Inspection on 26/09/08 for Ivy House Care Home

This inspection was carried out on 26th September 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ivy House Care Home 10/08/09

Ivy House Care Home 27/01/09

Ivy House Care Home 18/07/07

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 17/12/2008.

CARE HOMES FOR OLDER PEOPLE Ivy House Care Home 50 Ivy House Road West Heath Birmingham West Midlands B38 8JZ Lead Inspector Lisa Evitts Unannounced Inspection 26th September 2008 10:10 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.V372268.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.V372268.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 ivyhouse@fshc.co.uk www.fshc.co.uk Four Seasons Homes (No 4) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Manager post vacant Care Home 76 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) 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.V372268.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Currently under review 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. 18th July 2007 Date of last inspection Brief Description of the Service: Ivy House is a purpose built home situated in a residential area of West Heath, South Birmingham. The home offers nursing and residential care for up to 76 people who may also have dementia care needs. All bedrooms are for single occupancy with an en-suite facility consisting of toilet and hand basin. The home is divided into two floors. Two units upstairs are dedicated to nursing care and on the ground floor there is one residential and one nursing dementia care unit. Within each area there is a lounge/dining area and assisted bathing and toileting facilities. Corridors are wide to enable people who need adaptations to move around the home. The home has a range of equipment to assist people to move around the home and pressure relieving equipment for those who are prone to developing sore skin. The enclosed, well laid out rear garden is easily accessible to people living at the home. There is off road parking to the front of the property, which is sufficient for the home, one of these spaces is for disabled people to park closer to the home in a larger space. The home is situated close to a number of bus links. There are a range of local shops and community facilities nearby. Current fee rates for living at the home were not available on the day of our visit but should be available from the home on request. In the reception area there are leaflets of interest for anyone who wishes to read them. Ivy House Care Home DS0000068295.V372268.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 0 stars. This means the people who use this service experience poor quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. The visit to the home was undertaken by two inspectors over eight hours and was assisted throughout by the deputy manager. The home did not know that we were visiting on that day, when there were 64 people living there. Two people were receiving hospital treatment. There is an adult protection investigation in progress at the home and the police are taking the lead in the investigation. There is a suspension placed on the beds at the home, which means that Health and Social Care will not fund any new placements until the home makes some improvements. Information was gathered from speaking to and observing people who lived at the home. Three people were “case tracked” and this involves discovering their experiences of living at the home by meeting or observing them, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Three further files were partly reviewed. Case tracking helps us to understand the experiences of people who use the service. Staff files, training records and health and safety files were also reviewed. Random questionnaires were sent out to seven staff and to fifteen people who live at the home in order to gain their views about the service. Six people who live at the home and one staff member returned the questionnaires and their comments about the service provided and are included within this report. It is difficult to get peoples views about the home due to differing levels of dementia however three people who live at the home, two visitors and six staff were spoken to. A relative was also spoken to on the telephone following our visit. Prior to the inspection the Manager had completed an Annual Quality Assurance Assessment (AQAA) and returned it to us. This should tell us how well the home think they are performing and should give us some information about the home, staff and people who live there, improvements and plans for further improvements, which we would take into consideration. Unfortunately the AQAA did not provide us with much information about the home. Ivy House Care Home DS0000068295.V372268.R01.S.doc Version 5.2 Page 6 Regulation 37 reports about accidents and incidents in the home were reviewed in the planning of this visit. During our visit to the home the manager was on leave and a number of records that we needed to see were not available. Systems need to be in place to ensure that information is available to people even when the manager is not in the building. Following the visit we spoke to the Regional Manager via the telephone to discuss the concerns we found during our visit and to request that some information was sent on to us to review. The Regional Manager was very open about where improvements needed to be made and told us about how the organisation were going to do this. This will be reviewed at our next visit to the home. What the service does well: What has improved since the last inspection? There is an ongoing maintenance programme in respect of decorating and purchasing new furniture and equipment. This ensures that there is a homely and comfortable environment for people to live in. A gardener has been recruited so that the gardens are well maintained for people to use. A new home manager has been recruited so that people know who is responsible for the home. Ivy House Care Home DS0000068295.V372268.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. Ivy House Care Home DS0000068295.V372268.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.V372268.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): 1&3 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People do not have sufficient information about the home to enable them to make an informed decision about whether they would like to live there. People’s needs are not fully assessed to ensure that the home can meet their needs before they move in. EVIDENCE: The certificate of registration was clearly displayed in the reception area of the home however we need to issue the home with a new one so that it reflects the current registration of the home. There was no previous inspection report available for people to read and we were told that the manager would have to send a copy out in the post if anyone requested to see this. There was no statement of purpose or service user guide displayed in the home so that people are provided with information about the home. We asked to see a copy of these documents and a statement Ivy House Care Home DS0000068295.V372268.R01.S.doc Version 5.2 Page 10 of purpose was produced late in the afternoon. This document was in a ring binder appropriate for the home staff but was not readily accessible to the people who live there or for anyone who may be considering going to live at the home. We looked at pre admission assessments for two people who had recently moved into the home. One was not dated or signed and it was not possible to determine that the assessment had taken place prior to the person coming to live at the home. The second assessment we looked did not contain enough information so that home could be sure that they could meet this persons needs upon admission. People told us: “Its a lovely place, I’ve been here over three years” “I’m very happy here” The home does not offer intermediate care services. Ivy House Care Home DS0000068295.V372268.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): 7,8,9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans do not provide sufficient information for staff to assist people to meet individual needs. The management of medication does not ensure that people receive their medication as prescribed. EVIDENCE: Each person had a written care plan. This is an individualised plan about what the person is able to do independently and states what assistance is required from staff in order for the person to maintain their needs. We looked at three peoples care plans in detail and partially looked at three other files. The plans provided details of peoples individual needs, likes and dislikes such as “likes to have a bath in the evening” and “prefers female staff only for personal care”. This means that people should receive care in a way that they prefer. Ivy House Care Home DS0000068295.V372268.R01.S.doc Version 5.2 Page 12 When individual problems had been identified, care plans had not always been written or didn’t provide enough detail so that staff knew how to meet these needs and monitor any changes. For example: ▪ one person had been treated for an infection but no care plan had been written to manage this or to inform staff how to reduce the risk of the spread of infection. Staff were monitoring the infection however information was recorded in the daily records and was not easily accessible ▪ One plan said, “check pads regularly”, but didn’t say how often or what type of pad should be used to manage the continence care ▪ One plan for a urine catheter told staff to change the leg bags every three days. There were no dates recorded when the bags were changed. The deputy manager told us that the date should be written on the bag itself, however when we checked the bag, there was no date written on so staff would not know when it was next due to be changed ▪ One person should have their blood sugar levels monitored each week, however when this was refused there was no indication that staff had tried to monitor this on an alternative occasion. This meant that there were times when this person did not have their blood sugars checked for up to three weeks ▪ one persons plan said to observe for non-verbal signs of pain or discomfort but was not clear what the signs were ▪ one person who had showed aggressive behaviour did not have a plan for staff to follow to try and minimise the risk of this behaviour occurring, or to provide them with details about what to do if the behaviour occurred ▪ One plan for sore skin stated that the dressings should be changed every three days, however the records did not evidence that this was being completed. It was recommended that the Tissue Viability Nurse was informed about this persons sore skin as no external advise had been sought since seen by a podiatrist in May. Documentation includes a number of risk assessments including, risk of sore skin, nutritional needs and moving and handling. These were not always completed and therefore staff would not be able to monitor any changes in health and act appropriately. A plan for moving someone with a hoist was very detailed and provided a stepby-step description for staff to follow to ensure that the person was moved safely. People appeared to be well supported by staff to choose clothing appropriate for the time of year which reflected individual cultural, gender and personal preferences. In the six surveys returned to us two people said they always received the care and support they needed, three people said usually and one person said sometimes. Ivy House Care Home DS0000068295.V372268.R01.S.doc Version 5.2 Page 13 We looked at how the home managed people’s medication and were concerned that on a number of occasions throughout the day we observed medication trolleys being left open and medication being left on tables. This does not ensure the safety of people who may be wandering around the home or may be confused due to their dementia. We looked at seven peoples medications and it was concerning that the balances of these were not correct and meant that people were not receiving their medication as prescribed. On the Medication Administration Records (MAR) we found that there were often gaps where medications had not being signed for. Staff had used codes but did not always record what the codes meant so that people knew why medication had not been given. The deputy manager was present while we completed these audits and was therefore informed of the concerns at the time. The Regional Manager was informed of the concerns via the telephone. Ivy House Care Home DS0000068295.V372268.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): 12,13,14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Activities may not meet all the needs of the people living at the home so that they experience a meaningful lifestyle. People are offered a choice of meals to meet their dietary, cultural needs or preferences. EVIDENCE: We were told that the activity coordinator was not at work at present and that the managers were to look at the activities and prepare a rota with the staff in the interim. There were notice boards situated around the home, which gave details of activities including games and coffee mornings. An external entertainer had been booked to perform a show at the home. During our day at the home we did not see any activities being undertaken. Televisions and radios were on in various communal areas but majority of people were sleeping in their chairs. This may mean that people are not being stimulated to enhance their lifestyles. Two people told us there were usually activities they could join in and two people told us there were always activities for them to join in. One person said, “The activities are fantastic. Bingo, skittles, darts, quizzes and we have our own library”. This will be reviewed again at our next visit to the home. Ivy House Care Home DS0000068295.V372268.R01.S.doc Version 5.2 Page 15 A monthly church service is held and people can receive Holy Communion if they choose to. This means that people can continue to follow in their chosen religion. There was no one of any other religions living at the home at the time of our visit. The hairdresser visits each week and the home has its own hair salon. One person told us about a holiday that they had just returned from and this means that people are supported to continue to maintain links with family and the community, whilst continuing to enjoy holidays away. There is an open visiting policy, which means that people can see their visitors as they choose and maintain relationships that are important to them. The home has a four-week rolling menu. Lunch is the main meal of the day and two choices are offered for the main course. The evening meal also consists of two choices of soup and sandwiches or a hot meal. Fresh fruit is available in the home. The home is able to cater for diets for medical or cultural reasons. We observed the lunchtime meal and staff assisted people to eat their meals in a discreet manner so as to maintain their dignity. People told us: “Breakfast is ok” “There is a variation of meals, drinks and breakfasts” We observed two people having a cold beer with their lunches and this shows that people have choices and their personal preferences are met. Ivy House Care Home DS0000068295.V372268.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People are not always confident that their views are listened to and acted upon. Lack of staff training does not ensure that people are fully safeguarded from harm. EVIDENCE: The complaints procedure was displayed in the reception are of the home. Our contact details had not been updated and this was brought to the attention of the deputy manager at the time of our visit. The (Annual Quality Assurance Assessment) AQAA told us that the home had received nine complaints in the last twelve month’s. The deputy manager was unable to show us the complaint record for the home and therefore we could not determine the nature of any complaints made or how the home had responded to them. We had received complaints about the home, which we had referred back to the provider to investigate, using their own procedure. We were unable to determine the homes response to these, as the complaint log was not available. A healthcare professional had told us that the home had not responded to a complaint they had made. We discussed this with the Regional Manager who told us that they had replied, however it appeared that the complainant had not received the response. The regional manager confirmed that a second complaint we referred to the home in May has not yet been responded to and this does not ensure that peoples concerns are Ivy House Care Home DS0000068295.V372268.R01.S.doc Version 5.2 Page 17 addressed in a timely manner. We have asked the home to send us information about the number, nature and outcome of the complaints they have received. In the questionnaires returned to us five people said they knew how to make a complaint if they needed to and one person said they didn’t know how to make a complaint. One person told us that they had made complaints but nothing was done to resolve them. Since the last visit to the home in July 2007, there have been some adult protection cases opened and closed. There is an adult protection case open at present and the police are taking the lead in the investigation. There is a suspension placed on beds at the home, which means that social care and health will not pay for anyone else to live at the home until improvements are made. The home has a copy of the Birmingham Multi Agency Guidelines and this should ensure that staff have guidelines to follow in the event of any allegations of abuse. The staff-training matrix indicated that some staff had received training in Protection Of vulnerable Adults (POVA) in 2006/2007. We looked at the induction booklet for a new member of staff. The second day of induction should cover POVA, however this had not been completed. It is recommended that all staff receive an update in POVA so that they have the knowledge to act appropriately to safeguard people in the event of an allegation being made. The recruitment of staff was not robust and this does not ensure that people are safeguarded from harm. Ivy House Care Home DS0000068295.V372268.R01.S.doc Version 5.2 Page 18 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): 19,20,21,24,25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are provided with a comfortable environment in which to live. Cleanliness and infection control procedures do not ensure that the home is clean and safe for people to live in. EVIDENCE: The home is purpose built and each floor consists of two units, which have a communal area and dining room. Each unit has a kitchenette area where refreshments can be made however when we looked at these areas we found that fridges and microwaves were dirty. There was lots of spillage of drinks and foods and flooring and work services were in need of a clean. This was brought to the attention of the deputy manager at the time, as may be a potential risk of infection. Ivy House Care Home DS0000068295.V372268.R01.S.doc Version 5.2 Page 19 Communal areas are well decorated and homely and there are a variety of chairs for people to sit in. The exception to this was on Rose unit where part of the room was used as storage for the activity equipment. This equipment was piled high in boxes and could potentially fall over and injure someone. It is recommended that an alternative area is sought for this equipment so that a homely and safe environment is created. New carpets had been laid in the corridors to enhance the environment and there was a rolling programme to address other areas of the home. The corridors are wide and spacious and allow people at the home freedom to move around with any equipment they are assessed as needing. The home has four hoists to assist people to change their position and have special mattresses for people who are at risk of developing sore skin. We looked at the bathrooms and the home has both walk in showers and assisted baths so that people can choose what they prefer. Some of the bathrooms and toilets required some remedial work, for example a number of tiles were broken, one toilets grab rail was loose, a shower connection was loose and plaster to walls was damaged in places. In some of the bathrooms the call bells were tied up out of peoples reach and this meant that people would not be able to call for assistance if they needed to. We found bars of soap and toiletries in the toilets and bathrooms and these should be returned to peoples own rooms to prevent the risk of cross infection. We looked at the bedrooms of the people we case tracked and found that these were personalised with items that reflected individual choices and preferences. People had the equipment that they had been assessed as needing. One bedroom is located outside of the two units and it was of concern that the person who occupied this room was not safe due to not being within one of the units. This was discussed with the deputy manager and we have been told that a reassessment has taken place and this person will now move into an alternative room where they will be supervised to ensure they are safe. The home has a large and very well maintained garden area, which is accessible to people who may need to use a wheelchair. There are a number of bird tables to attract wildlife and a number of seating areas for people to use as they choose to. Ivy House Care Home DS0000068295.V372268.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. The recruitment procedure does not ensure that people are safeguarded from harm. Some staff training is required to ensure that they have the knowledge and skills to meet people’s needs effectively. EVIDENCE: There are two trained nurses and 6 -7 carers on duty throughout the day on the general nursing unit, with one trained nurse and three carers at night. One senior carer and two carers are on duty in the day with one senior and one carer on duty at night on the residential unit. On the dementia unit there is one trained nurse and three carers in the day and one trained nurse and one carer at night. In addition to the nursing and care staff the home also have laundry, domestic, kitchen, maintenance and administrative staff to meet all the needs of the people who live in the home. People told us: “Requests are not always passed on to the staff of the next shift” “Staff are always there” “The staff at the home are marvellous” “Staff are very helpful” “Some staff are very nice and some are a bit iffy” Ivy House Care Home DS0000068295.V372268.R01.S.doc Version 5.2 Page 21 Only six staff have a National Vocational Qualification (NVQ) level 2, and two staff have a level 3 in care. It is recommended that at least 50 of staff have this qualification so that a knowledgeable and skilled workforce can meet people’s needs individually and collectively. We looked at three staff files and it was disappointing that two of the files did not contain any references, as this does not ensure that people are safeguarded from harm. All staff had Protection Of Vulnerable Adults first (POVA 1st) checks, which deemed them safe to work with vulnerable people. The deputy manager told us that induction consisted of three days general induction to the home before starting the skills for care induction. We looked at the induction booklet for one recently employed member of staff but only the first day of the booklet was completed. This does not ensure that staff are informed about the home so that they know what to do if any incidents occur. A copy of the training matrix was provided, however this showed that there were some gaps in the training. The majority of staff had received training in moving and handling and fire. Some staff had received training in infection control, first aid, care planning and dementia. The deputy manager told us that two trained staff had completed a tissue viability course (sore skin) but this was not recorded on the training matrix. No care staff had received any training in this area and this is recommended so that staff have knowledge and skills to meet peoples needs. Ivy House Care Home DS0000068295.V372268.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The organisation of the home does not ensure that it is run in people’s best interests. EVIDENCE: On the day of our visit the manager was on leave and the deputy manager was acting as the manager. The manager has been in post since January 2008. It was of concern that a number of records we asked to look at could not be located. These records included staff references, complaints records, service user guides and minutes from meetings. A number of files were produced however these contained old information dated 2005 and 2006, some files had different names on the spine so the contents did not reflect what we were looking for. Ivy House Care Home DS0000068295.V372268.R01.S.doc Version 5.2 Page 23 We asked to see minutes from staff and residents meetings but these could not be located and no dates could be produced for when these meetings might have taken place. These meetings are important so that people have the opportunity to raise concerns or ideas about the home and how it can be improved and have some input into decisions about home. The deputy manager told us that the home is supported by a Regional Manager (who unable to join us for the inspection, but was available by phone) and that she could call for help of other home mangers if required. The deputy manager told us that she had expected a manager to come and assist with the inspection but no one came. External managers should complete Regulation 26 visits once a month to monitor the quality of service being provided, however the last report found was dated November 2007. Prior to the inspection the Manager had completed an Annual Quality Assurance Assessment (AQAA) and returned it to us. This should tell us how well the home think they are performing and should give us some information about the home, staff and people who live there, improvements and plans for further improvements, which we would take into consideration. Unfortunately the AQAA did not provide us with much information about the home and this has been discussed with the Regional Manager. The home has a quality assurance programme in place, which includes a number of audits. Questionnaires had just been sent out to residents and the results were being collated. Copies of audits and the last questionnaire results were sent to the home via email, but were not available for people to see in the home. These concerns were discussed with the regional manager as the information should be available within the home and staff should know where to find it when the manager is not present. There is a robust system in place for recording personal money, which should ensure that it can be held safely at the home, on behalf of the people who live there. Records of servicing, tests and maintenance in respect of health and safety for utilities, appliances and equipment such as electricity, fire; emergency lighting and hoists are well maintained and this should ensure they are safe to use. Staff receive fire training and complete fire drills to ensure they have the knowledge to act appropriately to safeguard people in the event of a fire. This information was located in three separate files and was not easy to retrieve. Accident and incidents were well recorded. The manager completes a monthly audit to ensure that any follow up is undertaken and to monitor any trends. Ivy House Care Home DS0000068295.V372268.R01.S.doc Version 5.2 Page 24 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 1 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 2 3 3 X X 3 3 2 STAFFING Standard No Score 27 3 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 X 1 3 Ivy House Care Home DS0000068295.V372268.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 12(1)(a) Requirement Care plans must be comprehensive to promote and ensure proper health and welfare of the people living in the home. Systems must be in place to ensure that people receive their medication as prescribed. Complaints records must be available and complaints must be responded to so that people know they are being listened to. Cleaning rotas should be reviewed to ensure that the home is clean and the potential for infection is minimised. Recruitment procedures must be robust so that people are protected from harm. Suitable arrangements must be in place for the management of the home in the absence of the manager. Timescale for action 20/11/08 2. 3. OP9 OP16 13 (2) 22 06/11/08 31/10/08 4. OP26 16(2)(j) 31/10/08 5. 6. OP29 OP37 19 Sch 2 17(3) 31/10/08 30/11/08 Ivy House Care Home DS0000068295.V372268.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. 2. 3. 4. 5. 6. 7. 8. Refer to Standard OP1 OP3 Good Practice Recommendations Written information about the home should be available to people so that they can make an informed decision about the home. Pre admission assessments should contain enough details so that people know their needs can be met prior to moving in. People should be referred to the tissue viability nurses for specialist advice when wounds are large or ongoing. The managers should ensure that the activity programme continues in the absence of the coordinator, so that people can continue with activities of their choice. Staff should receive training in adult protection so that they have up to date knowledge about how to protect people from harm. Alternative storage space should be located for the activity equipment so that a homely and safe environment in maintained for the people who live at the home. Remedial works should be undertaken in the bathroom and toilets to ensure that people’s safety is maintained. Staff should receive National Vocational Qualification training in care to ensure they have the knowledge and skills to care for people. OP8 OP12 OP18 OP19 OP19 OP28 Ivy House Care Home DS0000068295.V372268.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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.V372268.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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