plans help to ensure people who use the service receive all the care they need, for example in a consistent manner. Health care needs appear to be generally met but care must be taken to ensure any support needs outlined in either assessments or care plans are met. There also needs to be clearer information, in some cases, regarding any interventions by external professionals. Improvement is required to the medication system. This will ensure people who use the service can be assured their medication is managed to a satisfactory standard. People who use the service generally said they felt staff worked with them in a manner, which respected their privacy and dignity, and this was also evident from the inspector’s observations. Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 11 EVIDENCE: Care plans for some people who use the service were inspected. These appeared to be generally adequate. The manager is implementing a new care plan system, but some work is still required until this is fully completed. Subsequently at the moment, there could be a lack of clarity until the system is fully implemented. Care plans need to have more information regarding specific care interventions required by staff. For example: • There was no information regarding the catheter care for one man. • There was limited information and guidelines for one lady who can challenge the service. • One lady needs to have a lap strap- this needs to be included as part of a risk assessment. • One resident is diabetic and insulin dependent, but it was very difficult to find information regarding this in the care plan. This information was not even explicit in the nutrition section of the plan. Such essential information must be readily available, particularly for the benefit of agency and new staff. Care plans also need to contain the following information: • All care plans need to have a photograph attached to them. Although most care plans had these, they were absent from some files. Photographs help staff or agency staff, who for example, are new to the service to be able to identify the individual. • There should be a life history and profile for each person. This should include for example whether the person has any family or friends, where the person lived before they came to the home, what their interests are / were, their occupation, any likes or dislikes, preferred times of getting up and going to etc. This will assist staff to get to know the person; particularly if verbal communication is difficult. • All care plans need to include a clear risk assessment regarding manual handling. Although these were present in all files, in some cases they need to be more detailed particularly if there is a risk of falls. • Regular and thorough review. Although a system is to be developed, current arrangements are not satisfactory. For example in some cases it has just been documented the date of review, and recorded that care is appropriate. Where possible review should include the individual concerned and their representatives. • There should be a record for any external medical interventions. These were only contained in some files. These should detail any appointments with GP’s, dentists, chiropodists, opticians, community psychiatric nurses, district nurses etc. This will help staff in the home to track when people who use the service last saw the relevant person. Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 12 • Although the home has a satisfactory pressure sore policy, there needs to be clear records of individuals who have pressure sores. Currently one person has pressure sores. Although people who use the service, who the inspector spoke to, did not appear to be aware of their care plans, all people who use the service said the care they received was appropriate and carried out in a manner according to their wishes and needs. One of the inspectors completed an informal one-hour observation at 07:30 on the first day of the inspection, and a two hour formal ‘dementia mapping’ exercise from 11:15 to 13:15 on the first day of the inspection. The latter involved the use of the Commission for Social Care Inspection’s ‘ Short Observational Framework for Inspection’ (SOFI) tool. This in essence is a ‘fly on the wall’ observational exercise where the inspector records, at five-minute intervals, levels of resident engagement, resident mood, and whether staff interactions are satisfactory for randomly picked residents. The inspector concludes that staff interactions were generally good, there was some evidence that residents were engaged in what was going on around them, and residents appeared to be generally happy. Staff appear to treat people who use the service as individuals, support people with their needs to a good standard, and interact with residents well. Staff did not appear to be too rushed, and even when they were, made as much time for individuals as they could. People who use the service appeared to be generally well dressed and supported well with their personal care. The Commission for Social Care Inspection is currently involved in an investigation regarding staff interventions when a resident had a fall and fractured her hip. There is not any other recorded incidents of concern regarding personal care on CSCI records. Health care support appears to be satisfactory. People who use the service said they could see a doctor or other medical practitioner when this is necessary. Nursing staff said residents can see appropriate medical professionals such as chiropodists, opticians, dentists etc. when necessary. The manager said she was trying to develop links with community nursing services via a link nurse system (e.g. for tissue viability, incontinence etc.) She said this had proved difficult. The inspector has since discussed the matter with the Primary Care Trust’s Assistant Director of Commissioning who said she would make arrangements for someone to contact the home regarding this matter. Staff also stated they felt they needed more support with managing challenging or difficult behaviour. The manager said she was setting up regular link meetings with the community psychiatric nurse, and it is planned there will Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 13 be a monthly ‘clinic’ with the psychiatrist. The inspector said management should put in referrals for psychology support for residents who challenged the service. Current resources are limited for this type of service, but the level of need has to be established, so the Primary Care Trust can respond appropriately. A requirement has also been made else where to improve training regarding aggressive and challenging behaviour. The inspector has spoken to the Team Leader of the district nurse service. District nurse assessments were completed on some people who use the service after the inspection. Some concerns were expressed to CSCI that: (1) Although the care plan format being introduced was basically good, staff may need further guidance to ensure essential information is readily available to staff. (2) One resident who is funded to receive 2 to 1 staffing currently may not be receiving this at all times. The person is also meant to be checked every twenty minutes at night, but records show the person is only being checked hourly. The person should also be under constant observation during the waking day. The person’s needs may now not be so high and subsequently the Community Psychiatric Team will reassess the person. (3) Residents may not be being toileted as much now as when assessments were completed several months ago. These matters have been discussed with management. The medication system was inspected. Medication is administered via a monitored dosage system. Storage is satisfactory for most drugs. The pharmacist visited the home in May 2007 to assess the medication system and said it was satisfactory. However, on this inspection, CSCI assessed that some improvement regarding the operation of the system is required. For example: • The registered provider’s medication policy needs to be updated and reviewed. The policy needs to be specific for this home. It should include information regarding management of medication stored in the refrigerator, staff training and delegation of duties to non-qualified care staff. A copy of the updated policy should be forwarded to the commission. • Guidance regarding home remedies (i.e. non prescribed items) needs to be available. The manager said this matter is currently being addressed. • There needs to be clear protocols for individuals who receive PRN (‘as required’) medication. When PRN medication is administered it should also be recorded why it was administered either on the back of the medication sheet or the person’s daily notes. Such measures could protect staff and the registered provider from allegations of abuse. • There needs to be a specific cupboard for controlled drugs. • Royal Pharmaceutical Guidelines regarding the management of medication need to be available to staff. The following link is to the new guidance on this matter. Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 14 • • • • • • • • • • http:/www.rpsgb.org/pdfs/handlingmedsocialcare.pdf Consent forms need to be developed to authorise staff to administer medication for people who use the service. Recording of medication needs improvement. For example there were some gaps in records of medication administered. Disposal of medication needs to be improved. This should occur via a specialist waste disposal company. There needs to be clear disposal records. The date when creams are opened should be recorded on packages. Patient information leaflets need to be kept for all medication prescribed including medication within the monitored dosage system. Where medication is transcribed to medication sheets, this should be signed by two persons, should state the person who directed any change in instructions and any handwritten entries should be cross referenced to daily notes. Training should be improved. For example staff who administer medication should receive basic training during induction, and formal training for example from a pharmacist. There should be a record confirming when qualified staff are confident care staff are competent to administer creams. Information regarding training requirements this can be obtained on the CSCI website at: http:/www.csci.org.uk/professional/default.aspx?page=7328&key= There needs to be improvement in how medication pots are washed and dried. For example this should be completed in a specific bowl and not left to dry on the drainer. Insulin should be stored according to manufacturers guidelines for example between 2 and 8 degrees centigrade. Emergency equipment such as the nebuliser needs to be more accessible, plugged in and checked daily. Most people who use the service spoke positively regarding the attitude of staff. However a minority of people living in the home were not totally satisfied by a minority of staff attitudes at times. These matters have subsequently been discussed with the manager. The inspectors felt positive about staff attitudes and practice. Staff appeared to treat people who use the service with dignity and respect throughout the inspection. Staff were observed knocking on the doors of people who live in the home, before entering. Holywell Bay Care Home DS0000068129.V346016.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 generally good, although some improvement is required to provide residents with more activities. This judgement has been made using available evidence including a visit to this service. Routines are flexible to meet the needs of people who use the service although management should monitor residents are given choice regarding when they get up and go to bed. More opportunity for activities need to be offered and it is recommended an activities worker is appointed. These measures would help to ensure people who use the service can have a daily routine that suits their needs and have various opportunities for social activity. People who use the service have opportunity to receive visitors. People who use the service are encouraged to make some choices regarding how they live their lives- although in many cases individual capacity may be limited. Arrangements for meals are good and ensure that people who use the service have a varied and wholesome diet. EVIDENCE: The first day of the inspection started at 07:30 so the inspector could observe the morning routine. This was relaxed, but organised. When the inspector arrived at the home, thirteen of the twenty-four people accommodated were up and dressed. Staff said to the inspector that where residents are awake and wish to get up, they are given this assistance. The residents accommodated in Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 16 the home are very dependent and staff said that some residents do not sleep very well. The inspector was told that subsequently staff will help them to get ready and enable them to come downstairs where they will be safer than alone in their bedrooms. Some people who use the service who the inspector spoke to said they could get up and go to bed when they wished. No people who use the service expressed concern regarding having to get up when they did not want to. However one lady said two staff had tried to get her to go to bed at a time when she did not want to go, and had been upset by this. This matter has been discussed with the manager. Management need to monitor the situation to ensure people who use the service have a choice regarding the time they get up and go to bed. . Preferred times of getting up and going to bed need to be recorded in individual service users’ care plans. On the first morning of the inspection the residents who were up seemed happy, and personal care appeared to be delivered to a good standard. People were served with a cup of tea, and breakfast was served at 0800. The breakfast served was to an excellent standard. People will offered grapefruit to start, followed by a choice of cereals followed by eggs on toast. Residents all seemed to enjoy the food provided, and some people had seconds of some of the courses. Staff appeared caring and were attentive to any requests. Staff support was professional, relaxed and unhurried. A further ‘dementia mapping’ type observation was carried out later in the morning. This used the Commission for Social Care Inspection’s SOFI tool. An outline this methodology is included in the previous section of the report. The two-hour observation concluded staff support is good, staff individualised care and appear attentive to peoples’ needs. People who use the service seem happy. Although there was no organised activity during the period of observation, on the whole the individuals observed seemed engaged in activities which had a purpose to that individual. There are only limited activities available to people who use the service. There were no structured activities available on the days of the inspection. Some people who use the service said they were happy to arrange their own time. For example one man spent most of his time in his room, had purchased a ‘state of the art’ television and seemed happy to amuse himself and his time. He was very positive about the support provided and said staff were very nice and treated him ‘like a human being’. Staff said they do organise some activities for example one to one art. Records of activities provided had been kept but this had lapsed over the last few months. Some of the staff said some people who use the service were able to visit the aquarium in Newquay, and there are also other trips out occasionally for example to the local zoo. Some of the staff said it was difficult to motivate some of the residents to participate in activities. With current staffing levels it may also be difficult for staff to organise activities due to the pressures of peoples’ personal care needs. One person received funding for two to one staff Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 17 support, but from observation and her records it did not appear she is receiving this. One of the staff said a Christian group come to the home on a weekly basis, which is of benefit to the people who use the service. A religious minister also visits the home on a regular basis. Although the door from the main dining room to the hallway is locked, people who use the service could move between several rooms and the garden during the day- without supervision- unless this is required for safety reasons (e.g. due to the risk of falls). The registered provider must ensure people who use the service have more activities. These should be of benefit to people with dementia. It is recommended the registered provider employs an activities co-ordinator. Either one full time or two part time dedicated staff would be able to provide either one to one, or small group activities to those people who were interested. Training and guidance could enable staff to give some residents further opportunity to be involved in basic tasks such as baking, laying tables or helping with drying up dishes. The provision of a daily newspaper, local newspapers, magazines etc. could help residents keep some contact with the wider world. There are many other simple activities, facilities or equipment that could be provided, which would assist residents to have more stimulation throughout the day. For example considering all the space available in the home there could be a residents’ shop. Other opportunities such as visits from entertainers, school choirs, and / or The Women’s Institute etc. would help develop a more stimulating environment. The manager said she planned to set up a sensory room, re-establish the home’s Chapel and hairdressing salon, and perhaps get local army officers to visit from the local base. It is also planned to clear part of the garden to enable people who use the service to be able to do some gardening if they wish. Several people who use the service received visitors on the days of the inspection. The inspector spoke to some of the relatives who were positive about their relatives care. Considering the size of the building, and the number of unused rooms available, it would be beneficial for an additional quiet lounge be provided where people could receive visitors. Due to the nature of peoples’ mental health needs and/ or level of dementia capacity to enable choice is limited. There are some physical restrictions in the home which do prevent freedom of movement. Staff state this is to help ensure the safety of individuals. For example doors to the bedroom corridors are alarmed, and one of the bedroom doors of a resident’s room is alarmed. There is a keypad on the lounge door which connects to the corridor and a keypad on the front door. Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 18 If the manager has not already done so, these restrictions need to be risk assessed- for example within the registered provider’s health and safety risk assessment. Any restrictions on individuals also need to be risk assessed, and regularly reviewed as part of each individual’s risk assessment. Where people who use the service do have capacity, action needs to be taken to ensure these people are not subjected to unnecessary restriction. The principles of the Mental Capacity Act 2005 need to be adopted in regard to any restrictive practices. Senior staff have attended training regarding this legislation so they should be familiar with what is required. This matter will be fully inspected on the next key inspection. It is therefore recommended any restrictive practices are reviewed in line with the new legislation. People who use the service said they were generally happy with staff enabling them to make choices. However a minority of people did raise concerns as outlined earlier in the report. Another lady the inspector spoke to said she would like to move nearer to the Camelford / Launceston area where she came from. This matter has been discussed with the manager and it has been suggested the Department of Adult Social Care are approached so the person can be reassessed, and any other accommodation options explored. Staff were observed by the inspector as caring and enabling. It is obviously difficult at times balancing the need to give a full range of choices, with the need to keep people safe due to their health needs and /or cognitive ability. However staff must do their best to reach this balance and give people living in the home a full range of choices wherever this is possible. This is unless a reviewable risk assessment states restrictions needed to be in place. The inspector observed people who use the service having their breakfast and their lunch. The inspector did not share a meal with people who use the service on this occasion, but food looked appetising and nourishing. The substantial breakfast is described earlier in the report. Lunch on the first day of the inspection was home made meatloaf and vegetables, followed by semolina. The people the inspector spoke to said they thought food was to a good standard. The manager of the home said the menu had recently been reviewed, and a new cook had been employed. Where appropriate fluid and records of food eaten are kept for individual residents. Support provided at meal times by staff to residents is to a good standard. Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 19 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 poor. This judgement has been made using available evidence including a visit to this service. The registered provider needs to improve its complaints and adult protection procedures. Suitable complaints and adult protection policies should assist in ensuring people who use the service can be assured any concerns, complaints or allegations are taken seriously and dealt with effectively. Some improvement is required to pre employment checks to ensure staff are checked as suitable to work with vulnerable people. Some staff need to receive basic training regarding prevention of abuse and adult protection. This will help to ensure people who use the service, are protected against having staff working with them who are unsuitable to work in a care environment. EVIDENCE: The registered provider has a complaints procedure. However this needs amending for example to state complainants can approach the Commission for Social Care Inspection at any time. It would also be helpful if the policy, and it’s summary which is displayed in the hall, included the address of the registered provider. The CSCI address also needs to be updated on all documentation now CSCI is based in Ashburton, Devon. The registered provider has a complaints file. This documents three complaints received by the management in 2007. One is regarding the outside decoration of the home, one the care of one of the people who use the service and one regarding the attitude of a member of staff. These appear to have been Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 20 responded to. No complaints have been received by CSCI since the last key inspection in, although CSCI completed a random inspection on 11th July 2007 to investigate a concern raised regarding the support received by a resident prior to her death. Concerns were not substantiated, and it was concluded the registered provider acted appropriately. The registered provider has an adult protection policy. However the process to be followed if there is an allegation of abuse is incorrect. Any allegations once reported to management, should be referred to the Department of Adult Social Care. This agency will then take the lead in deciding how to investigate the matter, although the registered provider may deem it appropriate to suspend staff as an interim measure. The policy therefore needs to be changed. The policy should pay reference to local authority procedures and the Department of Health’s ‘No Secrets’ guidance. The Department of Adult Social Care guidance can be found at: http:/www.cornwall.gov.uk/index.cfm?articleid=14581 The Department of Health guidance can be found at: http:/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPol icyAndGuidance/DH_4008486 CSCI visited Holywell Bay care home on 25th June 2007 to inspect regarding concerns raised under Cornwall County Council’s adult protection procedures. Although no statutory requirements were issued, the commission was concerned regarding the lack of records available regarding disciplinary action taken regarding a member of staff, and the delay in the registered provider bringing the allegations forward. The commission was concerned management and staff did not at the time understand adult protection issues. It is acknowledged a new manager is now in post who has said she is trying to improve procedures. Some staff have received training regarding adult protection. Of fourteen staff records assessed, seven staff had a record of receiving this training. Further work needs to be completed in this area so all staff have received this training. Such training is available from Cornwall County Council (Department of Adult Social Care). Information regarding this can be found at: http:/www.cornwall.gov.uk/index.cfm?articleid=37718 A matter regarding one person who uses the service is currently under investigation by the Department of Adult Social Care. The matter is in regard to the circumstances how a resident broke their hip. The Commission for Social Care Inspection is involved in the investigation to ascertain if their are any breach in the care home regulations. Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 21 The majority of staff have received a Protection of Vulnerable Adults ‘First’ check (POVA First) and Criminal Record Bureau records (CRB) check. The inspector assessed the employment records for fourteen staff. Twelve staff had appropriate checks. Records of checks were absent for two staff, although there appeared to be records that an application may have been submitted for one of the staff. The manager said she was sure checks had been completed for all staff, but filing was very poor when she took over the management of the home. She said she had subsequently asked for the staff concerned to bring in their copy of the checks completed. If necessary the checks must be reapplied for as a matter of priority. Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 22 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, 20, 21, 22, 23, 24, 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Holywell Bay potentially provides a suitable facility to provide care for elderly people. However the building is very neglected, run down, and need refurbishment and redecoration. Bathroom and toilet facilities need improvement to offer suitable facilities to the frail and elderly. Current standards deflect from the generally satisfactory standard of care, which is provided at the home. However the building is clean and relatively homely. There was however an unpleasant smell in the communal rooms. With considerable improvement and financial investment, Holywell Bay could provide suitable facilities to meet the needs of people living there. EVIDENCE: The building was inspected. Holywell Bay is a large building with considerable potential as a care facility. There are several communal rooms. A large lounge, a large dining room with a lounge area, a TV lounge, a smoking room, a Chapel room (currently not used) and a hairdressing salon(currently not used). The garden is readily accessible to people living in the home, and was being Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 23 used by some residents on the days of the inspection. Bedrooms are primarily situated along two long corridors. There is a large kitchen, and laundry areas. The home has a sluice facility. There has been some redecoration of the lounge, dining room and the TV room. New furniture has been purchased, and these rooms are relatively homely. It is excellent the registered provider has a smoking room for residents who need this. However, the room is in very poor condition and needs complete renovation. There is also a ‘Chapel’ room which the manager has said it is planned to refurbish. It may be worth this area being an area for residents of quiet contemplation . It could then be used for Christian services, and also for other faiths, or for contemplation by those who do not have a religious faith. It should remain an area for residents’ use. Some of the toilet facilities, although clean need refurbishment to make them more appropriate for the resident group, and also more welcoming facilities. Some of the toilets did not have a lock on the door. These need to be fitted with an overriding facility where necessary. Bathroom facilities are unsatisfactory. Although many of the bedrooms have bathroom facilities, these are in many cases inappropriate for the resident group accommodated. Currently there are only two working bathroom facilities for twenty-four residents. Upstairs there is a bath with a chair lift. This may be difficult to use for some people who are frail or who have a physical disability. This bathroom has no frosted glass, and the only privacy residents have is a curtain. There is a ‘Mecamaid Ambulift’ in this bathroom. Although there is another hoist in the bathroom, the Ambulift was last serviced in May 2006, and the label states it needs to be serviced again in November 2006. No records were produced in the office to state this equipment has been serviced. There are satisfactory records regarding the servicing of other moving and handling equipment. There is a Parker bath on the ground floor, but the bathroom it is situated in is on the small side, and the bathroom is situated away from many of the bedrooms. Some staff said they only use the upstairs bathroom, although the manager said both bathrooms are used. The national minimum standard states there should be at least one assisted bath / shower to every eight people living in the home. All bedrooms were inspected. The manager has said there is a programme of upgrading bedroom facilities. There is a need to improve standards of many of the bedrooms. For example: • In some of the bedrooms, furnishings, curtains and carpets are very worn and in need of replacement. Many of the rooms need to be redecorated . Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 24 • • • • • • There was dry staining on the ceiling in room 14A. The manager said there was a leak but this has been repaired and the room will be repainted. Many of the bedrooms do not have a lock, and it is not clear whether residents have a lockable facility e.g. for personal possessions or valuables. Where appropriate residents need to be offered these facilities. If it is not appropriate it should be recorded in the persons care plan the reasons, and this should be accompanied by a risk assessment if the person lacks capacity. The door to room 20 is very stiff and needs to be either replaced or repaired. There is a smell of urine in at least one of the bedrooms. Appropriate cleaning arrangements need to be in place to avoid offensive odours. Many bedrooms had rugs which were curling at the edges. These present a significant hazard to people who use the service. An immediate requirement was made regarding their removal, and if necessary there replacement. On the final day of the inspection, the manager said these had been removed. The lift is small, and it is difficult to fit a wheelchair and a carer in it at the same time. Records show it has required maintenance on several occasions in the last year. On the service record some action was required by the maintenance company, and it was unclear whether this had been taken. However, the manager said this action had been taken and the lift was now in good working order. The manager has completed an audit of current standards. This has ascertained where redecoration, windows, furniture and carpets need replacing. Suitable action subsequently needs to occur within a reasonable timescale to bring residents bedrooms up to standard. Any refurbishment and redecoration should take account of guidelines for care homes for people with dementia. There are many publications available which would be useful for the registered provider to look at. For example-Dementia Voice: http:/www.dementia-voice.org.uk/index.htm or the Dementia Development Centre Stirling: http:/www.dementia.stir.ac.uk/publications/design_housing.htm Other organisations may be able to offer assistance or sell publications, which will offer advice regarding suitable design for homes for people with dementia. There are a significant number of rooms in the home which are currently not being used. Many of these were being used for storage. Many of the rooms are very untidy, potentially hazardous particularly people who use the service, and could present a fire risk. The manager said the home is currently storing the belongings of one resident, and is liaising with family and the Department of Adult Social Care regarding what happens to these items. This seems reasonable, but the rooms used for Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 25 storage should be locked so the belongings are safe, and to minimise any risk to residents. The other rooms for storage need to be cleared out (if the contents are no longer required), tidied, and at least locked to prevent risk to residents. The outside of the building is in a very poor state of repair and decoration. For example: • The outside is currently being painted, but progress is slow and only part of the front of the building has currently been painted. • Some of the staff have said the windows of the home need to be replaced. Although restrictors appear to be placed, on some of the ground floor windows, they may only be restricted via the internal double-glazing. It is therefore questionable whether this would prevent an intruder being able to override the restrictor to gain entry. There was no restrictor on one of the windows in the upstairs bathroom. • There was a large crack in the glass of one of the fire escape doors. • The enclosed garden is a very good facility, but looks neglected and needs to have some work done on it to make it a pleasant facility for residents use. • The woodwork to the main front door needs replacing. At the beginning of the inspection, the main front door did not shut automatically via the door closer due to the wood being warped. The manager said she was aware work was required. An immediate requirement was made on 9th October 2007 to ensure entry to the building was secure. Appropriate action had been completed by 10th October 2007. Two comments were noted that the new chairs were resulting in some problems for residents: • The relining chairs do not stay up, and do not take the weight of the residents’ legs, causing them to slip out. • One resident was unable to touch the floor in the chair she was sitting in. The Manager said the chairs are two heights and she would ensure the person got the appropriate chair. Otherwise the lengths of the chairs will need to be adjusted so residents can use them safely and the risk of falls is minimised. • One lady slips down her chair. The manager said a referral had been made to the physiotherapist regarding this matter. As these matters are a health and safety issue, they need to be attended to as a matter of urgency. The Commission for Social Care inspection has issued requirements to address these matters. A timescale of 01/10/08 has been given for the refurbishment of the building. The registered provider has said he has spent a significant amount of money to improve facilities since taking ownership of the home. However, the commission however requires a full action plan regarding how the matters above will be addressed. This needs to be sent to the commission by 01/12/07. In drawing up the action plan (unless works have already been Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 26 completed by this deadline) the registered provider needs to show how they intend to prioritise the most important matters. The commission will monitor progress over the next year to ascertain what action is being taken, and may issue further requirements or enforcement notices if satisfactory progress does not occur. The registered provider should also update the commission in the regulation 26 monthly visit reports regarding progress regarding these matters. The home appeared to be generally clean on all days of the inspection. The manager said a new carpet cleaner had just been purchased. However, there was an unpleasant smell in the lounge, TV room and dining room. Appropriate action must be taken to ensure there are no unpleasant odours in the home. Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 27 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 poor. This judgement has been made using available evidence including a visit to this service. Staffing levels are adequate, and issues below need addressing to ensure people who use the service receive appropriate levels of support when they need it. Recruitment needs improvement to ensure essential checks are carried out and appropriate documentation is maintained in the home. Staff training also requires improvement so staff have appropriate knowledge and skills to support people who use the service. EVIDENCE: On the first day of the inspection the following staffing was provided: • • • • A registered nurse throughout the waking day and night. (A second registered nurse is currently on duty each day from 0800 until 1600.) Five care staff from 0800 to 2000. Three care staff on duty from 2000 to 0800. Ancillary staff (e.g. maintenance, cooks, cleaners, laundry staff) In addition the registered manager and an administrator were working in the office. Similar staffing was provided on the other days of the inspection. Rotas indicate staffing levels are adequate considering the number of people who are currently accommodated. The SOFI observation, on the first day of the inspection, showed although staffing levels were satisfactory to provide basic care, there was insufficient Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 28 staffing to provide people with activities. A recommendation is made to employ an activities co-ordinator. The observation also showed at least another member of staff could have been deployed in the dining room to assist residents (It is not clear whether this was a matter of redeploying a staff member from the lounge, or whether this would not be possible as these staff were fully utilised). A query has been raised with management regarding the support needs of one person who is meant to have 2 to 1 staffing. The person did not receive this on the day of the inspection. CSCI understands this person will now be reassessed by the care trust as a result of this inspection. People who use the service were generally positive regarding the support they received from staff. Some concerns however were raised by people who use the service, and these have subsequently been discussed with the manager. The manager said some of the concerns might be not correct due to the people’s mental state. However this should not be assumed, allegations should be taken seriously and investigated appropriately. The staff, the inspector spoke to, said they did not believe there was any bad practice in the home, and felt staff worked well as a team. The commission are currently assisting other agencies to investigate the circumstances how staff dealt with an incident when a resident had a fall which resulted in a fractured hip. The registered provider has a suitable approach to enabling staff to have the opportunity to obtain a national vocational qualification (NVQ) in care. The registered provider has stated on the CSCI Annual Quality Assurance Assessment AQAA) [An annual return which registered provider’s are required to return to CSCI] that 94 of staff are working towards an NVQ 2 or 3 in care. It however is not clear how many people currently have this qualification, the manager needs to ascertain this, and ensure the appropriate certificate is placed on file. Recruitment checks completed when staff are employed need significant improvement. The records of fourteen staff (i.e. all the staff on duty on 23rd September 2007, and 8th October 2007) were inspected. This included one member of staff that commenced employment in September 2007. Records show most staff have an application form, copies of two references, and some records regarding training received. However, there is no evidence that some staff have, as required by the regulations; • Proof of identity (although this must be seen in order for the person to apply for a CRB). • An full employment history (for example this was not available for the member of staff who commenced employment in September 2007.) Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 29 • • • Two references (for example for four staff who started in 2006 and 2007 (including the member of staff who commenced employment in September 2007.) Three staff who commenced employment since 2006 (including the member of staff who commenced employment in September 2007.) did not have evidence of a POVA First check and CRB check. (Practices regarding other staff including those who started in the same period were satisfactory). There was not satisfactory evidence that two of the nursing staff had satisfactory nursing registration (i.e. an up to date Nurses and Midwifery Council PIN number). The manager said, when she took over the management of the home, that records needed significant improvement and it had taken her a lot of time to find most of the records. She said, for example, she was sure all staff employed had a POVA / CRB check, but could not find where these had been filed. Training records were also inspected for the same sample of employees. By law all staff must have: • Regular fire training in accordance with the requirements of the fire authority. • There must always be at least one first aider on duty (at appointed person level). • All staff must have manual handling training. • All staff must have basic training in infection control. • If staff handle food they must receive training regarding food hygiene. • All new staff must have an induction and there should be a record of this. Records kept to evidence appropriate staff training need improvement. There are significant gaps in training required by regulation. For example: • Fire Training. Eight staff had received some fire training, but records show only six of these had training in the last year-as required by regulation. There were no records other staff had received this training. • First Aid. Although there is always a nursing member of staff on duty there is no evidence that they have received a refresher in first aid, or management have verified their competence. Five care staff had received a first aid certificate, although two of these certificates were now out of date. • Manual handling. Twelve staff had received some manual handling training. However three of these staff had only had ‘video training’ and it was not clear if any physical instruction / demonstration had occurred. Six of the staff had received training in the last year. • Infection control. Three staff in the sample had received training in this area. • Food hygiene. Five staff in the sample had training in this area. Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 30 The manager said cooks had a food hygiene certificate. The manager said she had completed a manual handling ‘training the trainers’ certificate and plans to train the staff in this area. It is important manual handling training is comprehensive, a copy of the outline of training programme people will complete is available, and there is evidence the training programme has been completed by staff. Staff also need to receive training regarding the needs of people with dementia and mental health needs. There is also a need for staff to receive training regarding challenging behaviour. Currently seven staff in the sample have received some training in dementia. No care staff in the sample had received training regarding mental health, and only one member of staff had received training regarding challenging behaviour. Of the sample there is evidence that three members of staff had a written record of an induction (one person in 2003, one person partly completed in January 2007 and one person in 2007). No records were available for other staff. The manager presented an induction checklist, which looked comprehensive which she said she planned to use with new staff. It is of concern, the registered provider’s Crisis Manager wrote to the Department of Adult Social Care on 29th May 2007 stating staff training would be assessed and delivered (for example a timetable was attached). Although training sessions were held, the required training was not delivered to all staff. This situation must be rectified as soon as possible. Although the commission has provided a relatively generous timescale for action, it is essential that the registered provider prioritise thorough training for all staff regarding fire, moving and handling and first aid so people living in the home are not put at significant health and safety risk. The registered provider must provide the Commission with an action plan no later than 01/12/07 regarding how it is intends to meet the requirement within the timescale. Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 31 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 poor. This judgement has been made using available evidence including a visit to this service. Management arrangements currently do not meet regulatory requirements, as the current manager is not registered with the Commission for Social Care Inspection. Having an approved registered manager in charge of the home will ensure there is a legally accountable person managing the home on a day-today basis. The management of quality needs improvement to ensure standards are improved in the home, as outlined elsewhere in the report. The commission however acknowledges the registered provider has owned the home for less than a year, and appears committed to improvement of standards in the home. A monthly report of visits completed by the registered provider, or their appointed representative, is required by the commission as outlined in the regulations. The registered provider appears to have a generally satisfactory system of managing resident monies. The Department of Adult Social Care have Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 32 expressed some concerns regarding the management of one person’s finances which requires clarification. The management of health and safety needs improvement so people who use the service can be assured they live in a safe environment. EVIDENCE: The registered provider is Newport Care Limited. A manager has been in post for several months, although the registered provider still needs to submit an application to assess her fitness with the Commission of Social Care Inspection. The manager and registered provider said the reason for the delay was that the manager was serving her probationary period. A ‘Crisis Manager’ is also employed to assist the manager and the registered provider to bring the home up to required standards. The registered provider has stated the Crisis Manager will be eventually based at the home to assist with bringing it up to standard. The registered provider has a quality assurance policy, which is satisfactory. The manager has introduced regular staff and nurses meetings. The registered provider has returned the Annual Quality Assurance Assessment (AQAA) form to the Commission for Social Care Inspection. This has been completed to a good standard, and outlines positive plans to improve the service. The manager has also completed a survey of staff , residents and their representatives. Comments made are positive about the service provided, and the new manager. There are also a number of ‘thank you’ cards on file from relatives. The registered provider is required to complete a monthly visit to the home to assess the quality of service. This is required under regulation 26 of the Care Homes Regulations. There is evidence that one visit was completed on 31/7/07. These visits need to completed each month and it is requested a copy of the report is forwarded to the commission. Policies and procedures, unless stated elsewhere in this report, appear to be satisfactory. Policies should also have details of the CSCI office now this is situated in Devon. A copy of the current insurance certificate for the home was inspected. Management of the monies of people who use the service is generally satisfactory. Management look after some money on behalf of people who use the service. The registered provider acts as appointee for one person who lives in the home. The registered provider said the person’s next of kin did not want to be involved with the management of the person’s finances. The registered provider is requested to write to the Department of Adult Social Care regarding this arrangement as the department still has concerns regarding the arrangement. The manager and registered provider said they did not act as Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 33 appointee for any other residents monies or benefits. The registered provider said staff do look after some valuables on behalf of people who use the service, but records are kept regarding this. Records of cash looked after on behalf of people who use the service are satisfactory. The registered provider has a health and safety policy. The fire prevention system and fire extinguishers have been serviced. The home has a fire risk assessment, which was developed in December 2005. Staff regularly test the fire alarms, although there is no record of staff testing the emergency lighting system. Health and safety risk assessments have been completed. These are to a satisfactory standard. Some health and safety risks regarding new furnishings are highlighted in the ‘environment’ section of the report. This matter needs to be risk assessed and subsequently addressed. There is also not a risk assessment regarding the prevention of legionella. The manager has now set up a system to clean showerheads and run any taps which may not regularly be in use. The Health and Safety Executive publishes useful publications regarding what else needs to occur regarding this matter; for example see: http:/www.hse.gov.uk/pubns/indg253.pdf Advice can also be sought regarding this matter via the Health and Safety Executive, which is the regulatory authority regarding this issue. The local authority has tested the home’s private water supply on 9/9/2006, and has issued a certificate to state this is safe. An Immediate Requirement was issued on the first day of the inspection because mats in several of residents’ bedrooms were curled at the corner, and presented a trip hazard. The manager has subsequently said these have been removed, and confirmation of this is required, in writing, by the commission. The passenger lift now appears to be satisfactorily maintained, for example this was last serviced in September 2007. The report stated the handrail should be renewed and the isolator on the top floor should be renewed. There were a number of call outs prior to the service, but the manager said all of the maintenance company’s recommendations have been acted on. There are suitable records that gas appliances have been serviced and remedial action has been completed. The company that services the oil-fuelled appliances has stated on 19/4/07 that action needs to occur regarding moving the oil tank. The registered provider needs to inform the Commission for Social Care Inspection what action it will take regarding this matter. Portable electrical appliances appear to have been tested, although records to evidence this were only available in part. The electrical hardwire circuit has been tested in 2006, and the report states the circuit is satisfactory. Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 34 Suitable records of servicing of bath hoists, mobile hoists and specialist beds are maintained. This equipment was last serviced in September 2007. However there was one hoist in the upstairs bathroom which did not appear to have been serviced. The manager said this equipment is no longer used and will ensure the equipment is removed from the bathroom. The manager said the emergency call bell system has been serviced, although no certificate was produced to evidence this. This must be available for inspection and forwarded to the commission within the timescale. The manager thermometer testing water subsequently said the boiler controls the temperature of hot water. A was available in the upstairs bathroom, but no records regarding were available at the time of the inspection. The manager has introduced a system. The Environmental Health Officer last visited the home to inspect food standards in May 2007. Some requirements were issued in the report. This included implementing ‘Safer Food, Better Business’ guidelines. Infection control procedures appear to be satisfactory although some improvement regarding staff training is required in this area. Accident reports appeared to be completed to a satisfactory standard. The manager said she planned to set up a system of auditing accidents (and thus assisting in the process of minimising these in future.) One accident should have been reported to the Health and Safety Executive under RIDDOR regulations. A requirement has been issued to the provider to action this as soon as possible. A copy of this form should be sent to the commission. Training in various aspects of health and safety need to take place so the registered provider meets legislative requirements (e.g. moving and handling training, fire training). This is outlined in the previous section of the report, and some of this training needs to be delivered as a matter of priority to ensure people who use the service are kept safe. Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 35 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 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 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 1 1 2 1 1 X 1 X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 1 Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 36 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 OP1 OP2 Regulation 4, 5, 5(a)(b), 6 Requirement Timescale for action 01/01/08 2. OP7 15 The registered person shall produce a written guide to the care home (in these Regulations referred to as “the service user’s guide”). (i)This should include information as outlined in the regulations including the terms and conditions of accommodation, personal care and nursing care. Full information of what is required in this documentation is outlined within the regulation. (ii) The registered person shall supply a copy of the service user’s guide to the Commission and each service user. (iii)Where a local authority has made arrangements for the provision of accommodation, nursing or personal care to the service user at the care home, the registered person shall supply to the service user a copy of the agreement specifying the arrangements made. The registered person shall: 01/01/08 • After consultation with the resident, or a DS0000068129.V346016.R01.S.doc Version 5.2 Holywell Bay Care Home Page 37 3. OP8 12, 13 4. OP9 13(2) representative of her/ his, prepare a resident plan for each resident outlining the resident’s needs in respect of their health and welfare. • Make the resident’s plan available to the resident • Keep the resident’s plan under review • Where appropriate and, unless it is impracticable to carry out such consultation, after consultation with the resident or a representative of his, revise the resident’s plan; and notify the resident of any such revision. (For example the registered provider must address the issues outlined in the report regarding care plans and care plan review) 01/01/08 The registered provider shall ensure that the care home is conducted so as to promote and make proper provision for the care and where appropriate, treatment, education and supervision of service users. (For example matters of concern outlined in the report must be addressed. Service users must receive care and support as outlined in initial pre admission assessments, any multi disciplinary assessment and as outlined in individual care plans) The registered person shall make 01/01/08 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. (For example: • The operation of the medication system needs improvement as outlined in the body of the report. DS0000068129.V346016.R01.S.doc Version 5.2 Page 38 Holywell Bay Care Home 5. OP12 16 (2) (m) 6. OP16 22 7. OP18 13(6) These matters must be addressed within the timescale set. • Any staff administering medication must have training such as from a pharmacist.) The registered persons shall 01/03/08 consult with residents about their social interests, and make arrangements to enable them to engage in local, social and community activities. The registered person shall 01/01/08 establish a complaints procedure to consider complaints made to them by a service user or the person acting on the service user’s behalf. (For example the procedure must include, and consider the matters raised in this report, and also matters required by law, as outlined in the regulation i.e.22(1)-(8). ) The registered person shall make 01/01/08 arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. (For example the registered provider must: • Have a suitable adult protection policy and procedure. A copy of the policy should be forwarded to the Commission within the timescale. • Make arrangements for staff to have training regarding the prevention of abuse) (In regard to trainingprevious timescale of 31/08/07 not met Second Notification) Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 39 8. OP29 OP18 18. 19 9. OP19 16, 23 (2) (b)(d) (l)(o) From the date of the report, the 01/01/08 registered person shall not employ a person to work at the care home unless the person is fit to do so. Satisfactory checks must be completed on the person to ascertain this. (For example a Protection of Vulnerable Adults ‘First’ check and a Criminal Records Bureau check etc. as outlined in Schedule 2 of the Care Homes Regulations 2001). The registered person shall 01/10/08 having regard to the number and needs of the service users ensure that— (1) The premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally; (2) All parts of the care home are kept clean and reasonably decorated; (3) Suitable provision is made for storage for the purposes of the care home; (4) External grounds which are suitable for, and safe for use by, service users are provided and appropriately maintained; (For example the registered provider needs to provide the Commission with a maintenance and refurbishment plan outlining how concerns outlined within the report will be addressed and within what timescales.) The registered provider must provide the Commission with an action plan no later than 01/12/07 regarding how it is intended to meet the requirement within the timescale. Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 40 10. OP21 16(1), 23(2)(j) 11. OP24 OP26 16(k) 12. OP19 OP38 13, 23 13. OP24 OP22 OP38 13(4), 23 The registered person shall having regard to the number and needs of service users ensure that: • There are provided at appropriate places in the premises sufficient numbers of lavatories, and of washbasins, baths and showers fitted with a hot and cold water supply. • Suitable adaptations are made, and such support, equipment and facilities, including passenger lifts, as may be required are provided, for service users who are old, infirm or physically disabled. The registered person shall having regard to the number and needs of service users ensure that the home is kept free from offensive odours. The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. Any unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. Satisfactory precautions against the risk of fire should be taken. (For example rooms used for storage should be cleared of any items no longer required and kept locked to prevent risk to residents and of fire.) The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. Any unnecessary risks to the health or safety of service users are identified and DS0000068129.V346016.R01.S.doc 01/10/08 01/01/08 01/01/08 17/10/07 Holywell Bay Care Home Version 5.2 Page 41 14. OP27 18 15. OP29 OP28 18. 19 so far as possible eliminated.(For example: (1) Visitors must only be able to enter the building by someone from the inside of the home letting them in. The main front door must shut properly. This will help ensure as much as possible that intruders are prevented from entering the building (2) Mats in residents bedrooms which may present as a trip hazard are replaced) Action taken must be confirmed in writing to the commission within the timescale Immediate Requirement The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. The registered person shall ensure that persons employed to work at the care home receive training appropriate to the work they are to perform. This must include suitable assistance, including time off, for the purpose of obtaining further qualifications appropriate to such work. (For example: (a)This must include training required by regulation such as infection control, food hygiene, fire training, manual handling DS0000068129.V346016.R01.S.doc 01/11/07 01/03/08 Holywell Bay Care Home Version 5.2 Page 42 training and first aid. Training regarding fire, moving and handling and first aid must be prioritised and delivered as soon as possible (i.e. no later than 31/12/07). (b) Training regarding people with challenging / aggressive behaviour, dementia and mental health needs.) (c) There must be satisfactory evidence that all staff recently employed, and staff employed from the date of this report, have received a comprehensive induction when they commence employment. (d)Suitable records of training e.g. NVQ, induction training and other training certificates need to be maintained and available for inspection. (e)The registered provider must provide the Commission with an action plan no later than 01/12/07 regarding how it is intended to meet the requirement within the timescale. Previous deadline of 31/08/07 not met. Fourth Notification. From the date of the report, the 01/11/07 registered person shall not employ a person to work at the care home unless— (a) The person is fit to work at the care home. (b) Suitable records are obtained in respect of staff employed as specified in paragraphs 1 to 9 of Schedule 2 of the Care Homes Regulations 2001 are DS0000068129.V346016.R01.S.doc Version 5.2 Page 43 16. OP29 19 Schedule 2 Holywell Bay Care Home 17. OP31 7, 8, 9 maintained (For example a Protection of Vulnerable Adults Check, a Criminal Records Bureau Check, two written references etc.) These records must be available for inspection. The registered provider shall appoint an individual to manage the care home where— (a) There is no registered manager in respect of the care home; and (b) The registered provider (i) Is an organisation or partnership; (ii) Is not a fit person to manage a care home; or (iii)Is not, or does not intend to be, in full-time day to day charge of the care home. (For example an application must be submitted to the commission, in order for CSCI to determine if the manager is fit to be registered to manage the home.) Where the registered provider is an individual, but not in day to day charge of the care home, (s)he (or a nominated individual) shall visit the care home in accordance with this regulation. The visits shall take place at least once a month and shall be unannounced. A written report should be forwarded to the manager and the commission. The registered provider shall ensure that the care home is conducted so as to promote and make proper provision for the care and where appropriate, treatment, DS0000068129.V346016.R01.S.doc 01/12/07 18. OP33 OP31 26 01/11/07 19. OP38 OP8 12, 13, 01/11/07 Holywell Bay Care Home Version 5.2 Page 44 20. OP38 12, 13(4) 23(2)(c) education and supervision of service users. Any unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. (For example The Health and Safety Executive must be informed, as appropriate, of accidents or incidents reportable under RIDDOR without delay.) The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. Any unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. Any equipment provided at the care home for use by service users or persons who work at the care home is maintained in good working order (For example: • Ensure the chairs in the lounges for residents use are safe to use; liaising with the supplier as necessary. • Ensure a risk assessment is completed regarding the prevention of legionella, and any necessary preventative measures are taken to prevent legionnaires disease. • Ensure portable electrical appliances are tested according to HSE guidelines and a record of tests is maintained. • Emergency lighting must be tested at intervals prescribed by the fire DS0000068129.V346016.R01.S.doc 01/01/08 Holywell Bay Care Home Version 5.2 Page 45 • • • • authority, and a record must be kept of these tests. Inform the commission what action will be taken regarding recommendations regarding the storage of oil for the heating of the home. Evidence the emergency call bell system is serviced. This must be forwarded to the Commission within the timescale set. Maintain a record of the temperature of hot water (for baths and shower facilities). After taking advice from the HSE, fit thermostatic valves to control the temperature of hot water to baths / showers as necessary. 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. 3. Refer to Standard OP3 OP8 OP12 Good Practice Recommendations The registered provider should obtain a copy of the social services / NHS assessment as part of the assessment process for people moving into the home. Make an NHS referral for psychology support regarding residents who challenge the service Management should monitor people who use the service have a choice regarding what time they get up and go to bed. Preferred times of getting up and going to bed need to be recorded in individual service users’ care plans. Employ an activities worker. DS0000068129.V346016.R01.S.doc Version 5.2 Page 46 4. OP12 Holywell Bay Care Home 5. 6. 7. 8. OP13 OP20 OP14 Provide an additional ‘quiet lounge’ where people who use the service can receive visitors. Review all restrictive practices to ensure the home, and individual care, is compliant with the Mental Capacity Act 2005 Complete an annual development plan to improve the quality of the service. The registered provider is requested to write to the Department of Adult Social Care to clarify arrangements regarding the management of one resident’s finances. OP33 OP35 Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 47 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Holywell Bay Care Home DS0000068129.V346016.R01.S.doc Version 5.2 Page 48 - 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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