Inspection on 15/12/05 for Knowles Court

This inspection was carried out on 15th December 2005.

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

Knowles Court 08/10/07

Knowles Court 09/08/06

Knowles Court 08/02/05

Knowles Court 19/07/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Abbey The

Grayling

John Street Nursing Home

Pennine Camphill

Snydale Care Home

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Knowles Court 2 Bridgeway Bradford BD4 9SN Lead Inspector Nadia Jejna Unannounced Inspection 15th December 2005 11:00 X10029.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 Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 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 and Care Homes for Adults 18 – 65*. 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. Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Knowles Court Address 2 Bridgeway Bradford BD4 9SN 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) 01274 681090 01274 652916 BUPA Care Homes (CFH Care) Limited No. 2741070 Mrs Dianne Karen Parker Care Home 146 Category(ies) of Learning disability (26), Learning disability over registration, with number 65 years of age (26), Physical disability (120), of places Physical disability over 65 years of age (120) Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2005 Brief Description of the Service: Knowles Court Care Home is situated in Holmewood, a residential area on the outskirts of Bradford. The home is close to local bus routes. The home is made up of five individual single storey houses, which are linked by covered walkways. All rooms are single, and each house has central communal areas, which provide both lounge and dining space. Each house has a satellite kitchen so that drinks and snacks can be provided between mealtimes. All have access to gardens and patio areas, and many of the bedrooms are provided with patio doors. There is a central administrative building, which houses the Matrons office, laundry, main kitchen and hairdresser’s salon. There is also a support flat where visitors can stay overnight. The home is registered to provide care, with nursing to people with physical disabilities and people with learning disabilities from the age of 18 upwards. Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections; these may be announced or unannounced. The last inspection was unannounced and took place on the 14th June 2005. The purpose of this inspection was to monitor the home’s progress since the last inspection and to assess whether the care given to residents meets minimum standards. Three of the houses were visited, Fairfax, Rycroft, and Newhall. During the inspection records were examined, areas of the home were seen, such as bedrooms and lounges; care staff were observed carrying out their work; discussions, both on an individual and joint basis, were held with members of staff, the manager, visitors, and residents. Survey cards were left at the home for residents and their relatives or visitors to complete and return to the Commission for Social Care Inspection (CSCI). When this report was written six resident and ten relatives/visitors survey cards had been returned. The inspection started at 11:00am and ended at 5:00pm on the 15th December 2005 by two inspectors and was continued on 16th December 2005 by one inspector. Feedback was given to the manager on both days. The people who live in the home prefer the term residents, and this is the term that will be used throughout this report. What the service does well: Care is provided to residents in clean, tidy and well-maintained buildings. There are easily accessible gardens and a number of resident’s rooms have patio doors that open into these areas. Resident’s rooms are furnished and decorated in a homely manner and residents are able to bring their own belongings to personalise rooms. Visitors said that they could visit at any time and were made to feel welcome. Residents said that they were satisfied with the services provided by the home, also that the staff were kind, caring and responsive. Staff interactions with residents and their visitors were polite and respectful; it was clear that good relationships had been established. Staff were seen knocking on bedroom doors before entering. Residents said that they could exercise choice in their daily lives – getting up and going to bed when they wished, choosing where to spend their time be it in the communal areas or their own rooms. A team of activities coordinators are employed and each has been allocated a unit to look after. Weekly activity plans were on display. Group sessions were held in one unit (which is changed for each activity) and residents taken from other units to attend. These included entertainers, bingo and religious Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 6 observances. It was very positive to see that many seasonal and festive activities had been planned. Those who like to attend these types of session enjoy them. What has improved since the last inspection? What they could do better: Steps must be taken to make sure that the resident’s needs are reviewed with a view to making an application for a variation in registration, which more accurately reflects the needs of people accommodated in the home. Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 7 The work on improving the care plans must be continued. Staff must make sure that they provide an accurate picture of the residents medical, physical and social well-being. Appropriate risk assessments and care plans must be in place for residents at risk of losing weight and falling. The programme of social activities must be extended to include all residents, particulalry those with a learning disability. Activites provided must be appropriate to their needs and wishes. Appropriate training and guidance must be made available to the activities coordinators. The complaints procedure must be made available in a format that is suitable for people with a learning disabilty. The training provided to staff must be continued and steps taken to make sure that it includes training around adult protection, dementia, learning disabilities, infection control, communicating effectivley with residents and other topics related to the health, safety and well being of residents and staff. Staffing levels on each unit must be reviewed in order to ensure that they meet the needs, dependencies and abilities of residents. 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. Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 5. Resident’s needs are assessed but in some instances this information has not been used to determine if the home and staff team have the skills and abilities required to meet their needs. EVIDENCE: A new pre admission assessment form has been put into use. The manager said that when the unit managers have been out to assess prospective residents they bring back the information and discuss what the identified needs are and if they can be met. The form includes prompts to help identify any specialist equipment that might be needed. Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 10 A resident who had been in for three days said that they had chosen the home after looking round with a relative. They said that they were ‘highly satisfied’ and that they had found the staff to be very helpful and attentive. An application for variations in registration in order to more accurately reflect the categories and needs of residents in the home has not yet been made. One of the care plans seen was for a resident with mental health needs that could not be met by the home unless specialist training was provided to staff. Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10. Care plans are not consistently maintained and although most care needs are met, the lack of appropriate records provides the opportunity for important needs to be overlooked. Residents are treated with respect and they are satisfied with the services provided. EVIDENCE: Care plans were reviewed, three from Newhall, two from Fairfax and two from Rycroft. It was clear that staff have been working hard to improve the Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 12 information they contain. Some of the care plans seen were moving towards being person centred, particularly on Rycroft and Newhall, this progress must be encouraged and continued. It was disappointing to see that there was no care plan in place for one resident who had been admitted three days earlier even though a detailed pre admission assessment was in place. The care plans seen for residents of ethnic minorities did not address their cultural and religious needs. Not all of the care plans showed that the residents or their relatives had been involved in the care planning and review process. The manager said that each unit has been issued with copies of good practice guidelines around pressure area care and tissue viability. One of the nurses is acting as a link with the tissue viability nurse (TVN) and is responsible for liaising with her for wound care advice and support. Pressure area risk assessments were seen in the care plans. Specialist pressure relieving equipment was in use for those residents identified as at risk of developing pressure sores. The manager said that advice had been taken from the TVN about the usefulness of photographing wounds. The TVN said that this can be useful for monitoring progress and the practice will continue but staff will make sure that residents privacy and dignity is maintained. Nutritional assessments were seen in the care plans. But one plan showed that the resident was at risk of losing weight and an appropriate care plan addressing this had not been put in place. Another plan showed that the resident was at high risk of falls and that staff were checking their blood pressure but a care plan saying why this was being done and how the risk of falls would be minimised was not in place. The falls prevention team should be contacted for advice and training. The manager said that residents and their relatives are asked about leaving bedroom doors open at all times. Their decisions and agreements are recorded in the care plans on Hedley unit. This should happen for every resident. Residents said that they were satisfied with the services provided by the home, that the staff were kind, caring and respected their privacy and dignity. These views were repeated in the resident survey forms. Residents/relatives survey forms indicated that they were satisfied with the overall care provided. They confirmed that they could visit their relative in private and that they were kept informed about changes and important matters affecting them. Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Residents are encouraged to make choices regarding their own lifestyle and are supported to maintain contact with family and friends. Visitors are welcomed into the home at any time. Social stimulation for residents on the learning disability unit will meet their needs when staff have received appropriate training. EVIDENCE: The chef has contacted a dietician and received advice about diabetic diets and enriching food for those at risk of losing weight. Stocks of enriching agents such as cream, full fat milk and cheese are kept on the units to use as needed Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 14 for individual residents. Action has been taken to make sure that food is served attractively and at an appropriate temperature. This has involved the purchase of three new heated food storage and serving trolleys. The menus have been revised and the chef has put together a file with photographs of each meal. This is to show staff how to present the meal and can be used for residents to make their meal choices. The manager said that the organisation of activity provision has been altered. The senior activities organiser said each unit has an allocated activity organiser for a set number of hours a week. Weekly activities are planned for each unit and displayed on a poster. These could be anything from seasonal crafts, 1 to 1 discussions, manicure and pamper sessions or bingo. Group sessions are held in one of the units and residents from other units can join in. It was very positive to see that many seasonal and festive activities had been planned. Those who like to attend these types of session enjoy them. While the activity organisers have a number of years experience doing this kind of work, they have not received any training. This would be helpful to them particularly for planning activities for people with learning disabilities, as the planned entertainment on that unit was not based around the needs and preferences of the residents. There is an entertainment budget, which is used to pay for bingo prizes, small gifts for mother’s and father’s day, some craft items and external entertainers. Each unit fundraises to supplement this budget to buy residents Christmas gifts, Easter eggs, birthday gifts and special items that may be needed. The staff are to be commended for doing this. Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Residents feel safe. Most residents know who to speak to if they have any concerns. However the complaints procedure is not yet available to the residents with learning disabilities and there is a risk that they will not know how to make concerns known. EVIDENCE: The complaints procedure is displayed in the reception area of each house as well as being included in the Service User Guide and resident information file kept in each bedroom. Complaints leaflets are easily available in each unit. But the information is still not in a format that can be easily understood by people with learning disabilities. The unit manager for Newhall is looking into different methods of written and pictorial communication that will be appropriate. Adult protection policies and procedures are in place. Staff have been issued with copies of the adult protection and whistle blowing procedures. Training sessions for staff around adult protection and abuse awareness have been arranged. Staff said that they would not hesitate to report suspected or actual abuse to a unit manager or the manager. This has happened where staff have Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 16 had concerns about perceived bad practice. The manager has investigated these concerns and taken appropriate action. Residents said that they felt safe. Residents survey forms returned said that they knew who to speak to if they were unhappy and that they felt safe living in the home. But the relatives/visitors survey forms showed that some of them were not aware of the complaints procedure. Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Residents are living in a clean, tidy and safe home, which is suitable for their needs. Some work on the environment has taken place, but continued refurbishment is required. EVIDENCE: The manager said plans are in place for redecorating, refurbishing and replacing equipment on some of the units. These include a refurbishment of Newhall in 2006, which will be done to resident’s needs and personal preferences. This work is needed because many areas of the unit are showing Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 18 signs of wear and tear. Some of the other units will be given new carpets and moving and handling equipment. Risk assessments have been put in place around the use of ‘bucket’ type chairs. Some of the staff have received infection control training from the infection control nurse. Others are doing a distance learning course on the subject and one of the nurses has attended training on MRSA. Each unit has been issued with a copy of good practice guidelines on infection control. Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 30. Staffing levels must be reviewed in order to make sure that the needs of residents are met. EVIDENCE: The manager and Newhall’s unit manager have completed the Learning Disabilities Award Framework induction training and 4 care assistants from Newhall have enrolled on this training course. The manager said that it is intended for 4 staff at a time to complete this training until all staff on Newhall have completed it. Staff said that training provision had increased for all grades of staff. This included wound care, assertiveness, drug administration, care planning and team leaders training. They said that training in health and safety, fire safety, first aid and moving and handling had been provided but they were waiting for dates to receive training around infection control and food hygiene. Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 20 A number of residents in the home have some form of dementia. Staff said that they had not received training yet to help them care for these residents appropriately. The manager had arranged training for staff who speak English as a second language but the sessions were poorly attended. The manager said that new dates are being arranged. The manager said that enough staff have been recruited to fill all the vacancies, that agency staff are no longer being used and staffing levels were satisfactory. Staff working on the units said that numbers on each shift did not always reflect the needs and dependencies of the residents. For example the residential unit had four staff on duty for thirty residents, most of whom needed assistance and staff said they struggled at times to meet their needs. Relatives/visitors survey forms showed that they did not think there were enough staff on duty to meet the needs of the residents. Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32 and 38. Residents and staff are benefiting from the continuity and support being provided by the manager. Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 22 EVIDENCE: The manager has been in post for six months and has successfully undergone the registration process with the CSCI. They have almost completed a management qualification equivalent to NVQ 4. Staff said that there had been positive changes made during that time. These included improved communication between the manager and unit managers, regular meetings and a problem sharing/solving approach. Staff said that the manager was dealing with issues, was approachable and supportive, firm but fair and had a straight forward approach. They said that the unit teams were working together to provide good standards of care to the residents. On Newhall, the learning disabilities unit, a cultural change is taking place. The unit manager is establishing links with other homes within the organisation that provide this type of service and with other organisations in order to improve practice and standards of care. On two units staff were seen moving residents in wheelchairs without using the footrests. Staff said that this was individual residents choice but this had not been risk assessed or documented in their care plans. Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 2 4 2 5 3 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 X 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 2 STAFFING Standard No Score 27 2 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 3 33 X 34 X 35 X 36 X 37 X 38 2 Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 24 YES Are there any outstanding requirements from the last inspection? 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 The registered person must make sure that the resident and or their representatives are involved with the pre admission assessment process and that confirmation is made in writing that the home can meet their needs. The registered person must make sure that the home can meet the assessed needs of all residents admitted to the home. Appropriate training must be provided to staff around the specialist needs of residents. Where it has been identified that the home is not meeting identified service user needs, the registered person must make sure that the residents needs are reviewed with a view to making an application for a variation in registration, which more accurately reflects the needs of people accommodated in the home. A plan of care must be in place for each resident, which details clearly how all assessed health, DS0000029184.V271411.R01.S.doc Timescale for action 31/03/06 2 OP4 14 30/04/06 3 OP7 14, 15 30/06/06 Knowles Court Version 5.0 Page 25 personal, psychological and social care needs will be met. For the younger adults living in the home the care plans must also include detail around choice, risk taking and decision making. Staff must be trained in writing care plans and appropriate systems put in place to ensure this. The care plans must be kept under review and reflect changing care needs. The service user and their representatives must to be involved in this process, where possible. The registered person must ensure that staff are aware of and follow the information detailed in the care plans. (This requirement was first made in May 2005.) The registered person must 30/04/06 ensure that appropriate risk assessments are carried out to identify those residents at risk of losing weight and of falling. The manager must make sure 28/02/06 that residents rights to privacy is upheld. If bedroom doors are to be left open the care plans must evidence that this has been discussed and agreed with them. The registered person must 30/06/06 increase and extend the programme of social activities to include all residents, particulalry those with a learning disability. Activites provided must be appropriate to the needs and wishes of the residents. Appropriate training and guidance must be made available to the activities coordinators. (The timescale 30th November 2005 made in May DS0000029184.V271411.R01.S.doc Version 5.0 Page 26 4 OP8 12, 13 5 OP10 12 6 OP12 16 Knowles Court 2005 has not been met.) 7 OP16 22 The registered person must make sure that the complaints procedure is made availalble to all residents with learning disabilities in a format suitable to their needs. (The timescale of 30th September 2005 was not met.) The registered person must make sure that all staff are aware of the homes and local authority adult protection procedures and that they receive appropriate training. ( Progress is being made but the timescale of 31st December 2005 was not met. It has been agreed to extend this timescale.) The registered person must make sure the infection control training is provided to all staff. (The timescale of 30th September 2005 was not met.) The registered person must make sure that staffing levels on each of the units reflects the numbers, needs and dependency levels of residents. The registered person should ensure that a minimum of 50 of care workers have achieved NVQ 2 by 31.12.06. (This standard was not assessed on this occasion.) The registered person must ensure that staff receive training appropriate to the needs of the service users. This must include all areas of mandatory training, induction and foundation training to TOPSS standards and specialist training such as dementia and learning disabilities. The training needs of qualified nurses must also be addressed. ( The timescale of DS0000029184.V271411.R01.S.doc 30/05/06 8 OP18 13 30/05/06 9 OP26 13 30/07/06 10 OP27 18 28/02/06 11 OP28 18 31/12/06 12 OP30 18 30/06/06 Knowles Court Version 5.0 Page 27 13 OP30 18 14 15 OP31 OP38 9 13 31st December 2005 was not met.) The registered person must ensure that staff are able to communicate effectively with residents. ( The timescale of 30th September 2005 was not met.) The manager must achieve a management qualification equivalent to NVQ level 4. The manager must make sure that wheelchairs are used correctly and safely. If residents choose not to use footplates, appropriate risk assessments must be carried and agreements made. Records must be kept. 30/06/06 31/03/06 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations The registered person should review and increase the provision of suitable and appropriate sensory stimulation and quiet areas for the service users on Newhall. (This recommendation was first made in June 2005) An action plan with timescales detailing when the refurbishment, redecoration and repair works are to be carried out must be forwarded to the CSCI. ( The timescale of 31st December 2005 was not met.) The registered person should put an action plan in place detailing how comments made as part of the quality assurance survey are going to be addressed. (This standard was not assessed on this occasion.) DS0000029184.V271411.R01.S.doc Version 5.0 Page 28 2 OP19 3 OP33 Knowles Court Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 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. Knowles Court DS0000029184.V271411.R01.S.doc Version 5.0 Page 29 - 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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