Inspection on 15/04/08 for Ivy Leaf Care Home

This inspection was carried out on 15th April 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Ivy Leaf Care Home 15/11/08

Ivy Leaf Care Home 11/09/07

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Ivy Leaf Care Home 29 Gedling Road Carlton Nottingham NG4 3EX Lead Inspector Steve Keeling Unannounced Inspection 15th April 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ivy Leaf Care Home DS0000070390.V364178.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 Leaf Care Home DS0000070390.V364178.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ivy Leaf Care Home Address 29 Gedling Road Carlton Nottingham NG4 3EX 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) 0115 961 6785 Mauricare Ltd Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Ivy Leaf Care Home DS0000070390.V364178.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following category of service only:Care home only - Code PC To service users of the following gender:Either Whose primary care needs on admission to the home are within the following category:Old age, not falling within any other category - Code OP The maximum of service users who can be accommodated is 14. 2. Date of last inspection 11th September 2007 Brief Description of the Service: Ivy Leaf is an adapted residential property situated in the heart of Carlton, a busy area on the outskirts of Nottingham. The home is situated less than a five-minute walk away from shops, cafes, public houses and places of worship. There are very good public transport links to the home and a small car park to the rear of the building. The service is registered to accept up to 14 people within the category of old age only. Nursing care is not provided at the home. The accommodation comprises two lounges, a dining room with a conservatory and there are 10 single and 2 double bedrooms, none of these rooms have en suite facilities but there are sufficient toilet and bathing facilities available. There is a small garden to the rear. The current fees range from £325 to £400 per week. This fee does not include hairdressing, chiropody services or newspapers. Ivy Leaf Care Home DS0000070390.V364178.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views on the quality of service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. One inspector conducted the unannounced visit. The main method of inspection used was called ‘case tracking’ which involved selecting residents and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. The Acting Manager, Registered Individual (RI) a visitor to the home and one member of staff were spoken with as part of this visit. Documents were read as part of this visit and medication management was inspected to form an opinion about the health and safety of residents at the home. A partial tour of the building was undertaken which included the case tracked resident’s bedrooms and the communal areas they frequent to make sure that the environment is homely and safe. A review of all the information we have received about the home since the last inspection was considered in planning this visit, which included an Annual Quality Assurance Assessment (AQAA), provided by a registered manager who has recently relinquished her managerial post. Unfortunately the AQAA was of poor quality and was not useful in informing the inspection process. In addition two returned “have your say” surveys for relatives, carers and advocates and one returned “have your say” survey for residents was used to inform the inspection process. The quality rating for this service is 0 star this means the people who use this service experience poor quality outcomes. What the service does well: Ivy Leaf Care Home DS0000070390.V364178.R01.S.doc Version 5.2 Page 6 Medication administration practices promote the safety of residents. Residents are treated with respect and dignity and their privacy is promoted. Routines within the home are flexible in meeting the needs of residents. Residents can participate in limited social activities and are encouraged to maintain appropriate personal relationships within the home and the community. Residents benefit from the provision of an appealing balanced diet and are able to have snacks and drinks as they wish. The majority of the homes environment is pleasant, comfortable and clean. What has improved since the last inspection? What they could do better: Pre-admittance assessment documentation should be available to demonstrate that the holistic needs of the residents had been identified and met before being admitted to the home. The risk assessment, care planning and evaluation process should be further developed to ensure the healthcare needs of residents are fully met. The arrangements for recording complaints should be improved. The kitchen area should be improved and to ensure the area is fit for purpose. Recruitment practices should be followed to minimise the risk of harm or potential abuse of the residents. An effective management structure should be put in place to promote the health and wellbeing of residents. Ivy Leaf Care Home DS0000070390.V364178.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. Ivy Leaf Care Home DS0000070390.V364178.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 Leaf Care Home DS0000070390.V364178.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. No documentation was available to demonstrate that the registered person had obtained a summary of care management assessments from Social Service departments therefore it could not be demonstrated that the holistic needs of the residents had been identified and met. EVIDENCE: It is a regulatory requirement that all residents are admitted only on the basis of a full needs assessment undertaken by people trained to do so, and to which the prospective resident, his/her representatives (if any) and relevant professionals have been party. Ivy Leaf Care Home DS0000070390.V364178.R01.S.doc Version 5.2 Page 10 Information provided within the AQAA did not address Standard 3 of the National Minimum Standards, which relates to pre admittance procedures. The acting manager and RI stated that no residents have been admitted to the home since the last unannounced inspection was performed on the 11th September 2007. The case tracked resident’s care planning documentation did not show any evidence that the local authority Social Services Departments had undertaken a pre admittance needs assessment. Furthermore there was no evidence that a suitably qualified representative from the home had performed a pre admittance needs assessment. There was no evidence that confirmation in writing had been provided to the residents or their representative that the care home is suitable for the purpose of meeting the resident’s needs in respect of their health and welfare. The acting manager said that she was aware that residents had pre admittance assessment performed, which includes assessments by Social Services departments, but said the assessments could not be located. Given the lack to documentary evidence to show that a pre admittance assessment process had been undertaken it was not possible for the inspector to determine if the needs of the residents are being met, which could be detrimental in promoting the resident’s health and wellbeing. Ivy Leaf Care home does not provide intermediate care services. Ivy Leaf Care Home DS0000070390.V364178.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 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The risk assessment, care planning and evaluation process requires further development to ensure the holistic healthcare needs of residents are fully met. Medication administration practices promote the safety of residents. Residents are treated with respect and dignity but privacy could be compromised. EVIDENCE: Information provided within the AQAA did not fully address Standards 3, 8, 9 and 10 of the National Minimum Standards. In response to a previous requirement the acting manager has ensured that one system of care planning is now in place and the care-planning format had been in use for approximately two weeks. Ivy Leaf Care Home DS0000070390.V364178.R01.S.doc Version 5.2 Page 12 Given the shortfall identified above (OP 3) it was not possible to determine if the care plans, that were available, addressed the holistic needs of the residents. Care plans that were in place were basic and lacked specific details to inform care staff of the resident’s needs, which could compromise their safety. There was no evidence of the case tracked residents being involved in the development of her care planning documentation and residents spoken with confirmed that they were not aware of the content of their care plans. Risk assessments that are in place are of poor quality and were not signed or dated by the assessor. A recognised risk assessment tool relating to a persons susceptibility to pressure ulcer formation, was available in a resident’s care planning documentation but the tool had not been utilised. Concerns were highlighted, at the previous inspection, in relation to medication management. A requirement was made to ensure that the care staff have training on the safe storage, handling and administration of medicines. Medication management practice has improved. Staff training records showed that training has been provided for the care staff from a local pharmacist following the previous inspection and additional training was booked for the 22nd April 2008. Part of the lunchtime medication round was observed. Care staff observed residents taking their medication prior to signing the resident’s Medication Administration Records (MAR) and the case tracked residnets MAR charts were examined and found to be satisfactory. To promote the safety of resident’s it is good practice to have photographs of each resident attached to the MAR sheet to ensure that staff administer the right medication to the residents. An examination of MAR records showed that photographs were present. A medication refrigeration facility is available. The acting manager said that the facility had not been required for several months. An examination of past medication fridge monitoring documentation showed that the fridge temperature was recorded on a weekly basis and the temperature was outside the required 2-8 degrees centigrade. To address the concern the acting manager defrosted the medication fridge and reformatted the temperature recording documentation to specify the correct temperature parameters. Residents confirmed that their respect and dignity is always promoted and said that the routines in the home are flexible and their choice is respected in relation to how they spend their days. Ivy Leaf Care Home DS0000070390.V364178.R01.S.doc Version 5.2 Page 13 Care staff said and residents confirmed that bedroom and bathroom doors are always closed when attending to the resident’s personal needs to ensure their privacy and dignity is maintained. We observed interactions between the staff and residents throughout the day. The interactions were respectful and considerate to the needs and wishes of the residents. A resident said “the staff are very good and always considerate to my needs”. A Closed Circuit Television (CCTV) system with a sound monitor is currently being utilised on the stairs to monitor resident’s movements. Standard 19 (6) states, “The use of CCTV is restricted to entrance areas for security purposes only and should not intrude on the daily life of service users”. No evidence was available in the case tracked residents care plans to show that residents have given consent to the use of internal CCTV and this may constitute an invasion of privacy. Ivy Leaf Care Home DS0000070390.V364178.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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Routines within the home are flexible in meeting the needs of residents; they participate in limited social activities and are encouraged to maintain appropriate personal relationships within the home. Residents benefit from the provision of an appealing balanced diet and are able to have snacks and drinks as they wish. EVIDENCE: Information provided within the AQAA did not fully address Standards 12, 13, 14 and 15 of the National Minimum Standards as the AQAA simply stated “we keep our residents entertained with a variety of activities”. The RI has recently purchased an interactive computerised games consol for the residents use if they wish. Residents also said that they have singsongs on accessions, which they enjoy. Ivy Leaf Care Home DS0000070390.V364178.R01.S.doc Version 5.2 Page 15 A social activity rota displayed in the dining room showed that activities are advertised as being provided throughout the week, but residents said that the advertised activities do not always happen. The “Have your say” questionnaire asked residents “Are activities arranged by the home which you can take park in”, the response was “never”. Residents raised concerns in relation to the lack of trips out. A resident said that she relies on her family to take her out on day trips, which she enjoys. The acting manager and staff said that a Social Activities Coordinator is not employed at the home and the care staff are required to provide social activities as part of their duties. Residents expressed concerns that that due to the staffing level, social activities could be compromised. The acting manager said that an open door policy is promoted at the home to encourage friends and relatives to visit the home as they wish. Residents and a visitor to the home confirmed this and said that visitors are made welcome. Five residents were asked if the routines in the home are flexible in meeting their needs. They said that they are able to rise, bathe and retire at a time of their choosing. Residents were asked if they enjoyed the meals at the home. Residents said, “the food is good and a choice is available”. The “Have your say” questionnaire asked residents “do you like the meals at the home”; the response was “I enjoy the meals here and I always get what I want”. Interactions between staff and residents were observed at lunchtime. The care staff helped residents who required assistance to eat in a respectful manner. The dining area was clean and smelt fresh but would benefit from some remedial decoration. Residents said that meals incorporate fresh fruit and vegetables and it was noted that a sufficient supplies of tinned, dried and frozen foods were available. Ivy Leaf Care Home DS0000070390.V364178.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 and 18. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents said they felt safe at the home. A complaints procedure is in place but the arrangements for recording complaints are not robust enough to make sure that residents are properly protected from potential harm or abuse. EVIDENCE: Information provided within the AQAA did not fully address Standards 16 and 18 of the National Minimum Standards. The residents at the home said they feel safe and had never seen or experienced the staff acting in a way they felt was inappropriate. Residents said they feel able to complain to the acting manager or the RI and they felt confident that any concerns would be taken seriously. A complaints procedure is now on display in the foyer of the home, in addition the complaints procedure is provided within the Service Users Guide. Ivy Leaf Care Home DS0000070390.V364178.R01.S.doc Version 5.2 Page 17 CSCI has received two recent complaints in relation to the service provision and elements within the complaints have been utilised to inform this unannounced inspection. We asked a visitor if she was aware of the complaints procedure. The visitor said that she was aware of the procedure but said, “I feel that my complaints/concerns are not taken seriously”. The “have your say” questionnaire for service users asked, “Do you know how to make a complaint?” The single response stated “No”. The “have your say” questionnaire for relatives, carers and advocates asked “do you know how to make a complaint about the care provided by the home if you need to?”, both respondents said “yes” but one respondent commented “but its a complete waste of time”. The visitor informed us that she had a made verbal complaint to the RI over the telephone in relation to the care her mother was receiving at the home. The complainant stated that she did not receive a written response to her complaint. The RI said that he recalled the concern being made and said it had been addressed it in a meeting with the complainant and believed the complainant was happy with his response. The acting manager and RI said that a complaints/concerns book is not currently maintained at the home. Schedule 4 Section 11 of the Care Homes Regulations 2001 states that the RI must “maintain a record of all complaints made by residents or representatives of residents or by persons working at the care home about the operation of the care home, and the action taken by the registered person in respect of any such complaint”. It was agreed with the RI that a complaints book would be purchased at the earliest opportunity and any future complaints/concerns would be documented and addressed in accordance with legislation to ensure evidence is available to show that all complaints and concerns are managed effectively. At a previous inspection a requirement was made to ensure staff receive training on Safeguarding Adults. The acting manager provided documentation to show that all staff at the home has received accredited training in this area and staff spoken with was able to confirm this. A member of staff could not provide a satisfactory account of the actions to be taken if abuse was suspected. The member of staff said, “ I would inform the manager, document everything, sorry I cannot think of anything else”. It was evident that the member of staff viewed her role as reporting to the acting manager rather then consideration of completing an alert under safeguarding or the complaints procedure. In addition the member of staff Ivy Leaf Care Home DS0000070390.V364178.R01.S.doc Version 5.2 Page 18 was not aware of the location of the revised Nottinghamshire Safeguarding adults policy. This may have an adverse effect on safeguarding residents. Ivy Leaf Care Home DS0000070390.V364178.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): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The majority of the homes environment is pleasant, comfortable and clean but the kitchen area requires improvements and upgrades to ensure it is fit for purpose. EVIDENCE: Information provided within the AQAA relating to the environment stated “a resent refurbishment had been undertaken”. All residents spoken with confirmed that the home is maintained to a good level of cleanliness. Ivy Leaf Care Home DS0000070390.V364178.R01.S.doc Version 5.2 Page 20 The homes internal environment, which included the dining room and lounge areas, are clean, fresh and homely. The RI has initiated a refurbishment plan and the bathrooms have recently been upgraded to a good standard. Resident’s bedrooms were homely, safe and personalised with many personal possessions such as family pictures, small items of furniture, a television, radio and ornaments. Protective aprons and gloves were available in the bathroom areas and staff said that they are used at all times to promote infection control. The kitchen and pantry area was shoddy and would benefit from an enhanced cleaning programme. The pantry area within the kitchen has a substantial whole in the ceiling, which will require attention at the earliest opportunity to ensure the health and wellbeing of residents is promoted. The undersides of kitchen cupboards are not maintained to a satisfactory standard of hygiene and will require extensive cleaning. The acting manger and RI were not able to specify when the last Environmental Health Inspection had taken place. We contacted the department and were informed that a planned inspection was to be performed on the 16th April 2008. The home benefits from a private garden area, which is well maintained. Ivy Leaf Care Home DS0000070390.V364178.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): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Recruitment practice has not been followed which could place the residents at risk of harm or potential abuse. Staff have received training to ensure they can meet the needs of the residents. EVIDENCE: The staff duty rota showed that an adequate number and staff are on duty to meet the needs of the seven residents. Residents said that staff are available when they need them and they are not kept waiting. The staff were observed to be kind and polite to the residents and residents said, “the staff are friendly and considerate””. Residents said the staff appear competent and confident in performing their duties. Information provided within the AQAA showed that 45 of care staff have attained a level 2 National Vocational Qualification (NVQ) in care with the remaining 55 enrolled on the qualification. Staff training records showed, and staff confirmed that a training programme has been provided in First Aid, Moving and Handling, Health and Safety, Basic Ivy Leaf Care Home DS0000070390.V364178.R01.S.doc Version 5.2 Page 22 Food Hygiene, Fire Awareness and Infection Control to ensure the staff are effectively trained to meet the needs of the residents. The staff have also received a half day training in Dementia Awareness. The health and wellbeing of the residents could be compromised, as a member of staffs recruitment file did not provide evidence that pre-employment recruitment procedures adhere to SCHEDULE 2 of the Care Homes Regulations 2001. An immediate requirement was issued and the registered provider responded appropriately by suspending the individual in question with immediate effect until the required documentation was available. Staff files also showed that another member of staff had been in employment for a significant length of time before the required checks had been performed. Ivy Leaf Care Home DS0000070390.V364178.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): 31, 33, 35 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is a lack of accountability, as the acting manager is not registered with CSCI. Further developments are required to ensure that the current management structure is effective in promoting the health and wellbeing of residents. EVIDENCE: Quality assurance monitoring has been initiated in the form of quality assurance questionnaires sent to relatives, residents and visiting professionals. The surveys, which are distributed on a twice a yearly basis are designed to get feedback on the quality of services provided at Ivy Leaf. Ivy Leaf Care Home DS0000070390.V364178.R01.S.doc Version 5.2 Page 24 The Comments within the quality assurance documents were examined at a previous inspection and were found to be positive and complimentary. The RI and acting manager are not the financial appointees for any of the residents and they do not collect or receive the personal allowance for the residents. Small amounts of spending money are held on the premises and the records examined at the previous inspection showed that finances are managed effectively. As mentioned earlier in the report, the returned AQAA was very brief and gave very little information about the service. It is apparent that there was a lack of understanding of the purpose of the AQAA, as it did not provide a reliable picture of service provision. The RI said he became aware, when looking at the AQAA, that the previous registered manager had not fulfilled the administrative aspect of her responsibilities to a satisfactory standard. The RI confirmed that the registered manager has recently relinquished her managerial post. In the interim an acting manager has been appointed. The acting manager holds a NVQ qualification level 2 in care and has worked as a care assistant at the home for several years. To support the current acting manager at Ivy Leaf Care Home, additional support has been provided from an experienced acting manager from another home within the company. Given the issues of concern highlighted within this report it is evident that the acting manager will require additional experience and education in her management role to promote the health and well being of the residents. The RI informed us that due to a planned absence the acting managers post is currently being advertised in an attempt to recruit an individual who is competent and appropriately qualified. The registered provider said that once a suitable candidate has been appointed the individual will be put forward for registration with CSCI. Information provided within the AQAA relating to policies and procedures indicated that all policies and procedures had been reviewed in March 2008. Following a registration visit by a representative from CSCI on the 11.04.08 it was evident the policy relating to physical intervention/restraint was inappropriate. The policy said there should be no restraint of any kind under normal circumstances but advocated the locking of people in their bedrooms if they wander at night if there are few staff on duty. The policy stated that residents must be checked hourly and advocated the use of ‘over blankets’ to restrict movement by securely tucking them in around the resident in extreme cases. Ivy Leaf Care Home DS0000070390.V364178.R01.S.doc Version 5.2 Page 25 The RI said the policy was left over from the previous owners and did not accept ownership of it, as it was not theirs. Given the aforementioned issue it was evident that policies and procedures had not been reviewed effectively on the date specified in the AQAA. An immediate requirement was made on the 11.04.08 to amend the policy and the RI responded to the immediate requirement in an appropriate and timely manner. Regulation 18 (2) states, “The registered person shall ensure that persons working at the care home are appropriately supervised”. Although staff supervision documentation has been recently formulated it was established through discussions with staff that formal supervisions, at the frequency set out in the National Minimum Standards are not always performed. Furthermore no documentary evidence was available to demonstrate that staff meeting are performed to provide staff with support and direction. Information provided within the AQAA showed that resident’s health, safety and wellbeing is promoted by the provision of effective routine maintenance. At a previous inspection concerns were highlighted in relation to a ramp blocking an automatic self-closing mechanism on the fire door. This ramp has been removed, as it is no longer required. The RI will be required to provide an improvement plan by 30th June 2008 to show how improvements will be made to address the shortfalls identified within this report. If compliance is not achieved within the specified timescales identified within the improvement plan, enforcement action will be considered by CSCI. Ivy Leaf Care Home DS0000070390.V364178.R01.S.doc Version 5.2 Page 26 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 1 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 x 18 2 3 x x x x x x 1 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 3 x 3 1 x 3 Ivy Leaf Care Home DS0000070390.V364178.R01.S.doc Version 5.2 Page 27 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 OP3 Regulation 14 Requirement To promote the health and wellbeing of residents the registered person must not provide accommodation to a residents unless The needs of the residents have been assessed by a suitably qualified or suitably trained person; A copy of needs assessments has been obtained from a placing authority if applicable. There has been appropriate consultation regarding the assessment with the resident or their representative. Confirmation in writing has been provided to the residents or their representative that the care home is suitable for the purpose of meeting the resident’s needs in respect of his health and welfare. Timescale for action 30/06/08 Ivy Leaf Care Home DS0000070390.V364178.R01.S.doc Version 5.2 Page 28 2. OP7 15 To promote the health and well being of residents the registered person must ensure that each resident has a comprehensive care plan, which reflects his, or her current needs in detail. This must be compiled in consultation with residents/their relatives and be kept under review to make sure staff know how to meet their needs. To promote the health and well being of residents the registered person must ensure that a complaints book is purchased to demonstrate that all complaints are fully recorded and include the details of the investigation and the outcomes and actions following the complaint. To promote the health and well being of residents the registered person must liaise with the local Environmental Health Department (EHD) to ensure that advice is sought in relation to the standards of hygiene within the kitchen area. To promote the health and well being of residents the registered person must ensure that staff files contain all of the information and documentation required by Law to make sure that all staff members are suitable to work with vulnerable adults. To promote the health and well being of residents the registered person must give notice to the Commission of the name of the person (acting manager) so appointed and the date on which the appointment is to take place. To promote the heath and well being of residents the registered person must ensure policies and DS0000070390.V364178.R01.S.doc 30/06/08 3. OP16 22 30/06/08 4. OP26 24 30/06/08 5. OP29 19 30/06/08 6. OP31 18 (2) 30/06/08 7. OP31 17 30/06/08 Ivy Leaf Care Home Version 5.2 Page 29 8. OP36 18 procedures are revised and updated effectively for the protection of service users and for the effective and efficient running of the business To promote the health and well being of residents the registered person must ensure that staff receive formal staff supervision which covers all aspects of practice, Philosophies of care in the home and career development needs. 30/06/08 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 OP10 Good Practice Recommendations To promote the health and well being of residents the registered person should ensure that residents are informed and provide consent to the use of internal CCTV to ensure resident’s privacy is maintained. To promote the health and well being of residents the registered person should ensure that social activities provided at the home are reviewed in consultation with the residents to ensure they have the chance to be purposefully engaged in planned social activities. To promote the health and well being of residents the registered person should provide additional training or refresher training for staff in relation to the principles of Safeguarding Adults. To promote the health and well being of residents the registered person should ensure that staff meetings are performed on a regular basis to provide staff with an open forum to discuss any developments and concerns in relation to service provision within the home. 2. OP12 3. OP18 4. OP36 Ivy Leaf Care Home DS0000070390.V364178.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Leaf Care Home DS0000070390.V364178.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. 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