Inspection on 18/07/07 for Ivy House Care Home

This inspection was carried out on 18th July 2007.

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

Ivy House Care Home 10/08/09

Ivy House Care Home 27/01/09

Ivy House Care Home 26/09/08

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Ivy House Care Home 50 Ivy House Road West Heath Birmingham West Midlands B38 8JZ Lead Inspector Kath Strong Key Unannounced Inspection 18th July 2007 07:20 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 Ivy House Care Home DS0000068295.V346202.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. Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ivy House Care Home Address 50 Ivy House Road West Heath Birmingham West Midlands B38 8JZ 0121 459 6260 0121 459 6328 angie444422@aol.com 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) Four Seasons Homes (No 4) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Post Vacant Care Home 76 Category(ies) of Dementia (18), Dementia - over 65 years of age registration, with number (18), Old age, not falling within any other of places category (76) Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 76 persons - 40 for general nursing care, 36 in need of residential care for reasons of old age or dementia. To continue to provide care to two named residents who have a learning disability. 08/05/06 Date of last inspection Brief Description of the Service: Ivy House is a purpose built nursing and residential home situated in a residential area of West Heath, South Birmingham and is situated near to a number of bus routes. The home’s category of registration is for older people requiring either residential or nursing care. The home can also provide residential care for older people with dementia. All rooms are for single occupancy with an en-suite facility consisting of toilet and hand basin. The home is divided into two floors with the upstairs being dedicated to nursing care and downstairs to residential dementia care. Each floor is split into two areas and these are named after flowers. Within each area there is a lounge/dining area and assisted bathing and toileting facilities. The enclosed, well laid out rear garden is easily accessible to residents. Both floors are accessible via a shaft lift. The home has a comprehensive range of specialist equipment to enable staff to provide safe transfers of people who have restricted mobility. There is a range of pressure relieving equipment for those who are prone to developing pressure ulcers. The home has an open visiting policy and a varied activities programme including a sensory room. Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home did not know that the fieldwork visit would be carried out, this is to enable the inspector to obtain a snapshot of the normal everyday functioning of the home. At the time the home did not have a manager in post but it was anticipated that the vacancy would be filled shortly. Assistance was provided by the regional manager and the homes deputy manager. At the conclusion of the visit verbal feedback was given to the deputy manager. No Immediate Requirements were made. Information was gathered from speaking with people who reside in the home, a relative, visiting external professionals and staff. Care, health and safety and the arrangements for medications were reviewed. Staff personnel files were checked and staff were observed whilst performing their duties. A partial tour of the premises was carried out. Two of the eight care plans reviewed were case tracked. This involves obtaining information about individuals’ experiences of living in the home. This was done by meeting or observing people, discussing their care needs with staff, looking at care plans and focussing on outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is based upon the outcomes for people who live in the home and their views about the services provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and aspects of service provision that need further development. What the service does well: Ivy House is a purpose built home offering a range of services in a comfortable and pleasing environment whilst peoples healthcare needs are being met . Peoples personal and healthcare needs are well met to promote their health and wellbeing. Although the home did not have a manager in post the day to day operations of the home were being well managed by the deputy managers. Upper management had allocated sufficient time for management tasks to be completed. Also the manager of a sister home makes regular visits to provide support for the deputy managers. This permits competent running of the home and that staff continue to be supervised to ensure that good standards of care are continued. Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 6 People who are assessed as being safe to do so are encouraged and supported in going out unaccompanied. This promotes peoples maintenance of their skills of daily living and independence. Positive comments were made by people who live in the home, “Staff really looked after my wife, they were so good”. “Staff will help you when you want it”. External professionals also made comments, “Staff are responsive and have agreed to a proposal we have just made about working together as a team”. What has improved since the last inspection? A system has been introduced that permits use of agency staff when staffing shortages are identified. This ensures that staff are rostered in sufficient numbers to meet the numbers and needs of the client group. The home has completed the introduction of new care plans. Providing that recordings are comprehensive the care plans cover all aspects of personal and healthcare needs as well as peoples life history and background, personal preferences, hobbies and aspirations. This system indicates that care should be delivered in a way that suits the individuals’ activities of daily living and lifestyles. Two new hoists have been purchased and a good number of slings. The home is aiming towards provision of a sling for everyone who needs assistance due to restricted mobility. The proposed system will assist staff in minimising the risks of infections occurring. All communal areas/rooms of the ground floor have been redecorated and the carpets replaced. This achieves a pleasing environment for people who live in the home. There has been an increase in staff training because the home is aiming to supply all staff with the relevant training. When completed this will provide staff with the knowledge and skills to carry out their roles effectively. Staff roles have been reviewed and they are now clearly defined and staff are aware of their boundaries within their roles and accountability. This ensures that staff know what tasks they need to do and when to seek advice. Carers are encouraged to read care plans and senior staff provide explanations of medical conditions and why the recordings are necessary. This indicates that carers have a good understanding of peoples needs to assist them when delivering personal care. When an accident occurs that has been witnessed by carers or when they are the first person to be made aware of an accident they are being encouraged to Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 7 complete the necessary documentation. This eradicates unnecessary support from senior staff and highlights the importance of the roles within the care team. 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. Ivy House Care Home DS0000068295.V346202.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 Ivy House Care Home DS0000068295.V346202.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Written details about the services need to be up dated to assist people in making a decision about living at the home. Peoples’ needs are not fully assessed to ensure that the individual and the home can be sure that the placement is appropriate. EVIDENCE: A copy of the statement of purpose is on display in the reception area. Although the lists of contents are acceptable they were in need of review regarding staffing levels and the managers details. This is necessary to provide up to date information about the home and details about the registration of the home. Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 10 A copy of the service user guide is given to people when they are admitted. The document provides people with ample information about the home and the services provided. Four pre-admission assessments were reviewed including the two most recent admissions. The tool used is based upon a tick process with space for free text for each topic. The tool is accompanied by the dependency rating tool. Both documents permit comprehensive information to be recorded about a persons needs and illnesses. Activities of daily living and personal preferences can also be recorded. Following assessment a letter is sent to the prospective resident to confirm that the home is able to meet the assessed needs of the individual. Some shortfalls were found in respect of recordings: • One had not been dated to advise when it had been completed • There was little use of the free text boxes to expand on required information about the persons needs • One tool completed refers to a previous abdominal operation but no details were recorded about when or why the operation was necessary • A detailed social assessment mentions a previous heart attack but no recordings about when the operation was carried, why and whether any further treatment is required. Comprehensive pre-admission assessments are necessary to identify all conditions and the resultant care needs and for senior staff to determine that the home is able to meet the persons needs at the time of admission. The home does not provide intermediate care. Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Shortfalls need to be addressed for the home to fully demonstrate in the care plans that peoples’ needs are being fully met. Staff practices in administration of medications are unsafe. EVIDENCE: Each person has a written care plan, which should be developed with the respective person or their representative being invited to participate and agree it. This identifies the assessments carried out and the care needs that staff should deliver to promote the persons’ health and wellbeing. After completion the care plan should be regularly reviewed. Eight care plans were seen including the latest two admissions and a selection from each of the four units of the home. The implementation of new care plans has improved the recordings made by staff in identifying peoples specific needs and guidance for staff to follow to meet individuals needs. There were instances of very good recordings made that give a full and clear picture of Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 12 peoples needs. The files are indexed for ease of access to particular sections. They include peoples preferences such as time of retiring and rising and preferred bathing method and whether it should be morning or evening. Care plans include details about physical and mental health conditions and needs to enable staff to tailor the care to suit the individual. Other relevant assessments are carried out to determine nutritional status, skin integrity and risk assessments and what needs to be put in place to minimise the identified risks. These are regularly reviewed and the findings are incorporated into the care needs when necessary. Some shortfalls were found that require addressing: • One file states in the handling profile ‘move chair in position and use handling belt also oxford hoist medium sling’. Care plan number seven states ’wanders around the home independently’. This does not provide staff with accurate instructions regarding the assistance required • A recording dated 14/05/07 advises about a toe infection and treatment with antibiotics but a short term care plan had not been developed • Another file states ‘occasional incontinence of urine’. ‘------ is still encouraged daily with going to the toilet’. This does not provide staff with specific instruction about how often and suggested timings that are appropriate for that individuals normal pattern • A care plan states ‘feeling of isolation’, but fails to mention that her husband spends every afternoon with her • An activities care plan had not been dated or signed by the author • A care plan regarding a person who has dementia had not been reviewed since 12/07/06 • A care plan in respect of removal of the call bell must be accompanied by a risk assessment • A care plan dated 12/07/06 fails to include difficult to manage behaviour. Staff need to be advised of the likely triggers, the type of behaviour displayed and what they need to do to diffuse the incident • A Waterlow assessment had not been dated or signed. The outcome score of 26 means that special attention to this is required • Another file contained a pre-admission assessment that failed to include the date it was carried out or the date of admission to the home. The home is failing to demonstrate from documentation that all of peoples needs are being fully met. Comments received by people who live in the home were, “I quite like it here”. “Staff help me to have a wash, do my bed and tidy me up”. “I don’t mind, I’m quite happy here”. “Staff will help when you want it”. “The home is OK and staff do what they can”. A visiting relative said, “Its very good in comparison to the other five or six looked at”. Another visiting relative said, “The staff are alright, they do what she needs. They come and hoist her and take her to the toilet numerous times a day. I feed her but if I didn’t do it staff would do it”. Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 13 There was good evidence of the input of external professionals who are invited into the home to assess people and give staff advise about what needs to be done to restore good health as much as practically possible. Staff appeared to be responding positively to the instructions given to them regarding specific care needs. Two visiting professionals were spoken with, they reported that staff are responsive and a senior person had agreed to a suggested initiative regarding team working. They also advised that it is difficult to have their telephone calls answered and may have to give up trying. The medications were being regularly audited by senior staff. All of the arrangements for the safe administration were found to be good with one exception. The morning administration of medications in the residential unit was observed. It was noted that the MAR (medication administration record) chart was being signed before the medication was taken to the relevant person. MAR charts may only be signed after administration to confirm that it has been successfully carried out. Audits were carried of those persons who were being case tracked and two others whose care plans were seen, all were satisfactory. The recordings made appeared to be in good order and daily checks and recordings such as fridge temperatures were found to be correct. Staff were observed using the preferred term of address to people. Personal care was delivered in the privacy of peoples own bedroom or a bathroom. Peoples privacy and dignity appeared to be maintained, very good interactions between staff and residents were noted. Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The activities offered are extremely scant nor do they reflect that peoples preferences have influenced the programme and fails to enhance peoples lifestyles. A wholesome and varied diet is offered and specialist diets are catered for. EVIDENCE: The activities programme on display in the residential unit indicated that the main recreations provided were bingo and quizzes. Occasionally other events include old time sing a long, making Easter bonnets, card and board games. The programme failed to indicate that people have been consulted about the range of activities they would prefer. A communion service is provided every month on the residential unit and people from other units are supported in attending if they express a wish to. The unit where people with dementia live require one to one attention during provision of an activity but there are only two carers allocated to afternoon and evening shifts. Staff are also needed to pay constant attention to those who wander and those who display difficult to manage behaviour. This does not appear to be sufficient to meet their Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 15 personal and recreational needs. Staff on duty also expressed their concerns about the situation and the demands placed on them. It was reported that the activities organiser had been absent for over five weeks and it was evident that activities were not being provided or that interim arrangements had been made. During the visit there was no indication that activities were being provided during the morning or afternoon, people were seen having to devise their own things to do to occupy themselves. Staff reported that they do not have time to provide the activities but may instigate a board game in the evenings. A person who lives at the home said, “The activities organiser has been off for five weeks plus, none have been provided in the meantime”. People who live at the home were not being physically and mentally stimulated to enhance the quality of their lifestyles. People who are assessed as being able are encouraged and supported to go out unaccompanied. A person spoken with said that he goes out to the local shops daily or occasionally into town. Two people go to day centres to promote their daily living skills and independence. Others go out with family and friends, one informed the inspector she occasionally goes out with her son. People are encouraged to maintain contact within the community. No meetings with people who live in the home and their relatives have been held since March of this year. This does not give people opportunity to exercise choices that influence the day to day running of the home. However people spoken with did advise that they rise and retire at times that suit them and it was noted that one person who usually rises early was having a sleepin. Staff respected peoples preferences. The home operates a four week rolling menu. Breakfast includes choices of various cooked foods. Lunch is the main meal of the day and two choices are offered for the main course. The menu suggests that the choices are good and that fresh vegetables are included. The evening meal consists of soup, assorted sandwiches, a light cooked meal or salad dessert and cake. Toast, sandwiches and biscuits are available between the evening meal and breakfast. The cook is able to cater for specialist diets such as diabetes. The organisation uses the Guide to Eating and Nutrition in Care Homes when they develop or review their menus. This ensures that people are offered a range of meals that are varied and nutritionally balanced including a range of fresh ingredients. Serving of the evening meal was observed. Staff gave appropriate assistance whilst encouraging people to maintain their independence. Good relationships between people and staff were noted. It was noted that as well as soup, pizza and sandwiches that other preferences had been actioned with a variety of other foods that had been requested. Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 16 Positive comments were made, “They never have any problem here with the cooking, its good and the soup is very good”. “I usually have sausage, egg, tomato and toast for breakfast”. “You can’t grumble about the food”. Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are confident that their views will be listened to and that complaints made are dealt with effectively. Lack of staff training fails to ensure that people are fully protected from risks of abuse. EVIDENCE: The complaints procedure is on display in the reception area of the home. This provides people with information about how to make a complaint, what they expect senior staff to do and when a response is likely. Since the last inspection May 2006 the home has had three complaints. Two were sent directly to the home and the documentation indicates that they were dealt with appropriately and where action was needed it was carried out within a good timescale. The third complaint was sent to CSCI, the aspects of the complaint involved night shifts. The concerns raised formed part of this inspection process and to capture all necessary data the inspection commenced during the time when night staff were still on duty. The outcome was that none of the issues raised could be substantiated therefore Regulations had not been breached. The home has a comprehensive policy and teaching materials regarding adult protection. During discussions held with care staff they demonstrated Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 18 sufficient understanding to take appropriate action when abuse is suspected. Some trained and care staff had not received training in adult protection. There have been five allegations made since the last inspection. One concerned bogus people entering the home, another was in respect of two people who live in the home who did not get on with each other. Two complaints were raised by people who live in the home about a member of staff. Another concerned inappropriate staff practices, other agencies have been involved to evidence that all systems put in place by the home ensures that health and safety are as robust as possible. Only three of the five allegations were promptly reported to the appropriate agencies. Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with warm, comfortable and homely accommodation to enhance their enjoyment of living in a home. EVIDENCE: The building was purpose built and provides people with a good standard of accommodation. Each floor consists of two units, which are individually staffed during daytime hours. The home is light, airy and spacious. All areas were well decorated, hygienic and well maintained. The four well appointed communal rooms in each unit consist of a lounge/dining room with a kitchenette where refreshments can be made at all times. The units also have toilets and assisted bathing facilities. A person who lives at the home was observed Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 20 making himself a drink. The corridors are sufficiently wide to accommodate wheelchair users. All rooms have a call bell system to enable people to summon assistance. There was ample pressure relieving equipment to cater for the needs for the current client group. Staff use a range of lifting and moving equipment to assist people with restricted mobility in making transfers. The floors are accessible by a shaft lift. Four bedrooms were visited of people whose care plans were seen. The bedrooms comply with the dimensions that they are required to be. They were noted to be well appointed and had been well personalised by the occupant. One room contained lots of soft toys another had lots of photos on display. Bedroom doors had suited locks so that those who wish to and have been assessed as being safe to do so are offered their door key to ensure their privacy preferences are met. All bedrooms are for single occupancy and include en-suite consisting of toilet and wash hand basin. One person said, “I am happy with my room”. Although the rooms appeared to be clean one had a very strong malodour, which needed addressing. The kitchen has a full complement of staff and the standards maintained are very high with exceptional hygiene practices adhered to. Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are not maintained in sufficient numbers to ensure that all of peoples needs are being met. Some staff training is required to ensure that they are supplied with the knowledge and skills to carry out their roles effectively. EVIDENCE: Review of the staffing rota for a four week period indicated that staffing levels remained constant on each unit. It was noted that it was common practice to have one trained and two carers on duty in the unit where dementia people live. A staffing increase is required, senior staff had failed to take into account the high dependency levels that these people demand. When shortages are identified senior staff contact an agency to request staff to work shifts at the home. This ensures consistent levels of staff are available to cater for people efficiently. The handover of night staff to day staff was observed on the first floor. Each person was reported on and clarification sought by day staff where necessary. This ensures that staff have a good understanding of peoples needs and any changes that may be required. There is a full range of ancillary staff employed to ensure that all staff carry out their dedicated roles. Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 22 Some comments were made by people who live at the home. “The staff are fantastic”. “I am quite happy with the staff, they go out their way to help you”. “Staff are very good”. A number of staff personnel files were reviewed to determine recruitment practices. It was found that all necessary checks are carried out and two satisfactory written references are obtained before a position is confirmed. This indicates that peoples safety is paramount. Newly appointed care staff undertake a comprehensive induction programme that reflects the contents for Skills for Care programme. This supplies them with the basic ability to work within their role. Less than 50 of staff have successfully completed NVQ level 2 but two have also completed level 3. All staff had completed a moving and handling course but some gaps were found in other mandatory training areas. Some had not completed Health and Safety, Fire Safety and as mentioned previously adult protection. Approximately 50 of staff have received training in dementia care, this is needed to meet the specialist needs that people require. The training programme needs to be completed to provide staff with the knowledge and skills to meet peoples needs. Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. In the absence of a manager the day to day operations of the home are being well managed. The quality assurance programme is extensive and evidences that sustained improvements are an ongoing process. Arrangements in respect of health and safety are robust and this prevents risks of injuries from occurring. EVIDENCE: The home did not have a manager at the time of the visit. The two deputy managers were carrying out the role of acting manager. Upper management had ensured that they have adequate periods of time to carry out the role. A manager from a sister home had been visiting regularly to provide support and guidance to the deputy managers. The system appeared to be working well, Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 24 no concerns were raised about the management of the home. The regional manager also made regular visits to the home. She advised that interviews were planned to take place the following week and that she was optimistic that the managers vacancy would be filled. The home carries out an extensive quality assurance programme that includes peoples opinions about the services provided. At the conclusion of the many audits carried out a report is written and any shortfalls identified result in an action plan and timescale for resolution. The same system is utilised after questionnaires have been received. There are plans combine these two processes into one system. The regional manager carries out monthly inspection visits to the home and provides a written report to the person in charge. This demonstrates that the home is making continual improvements for the benefit of the people who live in the home. The arrangements for the safekeeping and financial transactions of peoples personal monies are robust, this prevents financial abuse. The accidents records are good and audits are carried out of the number and type of accidents that occur each month. All relevant checks and servicing of equipment are carried out to ensure that they are fit for purpose. The fire alarm and emergency lighting systems are regularly checked and the findings recorded to protect people from harm in the event of an emergency situation. Regular fire drills are carried out and staff names who have participated are recorded to ensure that all staff are captured at least annually. The home has an up to date and comprehensive fire risk assessment. An inspection carried out by West Midlands Fire Service July 2006 resulted in no concerns being found. The arrangements appear to protect people from risks of injury. Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 3 3 3 3 2 x 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 x 3 x x 3 Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4(1)(b) Requirement The statement of purpose must be amended in respect of staffing and management details and the emergency procedures. This will ensure that prospective residents and professionals will have up to date information about the services to make an informed decision about living at the home. Improvements in standards of pre-admission assessments must be made to include: • More free text to ensure adequate information has been obtained to make a decision • When used the tools must be dated • Full details are needed about previous operations to enable decisions to be made • Previous medical conditions must include when they developed and any treatment the individual needs. DS0000068295.V346202.R01.S.doc Timescale for action 30/09/07 2. OP3 14(1)(a) 15/08/07 Ivy House Care Home Version 5.2 Page 27 3. OP7 15(1)(b) This is required for senior staff to have comprehensive information to enable them to make a decision about the homes ability to meet the persons needs. Care plans must be fully 31/08/07 developed: • Include dates of entries and signatures of the author • Care plans must include difficult to manage behaviour, likely triggers, type of behaviour and what staff should do to diffuse the situation • Short term care plans must be developed for infections and other conditions • Staff instructions in respect of incontinence must be specific to ensure they have detailed guidance • Regular reviews must be carried out • Where part of the service is withdrawn such as the call bell risk assessments must be carried out • Follow up action and reviews must be carried out where Waterlow outcome scores are high. This is required for the home to demonstrate in care plans that all aspects of care are identified, planned and delivered. The practice of confirming in writing that people have taken their medications before they have been offered to them must cease. This is required to ensure that safe practices are adhered to. The programme of activities must be reviewed and tailored to DS0000068295.V346202.R01.S.doc 4. OP9 13(2) 15/08/07 5. OP12 16(2)(n) 31/08/07 Ivy House Care Home Version 5.2 Page 28 meet peoples preferences, aspirations and take into account the needs of people who have dementia. Activities must be provided at all times including when the activities organiser is not available. This is required to provide physical and mental stimulus and to enhance the quality of peoples lifestyles. All staff who provide personal 31/10/07 care must receive training in adult protection. This is required to ensure that staff possess the knowledge and skills to act appropriately when abuse is suspected. There must be adequate staffing levels on the dementia unit. This is required to ensure that all of peoples needs can be met appropriately and safely. All staff who provide personal care must receive training in Fire Safety, Health and Safety and Dementia care. This is required to ensure that staff have the knowledge and skills to carry out their roles effectively and to meet peoples specialist needs. 6. OP18 18(1)(a) 7. OP27 18(1)(a) 31/08/07 8. OP30 18(1)(a) 31/10/07 Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 29 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. OP14 2. OP19 3 OP24 Refer to Standard Good Practice Recommendations Consideration needs to be given to re-establishing meetings for people who live at the home and their relatives to give them opportunity to influence the day to day running of the home. Consideration should be given to installing a comprehensive signage system to assist people who live at the home in orientating and maintaining their independence. Consideration should be given to eradicate the malodour in the bedroom to make it a pleasant environment for the occupant. Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Ivy House Care Home DS0000068295.V346202.R01.S.doc Version 5.2 Page 31 - 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!