Inspection on 18/05/07 for Ingleby Care Home

This inspection was carried out on 18th May 2007.

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

Ingleby Care Home 22/09/09

Ingleby Care Home 26/03/09

Ingleby Care Home 25/03/08

Ingleby Care Home 17/05/06

Ingleby Care Home 19/09/05

Ingleby Care Home 16/05/05

Ingleby Care Home 22/09/04

Ingleby Care Home 15/06/04

Ingleby Care Home 27/02/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Ingleby Care Home Lamb Lane Ingleby Barwick Stockton-on-Tees TS17 0UP Lead Inspector Jackie Herring Key Unannounced Inspection 18th May 2007 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ingleby Care Home DS0000055360.V340314.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. Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ingleby Care Home Address Lamb Lane Ingleby Barwick Stockton-on-Tees TS17 0UP 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) 01642 750909 01642 750966 T L Care Ltd Mrs Valerie Thomsen Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That a maximum number of 5 places may be used at any one time for the accommodation of persons who are 50 years and over with a physical disability PD 17th May 2006 Date of last inspection Brief Description of the Service: Ingleby Nursing Home is a 50 bedded purpose built care home, which provide personal care to older people. All 50 rooms are single rooms with ensuite facilities and there is the required number of bathing facilities and communal space. Ingleby is owned by TL Care who also operate a further four homes in the Teesside area. Ingleby Nursing Home is close to the centre of Ingleby Barwick, being in easy reach of the local church, supermarket and parade of shops. The fees for Ingleby Care Home are a standard rate of £355 per week. Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key unannounced inspection and was completed across four-inspection day, thirteen inspection hours in total. As a key inspection, all of the key standards were examined. This was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use services, and that it does what the Care Standards regulations say it must. Residents and relatives were involved in discussion about the home and the care provided. Staff and the manager were also involved in similar discussions. A number of records were looked at including residents care records, medication records, staff records and maintenance records. Some of the systems were also looked at and included how the medication was managed in the home and how resident’s personal allowances were managed. The Annual Quality Assurance Assessment was completed by the manager and provided information about all of the National Minimum Standards, what the home does well, what has improved and what could be done better. Several visits were made to the home and at each visit the inspector walked around the home to look at the environment. A number of relative’s surveys were completed and returned. Prior to the inspection, an application for changes to some areas of the home had been made, as the directors wanted to increase the room sizes and also to increase the number of bedrooms in the home. During the first visit to the home, building work had commenced and serious concerns were identified about how this work was being planned and managed; a number of areas were identified as presenting potential hazards to residents, visitors and staff. Immediate action was taken by one of the directors and the operations manager to address this but it is of concern that this was the situation in the first instance. A number of the judgements in the outcome areas are as a result of this situation. During the inspection, there were comments received both verbally and within surveys received about the overall management of the home, not directly involving the current manager but more to do with the culture and some longer standing matters. These are being looked at outwith the inspection process although comment has been made. The manager and operations manager demonstrated a commitment to improvement of the service and took immediate action to address any issues that were within their control and have responded appropriately to any issues raised with them. Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Progress has been made in a number of areas since the last inspection, with improvement to the meals, which several people commented on. Development has taken place with care records and much more personal and individual care plans have been developed. Some improvement has taken place with the health care assessments but more work is needed and staff have to remember to cross-reference this information. The pre admission assessment has also improved. Building work to increase the room sizes has commenced and the bay window extensions to the bedrooms enhance these rooms. Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 8 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 Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 9 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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All residents have their needs assessed prior to admission to ensure that their needs can be met. EVIDENCE: Three sets of resident’s records were looked at, all of which contained a copy of the care manager’s assessment and the homes own pre admission assessment documentation. The manager confirmed that either she or a more senior member of the care team completed a pre admission assessment prior to anyone being admitted to the home. These assessment contained sufficient detail about individual needs. During discussion with residents and relatives they confirmed that they had visited the home prior to any decision being made about moving into the home. One resident said, “My nephews looked and thought it would be suitable” Ingleby Care Home does not provide Intermediate Care. Ingleby Care Home DS0000055360.V340314.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. Although residents and relatives are happy with the care provided, assessments of needs need to be completed to ensure needs are fully met. The system for managing medication is reasonably satisfactory, however up to date policies and procedures are needed to ensure staff have clear guidance on the safe handling of medication. EVIDENCE: Each resident has a plan of care in place within the home. Three sets of resident’s records were looked at in detail. The records included a recent resident who had been admitted, a resident who had been living in the home for over a year and a random sample for the third. The records showed some development and improvement in the specific plans of care since the last inspection, which are now more personal and individual. There was however a step in the process missing; that being the full detailed assessment of need following admission to the home, which is necessary to determine the specific care needs of individual residents. Some of the documentation had not been fully completed, for example on the nutritional Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 11 assessment, no height or weight is recorded; which is a key component of this assessment process. A number of the personal profiles had not been signed or dated and some of these profiles contained a limited amount of information. It was good to see that some of the records were more person centred and included information, such as “He/she likes small portions, he/she loves going to his/her daughters on a Sunday for lunch”. There were risk assessments in place for nutrition, skin integrity and moving and handling, these is also the need to develop other risk assessments where needs have been identified such as verbal abuse and potential aggression. There was also the need to ensure that these tools were completed accurately and that staff cross-referenced them with other information. The evaluations of care also need to be developed further as currently they do not contain any value-based information to say how effective the plan of care is, they contain the comments like “no change”. The care records did not show that residents/relatives had been consulted and that the assessments and care plans had been discussed with them and agreed. Details for GP, District Nurse, Optician and CPN visits were available within all of the files examined. The medication systems were looked at and a senior care worker was observed to be administering medication during the inspection, this was being carried out in an acceptable way. The actual ordering, storage and returns of medication was good and the records were well written with no gaps. All staff who administers medication have received the appropriate training in safe handling of medication and the manager conducts ongoing competency assessments for these staff. The actual policy and procedures for the safe handling and administration of medication are in need of review and update. An updated version was available within the home, however these were generic and not adapted to the systems in place within Ingleby Care Home. During the inspection, staff were observed to knock on residents doors prior to going in. Residents said, “Staff are all very good to me, they speak respectfully, I would put them in their place if they didn’t”, “Everything is lovely, everyone is so good and kind, at least they are to me. They speak respectfully and give me a kiss and cuddle”. Staff spoken to during the inspection spoke of the core values of care, one staff member said, “We encourage own decisions and choices, promote independence and ensure people are treated with dignity”. One relative said, “She didn’t settle into the home for a while, the staff were extremely patient and went along with her mood, she is fine now”, “Her care needs are well met, she is clean, well dressed and able to make her own decision”. Another relative said, “She has picked up smashing, it’s lovely here, girls are always happy and smiling”. Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live their lives as they wish and residents maintain contacts with families and friends. Residents have choice and control over what they do. The home provides a varied and balanced menu and there is flexibility when and where residents wish to have their meals. Activities are in the main well managed for residents ensuring social, religious and recreational needs are reasonably provided for, these could be linked to a more detailed social and lifestyle assessment. EVIDENCE: During discussions with staff they said that a range of social activities take place including regular coffee morning and bingo sessions. One member of staff said, “There is no set activities programme although activities do take place, these include bingo, coffee mornings, the music man, days out, music videos. Another member of staff said, “A lot of the residents love the bingos and the sing songs. They have visited a local pub for morning coffee and bar meals. Motivation classes take place and we use to take some residents to Tesco for coffee. All residents have TV’s in their rooms and a few have telephones for family contact”. Residents said, “I prefer to stay in my room and friends and family visit”, “I prefer to stay in my room and I can watch Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 13 what I want to on TV. I am comfortable enough and have everything at hand”. A small number of residents go out of the home on their own to the local shops. The manager and staff said that they are supported by “Friends of Ingleby” who arrange fundraising activities and coffee mornings as well as some outings. The care records that were looked at contained very little information about residents social and lifestyle interests. There is no actual social assessment currently completed. It was recommended that these are carried out and should be linked to individual and group activities. Staff said that visitors are welcome at any time, one resident said, “My daughter visits and I can telephone and my son also visits. You can go to church if you want to and have a Christmas party at church”. Staff also said that there is visiting clergy and that those who want it can receive Holy Communion. From the discussion that took place with residents it was clear that they were in control of their lives. Residents can get up early or late, stay in their bedrooms or go to the lounge areas. They are able to have meals where they chose. Individual bedrooms had resident’s personal possessions and belongings that included small items of furniture, pictures and ornaments. Through discussion with residents and staff it is clear that choice and autonomy is encouraged. Staff said, “We try to maintain independence through encouragement and explanation. It is prompting where necessary, this is their home and it is pretty relaxed”, “The residents are all individual and you can have a laugh with them. It’s their home. On the whole it’s a lovely home, the routine is relaxed and there is freedom of choice”. Meals were said to have improved and were now very good. Residents said, “The meals are very well cooked, it is home cooking with traditional British meals. You have two choices at dinnertime and you can have what you want, sufficient food. I have meals in the dining room”, “The food is smashing, if anyone grumbles about the food they are not used to good food, I am very satisfied”. The menu was a four-week rolling menu and showed choice and variety. Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the complaints procedure is in place and residents are confident about raising concerns, relatives are not wholly clear about the procedure and there is a level of dissatisfaction with the actions taken. Procedures are in place to protect residents from abuse although further staff training is needed. EVIDENCE: The complaints procedure was on display within the main reception of the home and had been updated since the last inspection and contained the detail needed. Residents who were spoken to said, “I don’t have any worries or concerns if I did I would speak to the staff”. Another residents said, “If I had any worries I would speak to my nephews. So far everything has been alright, can’t see why anyone would grumble about being in here”. Staff who were spoken to were clear about what to do if a resident did complain to them. The AQAA detailed that there had been seven complaints since the last inspection, two of which were upheld and three are still being investigated. The relatives survey contained mixed views about making complaints, although they did state that there had been occasion when they had made complaints either verbally or in writing. One relative was unclear how to proceed if they needed to take the complaint further than the home manager. Another comment suggested that the relative was not fully satisfied with the response and action taken. The surveys contained the following comments, “Have let Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 15 the care home know my concerns without making a formal complaint but to my knowledge nothing changed”, “On occasion the response appears to be more lip service than anything that results in regular positive action”, “On one occasion when I spoke to the matron, she immediately attended my friend and rang me back. However when one complains about missing articles, a quick look is made and then forgotten”. During discussion with one relative they said, “If I had any concerns I would speak to Val, the home manager”. A complaint was made directly to the inspector during the inspection; this was passed on to the operations manager and one of the directors to look into. It was unclear if all staff had received training in respect of Protection of Vulnerable Adults, as the training plan did not detail this. Of the three staff spoken to, two said they had received this training, the third did not know. The manager said that most of the staff would have received this training. The AQAA detailed that head office now have new training providers for Protection of Vulnerable Adults and that the required policy and procedure was in place. Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 16 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, 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. On the first inspection day, the home did not offer a safe, clean and well-maintained environment for residents to live, although improvements have now been made. A number of areas are still in need of improvement and the current building work needs to be completed, which should enhance the environment for the residents. EVIDENCE: Immediately on entering the home on day one of the inspection, concerns were identified about the environment and health, safety and wellbeing due to the current building work being carried out to increase the bedroom numbers and also to increase the size of the bedrooms. A number of issues were identified which related to the cleanliness of the home, in which building dust was observed to be all over the home and in areas where residents are occupying. The builders had moved on to commence work on a second unit, the one above the unit they have been working on, and there are three Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 17 residents in bedrooms in that unit, with the builders being in rooms next to them and staff and residents accessing the working corridor. There were bays being added to the rooms, and in one of the rooms, there were no builders, the door was open and there were no health and safety signs in place and there was a hole in the floor, which could have been a potential tripping hazard for residents. In the downstairs unit, work was still being completed but again this has not been sealed off and there appeared not to be any health and safety mechanisms in place, as such, residents and staff could freely access it. There were also other areas of the home where building work had commenced and again there were hazards such as tripping and generally unsafe areas should residents happen to walk into them. There was discussion with the Operations Manager and one of the directors and immediate action was taken to address these issues. Improvements were noted and sustained at subsequent visits to the home with the required health and safety mechanism being in place and areas that residents were occupying were more acceptable. The ground floor bathroom, which has not had a bath fit for use for some time remains in the same condition. The manager did confirm that this bathroom was being refurbished as part of the improvement plan. A number of corridor carpets are in need of cleaning or replacement as was the carpet in the ground floor dining room. A number of the newly refurbished bedrooms had patched carpets that had not been fitted properly. It was also observed that care was needed by the staff to ensure wires were not left trailing and that cleaning cupboards that contain chemicals were locked and not accessible to residents. A number of resident’s bedrooms were visited and the addition of the new bay window areas did enhance these rooms. One resident said, “It is a very nice room, I like it because it looks onto the garden and you can see people coming along. The added bay window area is very nice”. This resident had a large dial telephone, TV, photos, own chair and bookcase. Other residents whose rooms were visited also had a number of personal belongings. Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 18 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 good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are mostly met by the numbers and skill mix of staff who are generally trained and competent to care for the residents at the home although this would be enhanced further by more client specific training and completion of formal induction. Residents are protected by the home’s recruitment procedures. EVIDENCE: There were mixed views about there being sufficient staff on duty to meet the needs of the residents. A number of relative surveys stated that there was the need for more staff. They stated, “Provide more staff to provide all the services considered necessary to maintain a clean and healthy environment for all the residents”, “At the weekends there is a shortage of experienced staff. Inadequate cover for holidays, sickness and other causes of absence”. Residents believed there needs were being met but did say that staff did not really have time to sit and chat. Staff themselves had some mixed views but generally thought there was sufficient staff if everyone worked together and the day organised properly. One member of staff said, “There is sufficient staff if you all pull together and you organise and work as a team”. Another member of staff said, “There is sometimes not enough staff on duty, this reduces the level of flexibility, the staffing often depends upon the day and staff and how organised people are, this can be variable and things like escorts to hospital need to be planned in”. At the time of the inspection, there were Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 19 thirty-five residents living at Ingleby and they were being cared for by six care staff, two of which are usually senior care staff, one for each floor. During discussion with the manager and operations manager it was acknowledged that the building work may have impacted upon people’s views of staffing numbers and said that this has been a difficult time for the whole staff team, who had worked well through it. 81 of the care staff are qualified to NVQ level 2, this is well above the National Minimum Standard of 50 . 45 of care staff have also achieved their NVQ level 3, which is very good. One staff member said, “The manager is proactive about training and had given me a lot of inspiration. It’s a nice feeling, she takes an interest and I feel valued”. A training matrix was looked at and whilst it detailed the mandatory training such as first aid and fire training, it did not detail any client specific training. Staff did say that they would benefit from having more client specific training although some staff had completed Dementia Care training. A selected sample of staff files were looked at, all of which contained the required information with appropriate checks and references. Induction was discussed, and the manager confirmed that any new staff who did not have a National Vocational Qualification in care would undertake the Skills for Care Induction. There was evidence of an in-house induction being completed however the required Skills for Care induction could not be fully evidenced during the inspection. Residents said of the staff, “The staff are kind, very good, they mostly knock on the door. I am pleased with them and tell them, they are all very nice”, “My sister feels the care staff are excellent”. Relative surveys stated of what the care does well, “Looks after and cares well”, “All of the staff are friendly and helpful to residents and visitors”. Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 20 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. 32, 33, 35, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Whilst the home is managed by an appropriately qualified person, a number of areas have been identified as in need of improvement to ensure that the residents benefit from a well run and safe home. EVIDENCE: Ingleby is managed by a qualified Registered General Nurse who has the required knowledge and experience to manage this care home. Residents said of the home, “I am comfortable enough and have everything at hand. I am quite happy here. So far everything has been alright, can’t see why anyone would grumble about being in here”. Staff said, “The manager is proactive about training and had given me a lot of inspiration. It’s a nice feeling, she takes an interest and I feel valued. You can talk to her and she will listen”. Another member of staff said, “I can’t fault the matron, she respects Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 21 confidentiality, information never goes any further. I like her, I get on well with her; she is very approachable”. When asked what was good about Ingleby and what was done well, staff said, “The care is good. The home has improved since Val has been here, nothing is too much for her and for the residents, and it’s better run”, “Care of the residents, carers are fantastic with the residents and it is a lovely home”. There were some mixed feeling from relatives about the management of the home and a number of negatives comments were received, not directly about the manager but amongst other things, about some of the systems, communication, the culture and roles and responsibilities with some reflection on the previous organisation, this will be discussed separately with key individuals within the organisation. A number of suggestions were made about how to improve the service; these related to staff numbers, morale, communication and management of missing clothing and items. Other comments included, “We are well satisfied”. The personal allowance systems were looked at and found to be in order. It was a good system, with the required information and supporting receipts and the monies held on behalf of the residents balanced when checked. A number of quality assurance systems are in place, there is still the need to produce a report that is accessible to resident, visitors and other interested parties. As discussed within the environmental section of the report, the management of the building work was not adequate and a number of areas of potential risk were identified. This was at a time when the manager was absent from the home, during a period of annual leave. This matter was discussed with one of the directors on the first day of inspection and immediate steps were put into place to address the matter. It was of serious concern that this had been allowed to occur. A random sample of maintenance and service records were looked at and in the main they were up to date, this was with the exception of the fire alarm system, which had not be serviced. Again, immediate steps were taken to address this. The water temperatures were not being recorded on a weekly basis; this was recorded on a monthly basis and fire training needs to take place twice per year. A sample of policies and procedures were looked at and they continue to be in need of review and updating. This has been ongoing for some time and the directors did appoint an organisation some time ago to complete this work. This remains outstanding and the present policies and procedure do not give the guidance needed to fully ensure that the home is operated in the best interest of the residents within safe frameworks. Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 2 1 2 2 X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 X 2 X X 1 Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 14 15 Requirement The assessment of need documentation must be completed and care plans must be appropriately evaluated. There must be evidence of residents or representatives involvement with individual assessments and plans of care. This should ensure that resident’s needs are assessed with appropriately plans in place and needs met. Timescale for action 30/09/07 2. OP8 14 3. OP9 13 The health care assessment tools 30/09/07 must be accurately completed and staff must have an understanding of the need to cross-reference the information with assessment of needs and care plans. This should ensure that care needs are fully assessed and appropriate plans of care are in place. There must be an up to date 30/08/07 policy and procedures, which are relevant to the service to ensure that staff have the correct information and guidance for the safe handling of medication ensure residents are protected. DS0000055360.V340314.R01.S.doc Version 5.2 Page 24 Ingleby Care Home 4. OP18 13 Training on the protection of vulnerable adults must continue and must be rolled out to all staff and this must be recorded to show that all staff have received this training and are able to promote protection of the residents. 30/09/07 5. OP19 13 23 Immediate action must be taken 18/05/07 to ensure the safety of residents, visitor and staff while the building work is being carried out. There must be risk assessments in place and a detailed plan of works. This must be a planned process, which is fully managed which must protect everyone from potential risks. Residents must not have access to the areas where works are being carried out. Areas that are for resident use must not be used to store excess carpets and other equipment. The building work must be completed, ensuring a safe, clean, comfortable and homely place for residents to live. A number of corridor carpets must be cleaned or replaced; the ground floor dining rooms carpet must be replaced and the patched carpets in some of the bedroom must be fitted properly. This will improve the environment for the residents to live in. 6. OP20 23 30/11/07 7. OP21 23 The peach bathroom on the ground floor must have the bath replaced. (This is an outstanding DS0000055360.V340314.R01.S.doc 30/11/07 Ingleby Care Home Version 5.2 Page 25 requirement since 22/09/04) 8. OP24 16 The bedroom furniture must continue to replaced or refurbished. (This is an outstanding requirement since 22/9/04) There must be improvement in the management of the home, particularly relating to communication, information and roles and responsibilities to ensure the home is conducted properly and in the best interest of the residents. The current building work must be completed in a way that ensures the safety and protection of the residents, visitors and staff. 30/11/07 9. OP32 12 (1)(a) 13 31/08/07 10. OP38 13/23 18/05/07 11. OP38 13 12. OP38 13 13. OP38 13 23 The policies and procedures 30/09/07 must be reviewed/updated and must provide staff, residents and relatives with the information they need to ensure safety, wellbeing and protection. The fire alarm must be serviced 13/07/07 and all staff must receive fire training twice per year. This is needed to ensure residents are kept safe should an incident occur. Staff must be aware of health 13/07/07 and safety and must have the knowledge to minimise risks to residents, visitors and other staff member. They must be aware of areas which are not appropriate for residents and other to have access to and must ensure that there are no trailing wires that could cause trips and falls. Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations The recreation/social activities programme should be developed in accordance with detailed social and lifestyle assessments to ensure that residents have social outlets related to their lifestyle needs. The updated policy and procedure for dealing with complaints should be made more accessible to relatives to increase their awareness of the procedures to follow. Consideration should be given to the receipt and handling of concerns and complaints to ensure they are responded to appropriately. The home should remain clean and areas accessible to residents should where possible be clear of building dust. Staffing levels should remain under review to ensure that there is sufficient staff to meet the needs of the residents. Further client specific training should be available for staff to ensure they have the knowledge and understanding to meet the needs of the residents. Along with the home’s own induction process all new staff should complete the Skills for Care induction ensuring they have the minimum standard of competency to meet the needs of the residents and this should be completed in good time and records available within the home. 2. OP16 3. 4. 5. OP26 OP27 OP30 Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 Ingleby Care Home DS0000055360.V340314.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!