Inspection on 25/03/08 for Ingleby Care Home

This inspection was carried out on 25th March 2008.

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

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

Other inspections for this house

Ingleby Care Home 22/09/09

Ingleby Care Home 26/03/09

Ingleby Care Home 18/05/07

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 Unannounced Inspection 09:30 25 March 2008 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ingleby Care Home DS0000055360.V346935.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.V346935.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 no email 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.V346935.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 18th May 2007 Date of last inspection Brief Description of the Service: Ingleby Care Home is a 56 bedded purpose built care home, which provide personal care to older people. All 56 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 Care 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 £370 per week. Ingleby Care Home DS0000055360.V346935.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced Key Inspection as such all of the key standards relating to older people were looked at. 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 the services, and that it does what the Care Standards regulations say it must. The visit to the home was conducted in two inspection days. During the visit to the home, a number of records were looked at, including records of people who use the service, along with medication records, staff records, training records and maintenance information. Time was spent talking to people who use the service, a relative and staff. Time was also spent walking around the home, observing interactions and generally finding out what Ingleby Care Home was like for people living there and staff. Discussion also took place with the manager. A small number of relative surveys were completed and returned. The Annual Quality Assurance Assessment (AQAA), the services self assessment of how well they think they are meeting standards was not required on this occasion as this was a second Key Inspection within a twelve month period. It is acknowledged that the service has undertaken substantial changes including extensive refurbishment work and the deregistration of the nursing category. This has inevitably been a challenge for all and the manager and staff are looking forward to a period of stability in which they can embed some of the systems and build upon what is already in place. What the service does well: Ingleby Care Home provides a warm, friendly and spacious environment for people to live. People who live at the home spoke of being happy and were very positive about the staff who provided their care. A person who uses the services said, “I can’t fault the staff, they are absolutely brilliant, all of them”. People who live at Ingleby Care Home said they thought the staff were very friendly and helpful and believed they were listened to. Ingleby Care Home DS0000055360.V346935.R01.S.doc Version 5.2 Page 6 Relatives of people who live at the home said, “My brother/sister has nothing but praise for the personal care he/she receives. Matron and all staff are always willing to support and assist him/her, making suggestions which will help him/her”. A very high number of staff are trained to NVQ Level 2 and Level 3 and there is a good programme in place to ensure that staff undertake mandatory training. What has improved since the last inspection? What they could do better: The work that has commenced on further developing the care records needs to continue, as does the improvement to the activities for people who live at the home. Some additional work is needed to strengthen the medications system within the home, including amendments to the procedures. The review that is taking place in relation to the menu and meal provision should continue and needs to take into account likes, dislikes, preferences and also ensure that it meets the nutritional and health needs of people. Staff numbers need to be reviewed to ensure that these are appropriate to meet the personal care needs of people living at the home. The planned refurbishment programme needs to continue, with improvement also needed to corridor carpets and lighting, bedroom furniture and dining carpet. The policies and procedure are generic, they need to be reflective of the service and contain more specific detail to ensure that the staff have the information and guidance needed to support them. Ingleby Care Home DS0000055360.V346935.R01.S.doc Version 5.2 Page 7 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.V346935.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.V346935.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): Standards: 3 & 6 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People have their needs assessed before being admitted to the home and they were assured those needs would be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Two sets of care records of people who use the service were looked at, one for a recent admission and one for a person who had lived at the home for six months. There was a pre admission assessment in place in the records along with a care management assessment. Ingleby does not provide intermediate care. Ingleby Care Home DS0000055360.V346935.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): Standards: 7, 8, 9 & 10 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. People receiving the service are happy with the way in which care is delivered by staff. Some of the records detailing how health and personal care is to be delivered and associated risks need more detail and information. The system for managing medication is generally satisfactory and only staff who have received the appropriate training have any involvement with medication. Some additional measures are needed which will strengthen this further. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The same two sets of records were looked at in more detail. The actual format in terms of information flow was good. One of the records looked at generally contained the information needed to show how this person’s needs were being met. The other set of records did not have a full assessment in place. The manager said that if there is no problem in specific assessed areas then the Ingleby Care Home DS0000055360.V346935.R01.S.doc Version 5.2 Page 11 assessment pages are removed. There was discussion about this and it was agreed that a full assessment should be in place, as it should be giving holistic information about individual’s not just problem areas. The assessments continue to need to have more information and by increasing the level of detail this would enhance the records further and create a more person centred plan of care. The actual evaluation of care also needs more information to determine if the care plan and interventions are being effective or not. Through discussion with the manager, it was acknowledged that some progress had been made but it was agreed that further development is needed in regard to care needs assessments and plans. A range of supporting risk assessments are in place, including amongst others, one for nutrition, moving and handling and pressure risk. However, some of these are not being reviewed frequently enough. There are clear records that detail the involvement of other people such as GP’s, District Nurses, Optician and Continence Advisors. A district nurse was observed to be visiting on the day of inspection. A number of surveys were received and contained the following comments, “My brother/sister has nothing but praise for the personal care he/she receives. Matron and all staff are always willing to support and assist him/her, making suggestions which will help him/her”. “My aunt/uncle has been a resident for a year now, during that time she/he has settled well and formed good relationships with the staff. I visit often unannounced and have never found her/him less than comfortable. She/he has benefited from proper food and medicine. The staff are always kind and friendly who seem to genuinely care for the residents”. The medication systems were discussed with one of the two of the senior staff. The system was generally good in terms of ordering, storage and administration, with appropriate checks and supporting records in place. The records looked at contained appropriate information. It was confirmed that only staff who have received the appropriate training are involvement in the administration of medication and that there is some ongoing competency assessments. There were some areas that needed to be improved upon. The temperature of the fridge needs to be recorded daily as does the temperature of the upstairs medication storage room. The fridge needed to be tidied up. There was the need for an up to date British National Formulary. Where items are handwritten on to the Medication Administration Records this needs to be checked by a second person and be countersigned. The procedure and risk assessment for people who self medicate needs to be reviewed as it did not contain sufficient information and was unclear about the ongoing monitoring. The use of the waiver that is also in place also needs to be reviewed. One Ingleby Care Home DS0000055360.V346935.R01.S.doc Version 5.2 Page 12 person who self medicates did not have appropriate lockable facilities for their medication; this needs to be addressed to ensure safety to all. The policy and procedures for all aspects of medication management within the home needs to be reviewed. They are currently generic, as such do not reflect the way in which medication is managed and administered in Ingleby and do not give staff the guidance and information needed to ensure safe practise. Ingleby Care Home DS0000055360.V346935.R01.S.doc Version 5.2 Page 13 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): Standards: 12, 13, 14 and 15 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. People who use the service have some opportunity to take part in activities. They are supported to live in a flexible environment where there is choice of routines and independence. The food provided does not fully meet preferences, like; dislike and the dietary and cultural needs of the people who use the service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager said that she was in the process of recruiting an activities person as the previous person has left. During discussion with staff they said that it would be beneficial to have some more arranged social and recreational activities for the people who lived at Ingleby Care Home. A relative survey stated, “One or two more staff per shift would allow more time to organise simple activities for residents - sewing, knitting or other handicrafts listening to music or simple exercise/clapping classes”. Ingleby Care Home DS0000055360.V346935.R01.S.doc Version 5.2 Page 14 It was confirmed through discussion with people who live at the home and with staff that visitors are welcome at any time. Some people also had telephones in their rooms so that they could maintain contact with their loved ones. A relative survey contained the following comment; “I visit my brother/sister several times a week as I live close by. He/she can phone me daily and matron and staff are aware of our contact”. There was much discussion with people who use the service about the meal provision within Ingleby and a number of surveys also made comment. The comments included, “They give my mum/dad sandwiches at teatime 7 days a week, she/he does not like them finds them difficult to eat them with her/his teeth not being the correct size. Lunchtime food ok but teatime is terrible what is served up. Some times by an unqualified cook”. “I feel the choice of meals could be better. I appreciate there are budgeting restraints, but heavy meals are not always appetising to the elderly where there is a choice for a main meal it is often little different from choice one”. Discussion with people who live at the home also raised concerns about the food. They said, “Likes and dislikes are not being catered for and you sometimes get burnt offerings”. “ The vegetables are overcooked and the teameal is not that good really. It would be helpful to have the menu’s available to us for example on the tables”. “There is apparently some problem with the cooker as some of the food has been burnt”. The menu was looked at and particularly the tea meals were repetitive and not of sufficient nutritional value, for example cold meat fritter on Wednesday and spam fritter on Saturday. There was discussion with the manager about the meal provision. She confirmed that concerns had been raised and that she was in the process of reviewing the menu and involving a number of people in this. It is recommended that the new menu should be sent to the dietician for comment and advice. She also confirmed that there was a problem with the cooker, which was being looked at currently. Ingleby Care Home DS0000055360.V346935.R01.S.doc Version 5.2 Page 15 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): Standards: 16 & 18 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People who live at the home are generally confident their complaints would be listened to, taken seriously and acted upon. People who live at the home are protected from abuse by the home’s policies and procedures. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The complaints procedure is on display within the home and contains the information needed. The complaint records were looked at and fully detailed the complaint made, the investigation and outcome correspondence. One complaint had been made directly to CSCI and passed back to the provider to investigate, this investigation was still underway. People who live at the home confirmed that they were aware of the complaints procedure and would be confident in raising concern if they needed to. Recently at a meeting a number of people raised concerns about the meal provision, this is in the process of being addressed. The training matrix detailed that the majority of staff had received training in respect of Protection of Vulnerable Adult. Staff confirmed that they had received this training. There have been no issues of this nature since the last inspection. Ingleby Care Home DS0000055360.V346935.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): Standards: 19 and 26 were looked at during this inspection. People who use the service experience good quality outcomes in this area. The home provides an environment that is appropriate to the specific needs of the people who live there. People are able to personalise their bedrooms and the home is warm, clean and comfortable. There have been improvements to the environment, which need to continue. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Significant improvements have been made to the environment since the last inspection. It was observed to clean, warm, homely and comfortable. The home has increased it bedroom numbers and has also extended the communal area with the construction of a well-situated sun lounge that leads out onto the garden. A number of carpets have been replaced, redecoration has been carried out to a number of areas, new bathing facilities have been installed Ingleby Care Home DS0000055360.V346935.R01.S.doc Version 5.2 Page 17 and there are a number of new curtains throughout the home. Plans are also underway to develop the garden further with a patio and garden furniture. These improvements most certainly enhance the environment for the people who live at Ingleby Care Home. In addition, the staff work/observation areas have been improved which increases the level of confidentiality in these areas. Some further improvements are needed to complete the refurbishment programme. The corridor carpets are somewhat tired looking. A ground floor dining room carpet needs to be replaced. The lighting in the corridors could be improved to make it brighter. It was also noted that some of the ensuite light fittings needed covers. The manager said that some of this work is planned. Access to the staff room and kitchen should be looked at from a safety aspect, as these areas are freely accessible to the people who live at Ingleby and there is ready access outside. Relative surveys contained the following comments about the environment. “The wardrobes are very difficult for a disabled person to get clothes out of and the drawers are stiff and the rails are too high”. This has been identified at previous inspections and also echoed by some people who live at the home during the inspection. There is also the need to ensure that people have accessible lockable facilities within their rooms for the valuables. One person said, “I am not really satisfied with the wardrobe, the door does not stay shut and the table fitment is not very good. I also do not have somewhere to lock my medication away”. Some comments made about improving the home further included, “By having better toilet facilities - very hard to get into the patients own toilet with a wheelchair”. “A better alarm call system. When my mum/dad is in the lounge there is no buzzer. The residents need to wear a buzzer around their necks so safe anywhere”. Although there is a call system in the lounge, the only way it can be used is if you are sat next to it or have the mobility to walk to it. This was discussed with the manager who agreed to look at some alternatives. Ingleby Care Home DS0000055360.V346935.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): Standards: 27, 28, 29 & 30 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. People are generally satisfied with the care they receive, but there are times when they may have to wait or may not have their needs fully met. The recruitment procedures generally ensure that people are protected. The manager recognises the need to ensure all staff are well trained, however further specific training would enhance their knowledge and awareness in meeting people’s needs further. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There are concerns about the staffing levels within the home; which people who use the service, relative and staff member’s expressed. One person who lives at the home said, “The carers have too much to do, there is not enough time to spend with people, they are meeting basic needs”. Another person said, “I have said don’t bother bathing me today, I know you haven’t time”. A relative spoken to said, “They are so short staffed, they are worked off their feet at times, one of the residents fell and there was no supervision or observation”. Relative surveys contained the following information, “The staff are lovely and work very hard but because of the drop in numbers of residents Ingleby Care Home DS0000055360.V346935.R01.S.doc Version 5.2 Page 19 there are only 2 carers to a floor and this is not enough. Sometimes mum/dad needs help to get ready for us picking her/him up and she/he is struggling when we get there”. “I just think the staff shortage is letting the home lack in certain areas”. Staff spoken to said, “There is insufficient staff to meet the needs of the residents, mealtimes can be problematic and there are not enough staff to cover appointments, we are meeting residents basic needs”. Another member of staff said that some of the difficulties have arisen as a result of care staff now having to do what were once catering staff duties and that they are being diverted more from delivering personal care and spending time with the people who live at the home. A further member of staff said, “I am concerned about the staffing levels, we have more and more jobs to do and are being stretched in too many different directions, it is like we are seeing to the task and not the whole person”. There were numerous more comments from staff about this. There was a general sense of their being a very dedicated staff team who were frustrated because they felt unable to care in the way they wanted to needed to. This was clearly having an impact on their morale. All of this information was shared with the manager, who was aware of it and said she was in the process of looking at workload planning. The inspector confirmed the staffing levels needs to be determined primarily by the needs of the people who use the service; the layout of the building also needs to be considered, as does the number of people within each of the units. It was clarified that the providers and not CSCI determine staffing levels. Despite the staffing levels, people who live at Ingleby Care Home spoke positively about the staff. They thought they were very friendly and helpful and believed they were listened to. By day two of the inspection staffing numbers had been increased. Two sets of staff files were looked at during the inspection and in the main contained the information needed such as, application form, references and Criminal Records Bureau Checks. As discussed with the manager, where staff from overseas are appointed, there is the need to ensure that they have the appropriate work status or work permit. At the last inspection, which took place within the past light months, 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. A training matrix was made available which showed a rolling programme of mandatory training and showed that the majority of staff were up to date with Ingleby Care Home DS0000055360.V346935.R01.S.doc Version 5.2 Page 20 this. The matrix also detailed more client specific training such as incontinence, diabetes and dementia. It was agreed with the manager that more of this training was needed to ensure that staff had an awareness and knowledge of the healthcare conditions that people are suffering from. A relative survey stated, “Mum/dad says sometimes she/he feels the carers don’t understand her/his problems with Parkinson’s disease”. Through further discussion with the manager it was also identified that the current induction is not in line with the Skills for Care common foundation, it was agreed that this would be addressed. Ingleby Care Home DS0000055360.V346935.R01.S.doc Version 5.2 Page 21 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): Standards: 31, 33, 35 & 38 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. The manager has the required qualification and experience to manage Ingleby Care Home. A small number of areas require further development to ensure good management systems are in place and that health and safety is fully promoted. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Ingleby is managed by a qualified Registered General Nurse who has the required knowledge and experience to manage this care home. Ingleby Care Home DS0000055360.V346935.R01.S.doc Version 5.2 Page 22 There have been a number of changes within Ingleby over the past twelve months with a substantial amount of building work and upgrading taking place. Along with the home no longer providing nursing care, this inevitably has had an impact on the people who live there and the staff. There are some morale issues with the staff, however they are looking forward to a level of stability. The manager acknowledged that it has been at times quite challenging and is also looking to build upon what is in place for the benefit of all. Quality assurance was discussed with the manager. A number of audits and satisfaction surveys take place, including a food, medication, relative surveys, residents surveys, environmental audits and care plan audits. It was agreed with the manager that there is the need to detail the actions being taken and where appropriate to produce a brief report. 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 people who live at the home balanced when checked. A sample of maintenance records was looked at such as water temperatures and weekly fire checks. Care was needed to ensure that these were being tested at the appropriate frequencies. A sample of policies and procedures were looked at and it was identified that it was not easy to find specific procedures and perhaps would be more helpful if the employment policies were contained within a separate folder making the care related procedure easy to access. It was noted of the procedures looked at that they were generic and not reflective of the service. Additional information is needed to ensure that staff have the relevant information needed to implement the said procedures. Ingleby Care Home DS0000055360.V346935.R01.S.doc Version 5.2 Page 23 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 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 X X 2 X 3 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 X 2 X 3 X X 2 Ingleby Care Home DS0000055360.V346935.R01.S.doc Version 5.2 Page 24 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 Timescale for action 01/08/08 2. OP8 14 3. OP9 13 The work that has commenced on improving the care needs assessments and care plans must continue and staff must receive further training. 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. The health care assessment tools 01/06/08 must be accurately and regularly 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. 01/05/08 • There medication policy and procedures must be reflective of the systems in place within the home, which are relevant to the service to ensure that staff have the correct information and guidance DS0000055360.V346935.R01.S.doc Version 5.2 Ingleby Care Home Page 25 4. OP15 16 5. OP24 16 6. 7. OP24 OP27 16 19(1) 8. OP38 13 for the safe handling of medication • The risk assessment and supporting records for people who want to selfmedicate must be reviewed and people must be provided with an appropriate locking facility. This will ensure that good systems are in place and people are protected. The menu review must be completed and must take into account people’s like, dislikes, preferences and ensure that meal meet the health, nutritional and cultural needs of people living at the home. The bedroom furniture must continue to replaced or refurbished. (This is an outstanding requirement since 22/9/04) Lockable facilities must be available with people’s room that are accessible for their use. The numbers of staff must remain under review to ensure that the appropriate numbers, and skill mix of staff are on during and able to meet the needs of the people who use the service. The new policies and procedures must be amended so that they are reflective of the service and give the staff the information and must provide staff, residents and relatives with the information they need to ensure safety, wellbeing and protection. These must be easily accessible to staff. 01/06/08 30/09/08 02/04/08 31/03/08 30/09/08 Ingleby Care Home DS0000055360.V346935.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 people have social outlets related to their lifestyle needs. • Handwritten additions to the MAR sheet should be witnessed and have a double signature. • There must be an up to date BNF. • The temperature of the medication rooms and fridge should be monitored on a daily basis. • Ongoing competency assessment should be carried out on a regular basis for all staff responsible for the administration of medication. • The refurbishment programme should continue. This should include the replacement of a number of carpets and improved lighting to the corridors. • Where necessary, further advice should be sought to look at ways of making the ensuite facilities more accessible for people in wheelchairs. • The call system within the lounge area should be looked at with a view to making it more accessible to people who are in the lounge. • 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. The quality assurance systems should be developed further and the outcomes should be available to people in an accessible format. The water temperatures and fire checks must take place at the required intervals. 2. OP9 3. OP19 4. OP30 5. 6. OP33 OP38 Ingleby Care Home DS0000055360.V346935.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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.V346935.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. 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