Inspection on 18/05/05 for Honresfeld Cheshire Home

This inspection was carried out on 18th May 2005.

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

Honresfeld Cheshire Home 22/11/06

Honresfeld Cheshire Home 07/02/06

Honresfeld Cheshire Home 16/02/05

Honresfeld Cheshire Home 29/07/04

Honresfeld Cheshire Home 05/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOME ADULTS 18-65 Honresfeld Halifax Road, Littleborough, Rochdale, OL15 0JF. Lead Inspector Jenny Andrew Unannounced 18th May 2005 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Honresfeld Address Halifax Road, Littleborough, Rochdale, OL15 0JF. 01706 378627 01706 370678 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Leonard Cheshire Foundation Mrs Laura Keita Care Home with Nursing 28 Category(ies) of Physical Disability 28 Terminally Ill 2 registration, with number of places Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Within the total of 28 places there can be a maximum of:2. 28 Physically disabled (PD) 3. 2 Terminally ill (TI) Date of last inspection 17th February 2005 Brief Description of the Service: Honresfeld Cheshire Home is a large period building with extended accommodation, situated in 2 acres of beautiful well maintained lawns and gardens. Patio areas are accessible to people in wheelchairs. There are good car parking facilities. The home is approximately half a mile from Littleborough centre where there is a good selection of shops and other community services , including the train station. Hollingworth Lake Country Park and the Pennine Way are also situated closeby. Whilst the home is on a main bus route, the service is infrequent. The home accommodates male and female residents aged between 18 and 55 years (on admission), in single bedrooms on two floors. Twenty four hour nursing care is provided by qualified nurses, supported by care assistants, physiotherapists and therapists. Staff are also able to access other specialist nursing services as necessary. Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day although the Inspector returned the following day to let the manager know how the inspection had gone and to check out some other things. Two inspectors spent time at the home, one stayed all day and the other stayed for half a day. The inspectors looked around parts of the building, checked care plans and some records and watched how much time staff were able to spend with residents. The manager, 10 of the 28 residents, 3 care assistants, 3 nurses, the cook, handyman, housekeeper and activity/volunteer co-ordinator were spoken to during the inspection. What the service does well: What has improved since the last inspection? The manager was making sure the home were following the policies when they were recruiting new staff and the files looked at were in good order. The nurses spoken to said they were enjoying their jobs much more now and that they were being given good support by the manager. A lot of the staff had received training in how to make sure residents were protected from abuse. Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 6 More trips out to the theatre and other places of interest had been arranged since the last inspection in February 2005. What they could do better: 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. Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 & 4 A good assessment process was in place, which ensured the home could meet the physical needs of individuals. EVIDENCE: The pre-admission assessment for the most recently admitted resident had been completed in detail. The document contained all the required information to determine whether the home could meet his needs. Whilst he had not visited the home prior to admission, due to his health care needs, his parents had visited twice to look around the home. Other residents spoken to confirmed they had been to look around prior to admission. The staff team had the skills and expertise required to ensure the physical needs of the residents were met. However, due to staffing levels, the emotional/social needs of residents were not being fully met and a requirement to increase staffing levels is made below. A new resident said he was disappointed in the lack of social activities within the home. The staff spoken to demonstrated a high level of commitment to ensuring the needs of residents were met, but said at times this was difficult to manage as quickly as they would have liked. Several residents spoken to said they often had to wait for quite long periods of time before they received attention, due to the staff being so busy. Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 9 Where necessary, other health care professionals were consulted and utilised and this was evidenced on some of the care plan files inspected. During the visit, Physiotherapists and therapy assistants were seen to be working on intensive therapy programmes with some residents. Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 Whilst the content of care plans and risk assessments was detailed, they were not always kept updated, which could result in staff working inconsistently with residents and not giving the correct care. Rules and regulations were kept to a minimum, thus ensuring that residents had control over their lifestyles. EVIDENCE: Care plan files were kept in the nurses’ office and were not easily accessible to care staff. Whilst they were, in the main, detailed and written in clear, user friendly language, they were not all up to date and it was difficult to determine from all the different documentation in use, exactly what the needs of each person were. The care plan for the most recently admitted resident, had not been fully completed using relevant information from the pre-admission assessment. In one instance, a psychologist had been consulted with regard to the behaviour of one person and the manager was still awaiting the report. In the interim however, there was nothing in the care plan to indicate how staff should support him in order they were all working consistently. The manager agreed to address this as a matter of urgency. Nurses interviewed said that due to staffing shortages, they had been finding it difficult to keep records updated but that as soon as the new staff commenced, Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 11 they would be reviewing the key-worker system to ensure they had a manageable number of residents to key-work. Basic personal care documentation was held in the residents’ rooms, which care assistants kept updated. Residents did not however, retain a copy of the complete care plan nor did they know what was contained in it. All residents should be consulted when care plans are drawn up and, where possible, sign to say they are in agreement with the contents. Where this is not possible, relatives/advocates should become involved. The manager stated that the care planning system was about to be reviewed in order to make it an effective working tool for all staff to use. All but one resident spoken to, felt that staff respected their right to make decisions about their routines and how they were cared for. One person did however state that on occasions, they felt that rather than being consulted, things were imposed on them. Several residents spoke about holidays they had enjoyed, supported by staff from the home. Any areas of potential risk were discussed with the resident and efforts made to reduce the identified risk wherever possible. This was evidenced in the risk assessments seen and from speaking to staff. Residents managed their own finances as far as they were able or relatives/advocates assisted as necessary. Whilst detailed risk assessments were in place for many identified risk areas, they were not always being reviewed on a six monthly basis, or when needs changed i.e. in one instance a risk assessment regarding epilepsy had not been reviewed since December 2003. Some risk areas identified during the inspection had not been assessed i.e. behaviour, nutrition. Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14, 16 and 17 Opportunities for integration into community life and leisure activities need to be further expanded so that residents can develop their skills and live more independent and fulfilling lifestyles. The dietary needs of residents were well catered for enabling them to exercise choice and control over what they ate. EVIDENCE: There is an activity/volunteer co-ordinator in post and 14 hours per week of his time are allocated for arranging outings/activities. Feedback from relatives and residents about the activities co-ordinator and one therapist in particular, was excellent. It was apparent however, that due to the complex needs of the residents, the worker did not have the time or resources to fully meet their social needs. Since the last inspection, more local outings and trips to the theatre had been arranged for a small number of residents. The home was however, reliant on voluntary workers and the co-ordinator was currently advertising to try and increase the number of regular volunteers. Carers do not have the time to organise and support residents to pursue their interests/hobbies. Since the last inspection, an activity programme had been written, but residents had not been consulted about the content. It was Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 13 unimaginative and was not meeting their needs. Residents said they were “bored”, “fed up”, “watched telly all day” and “wanted to go out”. Whilst staff had started to consult with residents to find out what their past interests and hobbies had been, the majority of files did not contain reference to preferred activities. The requirement made at the last inspection remains outstanding and action must now be taken to address the social needs of the resident group. There was a room identified as a snoozlem, but the room was bare, cold looking and in need of upgrading to provide a stimulating and comfortable room in which to relax. Given the profound physical disabilities of some residents, this room would be very beneficial to them. The inspector was advised that some of the fund raising monies would be allocated for this purpose. Residents spoken to said that staff respected their privacy and would knock before entering their rooms. They also said they were treated with respect and were free to choose to spend time in their rooms. Staff interviewed were very aware of the importance of ensuring residents privacy and dignity was upheld when assisting with personal care tasks and gave examples of how they did this in their daily routines. The library was the designated smoking area, and a minority of residents were seen to use it during the inspection. Residents said the quality of food was good and that they were always able to have a choice at each meal. Whilst some people preferred cereal and toast for breakfast others enjoyed a cooked breakfast, which they either had in the dining room or in their own rooms. Menus were nutritious and balanced and included a good variety of meat, fish, fresh vegetables and fruit. The fruit and vegetable delivery was seen on the day of the inspection which included broccoli, carrots, cabbage, cauliflowers, swedes, celery, mushrooms, salad ingredients, plums, strawberries, melons and grapes. Should a resident request something that was not on the menu, they said the cook would usually try to oblige. A good selection of desserts was available on the sweet trolley, including healthy options of fruit and yoghurts. Special diets were well catered for i.e. vegetarian, diabetic. The Inspector had a bowl of the home-made soup at lunch time which was hot, thick and very tasty. Staff assisted those residents requiring help at lunch time in a caring, sensitive and unhurried manner. Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 19 Due to the continued use of agency staff, residents were not always receiving personal support in a consistent way. Whilst the physical health of residents was being met, staffing levels were insufficient to ensure their emotional needs were fully met, resulting in some residents feeling isolated in their bedrooms. EVIDENCE: All staff interviewed demonstrated their commitment to providing good care to the residents. However, due to inadequate staffing levels, all but one person felt they had insufficient time to spend on a one to one basis talking with the residents for whom they were key-worker/co-worker. Due to holidays and sickness, agency staff were being utilised on a very regular basis. Residents said that some of the staff were good, who had worked at the home before, but others did not know how to support them in the way they preferred. One resident identified that whilst he received assistance with bathing once a week, he would have preferred to have at least another bath each week. Residents must be consulted about their preferences for personal care, which should be recorded on their individual plan of care. Requirements regarding increasing staffing levels have been made below. Residents said they were supported to access dental, chiropody and optical care but in some instances, entries in care plans had not been updated and did not reflect this. All residents were registered with a G.P. and other health care Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 15 professionals were consulted as necessary. Evidence of this was seen on one of the care plans that was inspected. Visits by health care professionals take place in residents’ bedrooms. Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 There was an ineffective system of recording complaints that meant it was difficult to determine whether service users views were listened to and acted upon. A vulnerable adults policy/procedure was in place and many staff had received training, ensuring that they were knowledgeable about this aspect of resident care. EVIDENCE: A complaints procedure entitled “Have Your Say” is issued to each resident as part of the admission procedure. A simplified version was also contained in the service user guide and several residents confirmed they had received a copy. The manager showed commitment to ensuring that all complaints were investigated thoroughly. The complaints records were not however, to hand and the complaints recording pad could not be located. Staff interviewed were vague about the process they should follow and were unclear where they would log complaints. The manager must ensure that all staff are clear about the procedure should a resident make a complaint. All complaint records should also identify what action has been taken to address the complaint and a file containing all logged complaints must be maintained. Over the last 12 months, 5 complaints had been investigated by the Commission for Social Care Inspection (CSCI) and in all instances, some elements were upheld. Many were in connection with staffing issues. The home was currently conducting its own investigation into one complaint. Since the last inspection good progress had been made with regard to staff receiving vulnerable adult training. All carers interviewed had done the Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 17 training and the manager said this would be ongoing until all staff had attended. At the time of the inspection, there was an adult protection investigation ongoing. The investigation was about the behaviour of a support worker, independently employed by a resident’s case manager. The investigation was being conducted in line with the Local Authority’s Protection of Vulnerable Adults Procedure and all relevant agencies had been involved. A Whistle Blowing policy was in place and staff were encouraged to use it. A quarterly return sheet was submitted to the head office, recording any such reports. Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30 The standard of furnishing and fittings within the home was good providing a homely, safe, well adapted, clean and comfortable environment for residents. EVIDENCE: The home catered for physically disabled residents and was well adapted. The main entrance to the home was in the original building, which was a traditional large stone Victorian house in which many of the original features had been retained. There had been 2 extensions to the property, in order to provide additional bedrooms, bathrooms and therapy space. The rear of the building overlooked beautiful mature, gardens, lawn and various patio areas. The grounds were well maintained and the patios areas on both the ground and first floor levels were accessible to residents in wheelchairs. One resident said he very much enjoyed the independence of being able to take himself into the garden, independent of staff. Furnishings and fittings were of a good quality and residents interviewed were extremely satisfied with their bedrooms, some of which opened onto the landscaped gardens and patio areas. Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 19 A handy-man was employed who was responsible for the general maintenance of the home. The records he was required to keep were in order. An Environmental Health inspection had recently taken place and there were no requirements made in the report. CCTV cameras were restricted to the entrance area, for security purposes only and did not infringe on the daily life of the residents. The home was seen to be clean and free from any offensive odours. Staff were seen to observe good hygienic practices i.e. the use of blue & white disposable aprons, disposable gloves, liquid soap, paper towels and bins in all bedrooms, bathrooms and toilets. Laundry facilities were excellent with two new washers having recently been purchased, guaranteed to kill all bacteria, including super-bugs such as MRSA. A laundry assistant for week-end work was due to commence work the week following the inspection, in line with a requirement made at the previous inspection. Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 36 Whilst the skill mix of the staff team was satisfactory and the staff keen and willing to perform their duties, inadequate staffing levels and lack of staff supervision could place residents at potential risk. EVIDENCE: Care at the home was delivered by a multi-disciplinary team of staff including nurses with general training, mental health and those with experiences in younger adult disabilities and palliative care. The services of Physiotherapists and Occupational Therapists were purchased independently by residents as needed. Assistant therapists were also employed who ensured that the exercises prescribed by the physios, were implemented. A large number of the care assistants had undertaken NVQ level 2 training and those interviewed were clearly committed to undertaking whatever training was offered. From interviewing residents, staff and relatives, it was identified that the current staffing levels were not meeting the needs of the residents. Normal staffing levels for the 28 residents were 2 nurses and 6 care assistants from 08.00 – 14.30 and 2 nurses and 4 carers from 14.30 to 21.00. Five residents spoken to said there were never enough staff on duty and other comments included “staff do their best”, “they’re very hard working” and “staff are overstretched”. Two relatives also confirmed this. Residents did however, speak well of the staff team and one relative said “the young carers are working Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 21 above and beyond what can be expected. Two carers particularly are always willing to go the extra 100 yards”. Problems were particularly highlighted in the afternoon and evening when staffing levels of carers dropped from 6 to 4. Call bell print outs on the day of the inspection, showed that staff response was slow with residents regularly having to wait anything from 11 to 25 minutes before receiving assistance. At teatime, there were 6 people who needed assistance but only 4 carers on duty. Staff felt under particular pressure during the evening, as they had to work in pairs, in accordance with the moving/handling assessments. Two carers worked on the ground floor and 2 on the first floor, which again, meant that when assisting residents to bed, other residents needing help were having to wait lengthy periods of time for attention. In order to ensure the needs of the current resident group are met, the manager must undertake a thorough staffing review and ensure that at least one additional carer is employed on both the morning and afternoon/evening shifts. Problems were also identified with regard to the use of agency staff with residents commenting that “there are too many agency staff employed” and “agency staff don’t know our needs”. Records seen showed the home had been reliant on agency staff over the past few months to cover for absences due to sickness, holidays and vacant posts. The nurses and manager stated they did try to get the same staff who knew the residents needs. At the time of the inspection, the manager was in the process of recruiting staff. Two new full-time RGNs, 2 full-time carers and a bank night care assistant had been recruited during the week of the inspection and the recruitment drive was ongoing. Whilst 1 staff spoken to confirmed she received regular supervision, another person said she had not received supervision since she started work approximately 8 months ago. The manager acknowledged the home had still some way to go with regard to an effective system being in place but felt this would be addressed when the full nursing team were in post. She further stated that at the next nursing team meeting, discussion would take place with regard to staff receiving supervision training. Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Maintenance of equipment was up to date but not all staff had received relevant health and safety training, which could result in some practices that do not promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: The handyman was responsible for the maintenance and over-seeing of equipment within the home. Maintenance records showed that all equipment had been regularly serviced/checked in accordance with the regulations. It was noted that a fire drill within the home was over-due but the Inspector was assured this would be prioritised. Training records were unavailable at the time of the inspection, so it could not be determined how many staff had undertaken training in first aid, food hygiene, fire, infection control, moving/handling and general health and safety. From speaking to staff it was identified they had not all undertaken the mandatory training and this must be addressed. Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 2 3 x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 4 x x x x x 4 Standard No 11 12 13 14 15 16 17 x x 2 2 x 3 3 Standard No 31 32 33 34 35 36 Score x x 1 x x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Honresfeld Score 2 2 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 24 YES Are there any outstanding requirements from the last inspection? 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 6 Regulation 15 Requirement The care plans must be reviewed and updated in order to accurately reflect the needs of the residents. The care plan for the most recently admitted resident must be fully completed with information from the preadmission assessment being utilised. Where residents have psychological problems, these must be identified in the care plan and an action plan completed in order that staff work consistently with the individual. Risk assessments must be undertaken for all identified risks and they should be updated on at least a 6 monthly basis. Residents interests/hobbies must be recorded and opportunities afforded for stimulation through leisure and activities in and outside the home that suit their needs, preferences and capabilities. (Previous timescale of 30 April 2005 not met). The complaints recording system must be reviewed in order to F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Timescale for action 31.07.05 2. 6 15 30.06.05 3. 6 15 30.06.05 4. 9 13 30.06.05 5. 14 16 30.06.05 6. 22 22 30.06.05 Page 25 Honresfeld Version 1.30 7. 33 18 8. 32 18 9. 34 19 10. 36 18 11. 39 24 12. 42 18 ensure that accurate records are maintained and held within the home. Such recordings must also show the outcomes of the investigations. Staffing levels within the home must be reviewed and increased to ensure the needs of the current resident group are being met. A minimum of 1 additional carer on morning and afternoon shifts must be provided. Training and development records must be retained inhouse. (previous timescale of 30.04.05 not met) Two references must be obtained for new employees before they commence work. (previous timescale of 30.04.05 not met). All staff working at the home must receive regular supervision. (previous timescale of 30.04.05 not met). Residents views of the home are obtained and made available to them, their representatives and other interest parties including the CSCI. (previous timescale of 30.05.05 not yet expired). All staff must receive mandatory training as set out in the body of the report. 30.06.05 30.06.05 30.06.05 31.07.05 31.07.05 30.09.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 6 6 Good Practice Recommendations All care staff should be encouraged to read the residents care plans and use them as a working tool. Care plans should be written in consultation with residents who should retain a copy and sign their agreement to the plan. F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 26 Honresfeld 3. 4. 18 18 Residents should be consulted with regard to frequency of baths/showers and this information should be recorded on their care plan. Staff should update care plans to reflect when residents have received dental, chiropody or other treatments. Honresfeld F06 F56 S17344 Honresfeld V227115 18.05.05 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Turton Suite, Paragon Business Park, Chorley New Road, Horwich, Bolton, BL6 6HG. National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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