Inspection on 03/09/08 for Lady Of The Vale

This inspection was carried out on 3rd September 2008.

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

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

Other inspections for this house

Lady Of The Vale 08/09/06

Lady Of The Vale 21/12/05

Lady Of The Vale 08/07/05

Lady Of The Vale 19/10/04

Lady Of The Vale 18/05/04

Lady Of The Vale 23/09/03

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 26/11/2008.

CARE HOMES FOR OLDER PEOPLE Lady Of The Vale Grange Road Bowdon Altrincham Cheshire WA14 3HA Lead Inspector Elizabeth Holt Unannounced Inspection 3rd, 5th and 15th September 2008 09:30 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 Lady Of The Vale DS0000006715.V368283.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. Lady Of The Vale DS0000006715.V368283.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lady Of The Vale Address Grange Road Bowdon Altrincham Cheshire WA14 3HA 0161 928 2567 0161 941 7305 matron@ladyofthevale.co.uk 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) Sisters of St Joseph Joanna Catherine Pimlett Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Lady Of The Vale DS0000006715.V368283.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users requiring nursing care shall be 36. In addition a maximum of 2 service users who require personal care only may be accommodated. The home will comply with the minimum staffing levels as specified in the Notice of Proposal issued under Section 13 of the Care Standards Act 2000 on 15 December 2003. The service should, at all times, employ a suitably qualified and experienced manager who is registered with National Care Standards Commission. The nighttime staffing hours should include one nursing assistant who is qualified to NVQ level III. Only service users who actively wish to share a room can be accommodated in the double bedrooms. This agreement to share must be recorded in the service users` plans. 8th September 2006 2. 3. 4. 5. Date of last inspection Brief Description of the Service: Lady of the Vale is a large detached care home providing nursing care and accommodation for up to 38 older people. The home is a large detached house providing 34 single bedrooms and 2 double bedrooms over 3 floors. The home is owned by the Sisters of St Joseph of the Apparition. There are 4 lounge/dining areas for residents/relatives and a chapel where Mass is said on a daily basis. The home is surrounded by mature, well-maintained gardens and residents can access these. Ample car parking is provided at the front and side of the building. Lady Of The Vale DS0000006715.V368283.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by the Commission for Social care Inspection in relation to this home prior to the site visit. The inspection was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was made to make a judgement on the quality of the service provided by the home. Prior to the inspection the provider completed an Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment and a dataset that is filled in once a year. It is one of the main ways that the CSCI obtains information from providers about how they are meeting outcomes for people using their service. The AQAA also provides the CSCI with statistical information about the individual service and trends and patterns in social care. A discussion with the manager highlighted that this self-assessment did fall short of some supporting evidence to show what they have done in the last twelve months in some of the outcome areas. Service user, staff and relatives surveys were provided for distribution before the inspection and twelve were returned from service users/relatives and six from members of the staff team. Comments from these surveys have been included in this report where possible. The visit was unannounced and took place over the course of ten and a half hours on Wednesday 3rd and Friday 5th September 2008. A pharmacy inspector assessed the arrangements the home had in place for dealing with medicines during a separate visit on the 15th September 2008. During the course of these visits time was spent sitting and chatting with people who use the service, some of the staff including the registered manager and visitors to the home. Records were looked at in relation to the running of the home and health and safety and a partial tour of the premises was made. What the service does well: The internal and external appearance of the home, including garden areas provides a clean, homely, comfortable environment for the residents to live in. Lady Of The Vale DS0000006715.V368283.R01.S.doc Version 5.2 Page 6 Residents said they liked their bedrooms and commented in surveys that the home was kept clean and well looked after. One resident said, “This is so homely and comfortable here and I like having my family pictures around me.” An assessment of the prospective residents care needs was carried out before they moved into Lady of the Vale. The home has open and flexible visiting arrangements and relatives stated they were always made to feel welcome. The management encourage residents to stay in touch with relatives and friends. Residents and relatives said the staff. “Genuinely seemed to care”, another relative wrote in the survey, “I feel they are very caring and loyal people and I am thrilled knowing my sister is very happy in the nursing home.” A choice of food is available at each meal and the residents spoken to were happy about the choice and the quantity of food provided. The home do have a procedure to follow to raise any concerns or complaints. The residents, staff and relatives benefit from the commitment of the management team. What has improved since the last inspection? What they could do better: During this inspection some of the concerns raised at previous inspections were identified, the care plans did not always fully reflect the care needs of residents or were regularly updated to show the residents’ changing needs. A risk assessment for the safe use of bed rails must be introduced. Although in the self-assessment the manager stated there was an improvement in the recreational activities provided. There appears to be a shortfall in this area for some of the residents. Lady Of The Vale DS0000006715.V368283.R01.S.doc Version 5.2 Page 7 Audits of care practices, medication and staff records must be carried out on a regular basis to monitor the practice and compliance in these areas. Some shortfalls were identified in the management of medication. Although the residents appear well cared for and comments from relatives and friends support this. The care plans need to be more person centred and central to the needs of the individual. The staff must make sure the changing needs of the residents are recorded and the evaluations of the care delivered are kept up to date. There was a lack of recreational activities provided for residents on a daily basis. One relative said they visited regularly so their relative had some “input”. Another relative wrote in the survey, “I think a way to improve would be by providing some more activities”. The management need to improve the programme of staff supervision and the induction available for new starters. The home encouraged staff training but a training matrix needs to be provided so that the training and development needs of the staff can be clearly identified and recorded. Some improvements are needed in the recruitment procedures and the staff files. A recommendation was made that policies are reviewed on a yearly basis and the policies and procedures regarding medicines are reviewed and revised. The need to develop quality surveys for residents, relatives and visiting professionals needs to be developed to gain their opinions of the home. 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. Lady Of The Vale DS0000006715.V368283.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 Lady Of The Vale DS0000006715.V368283.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 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with information about the home before admission and people who use this service can be confident they will have their needs assessed before admission to the home is agreed. EVIDENCE: A Statement of Purpose and Service User Guide is available and contains the information required in the National Minimum Standards. In the home’s self assessment the manager wrote that prospective people are able to visit the home as often as they feel necessary, they can come on a trial visit and stay overnight or longer if they wish. For residents who are referred through Care Management arrangements the home obtains a summary of the Care Management Assessment prior to admission. Lady Of The Vale DS0000006715.V368283.R01.S.doc Version 5.2 Page 10 Three residents were case tracked. Copies of the inter agency care plans were available and the information was generally transferred into a long-term needs assessment form completed by the staff at the home. There was evidence that the admission process included involvement of the prospective resident, his/her representatives and any relevant professionals. The home does not provide an intermediate care service. Lady Of The Vale DS0000006715.V368283.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 adequate. This judgement has been made using available evidence including a visit to this service. Systems and practices for monitoring and recording the healthcare needs of people living at the home are not always sufficient to meet their needs. EVIDENCE: The care plans for four people living at the home were looked at. Although the records were generally more up to date than found at the previous inspection there were some shortfalls identified. A requirement was made at the last inspection for the plans of care to fully identify the needs of the residents accommodated and to be reviewed when residents’ needs change. Although the care plans generally showed more up to date information to allow the staff to follow the progress of a resident’s health and personal care some issues were identified. A change in one of the resident’s needs showed the person had a long-term catheter in place. The daily statement showed this had been pulled out at a later date and a new one needed re inserting. A discussion with the nurse in Lady Of The Vale DS0000006715.V368283.R01.S.doc Version 5.2 Page 12 charge highlighted this resident no longer had a catheter in situ. The evaluations and care plans must be kept up to date to accurately reflect the current needs of the resident. Resident’s needs may not be met in full if the records are not accurate and may be confusing for staff in charge of shifts. A number of risk assessments were in place including moving and handling, falls and nutrition, however the risk assessment for bed rails was not in place. A change in one of the resident’s needs showed the person needed safety and close observation and was restless and agitated at times. Bed rails and bumpers were put in place even though there was no completed risk assessment. On the day of the second visit the manager said she was going to address this shortfall and stated she had found the necessary information to address this with the staff. She had found some guidance and was planning a study day to advise the staff. This shortfall may put the people with or without bedrails in place at risk of not being appropriately monitored. One of the care plans did not clearly audit trail the detail of the residents condition in relation to her wound and in relation to the correct pump setting of the pressure relieving equipment in place. A discussion was held with the nurse in charge in relation to introducing a form so that staff were made aware to check the pump settings. A shortfall in checking the mattresses and the pump settings has the potential to put the residents at risk of damage to their skin. A brief discussion with the visiting tissue viability nurse highlighted that the staff had made improvements in the management, monitoring and recording of wound care management in the home. There was evidence of records in the care plans of notes from visits by speech and language therapists, dieticians, General Practitioners and opticians. The recording for a number of resident’s weights in August 2008 had not been made due to the scales needing a new battery. There was a gap on the resident’s chart rather than a note made that staff were unable to weigh the resident due to a lack of equipment. Although the new battery was not yet in place at the time of this visit the manager had ordered one and was awaiting its delivery. A discussion with the manager showed the care plans lacked some personalised detail and the likes and dislikes of the individual. One care plan stated, “Daily body wash”, “Immersion bath x2.” The need for a more person centred approach to the care plans would show individual needs of the residents. The manager had identified this in the selfassessment form as an area for development and in discussion she talked about finding a more appropriate care planning documentation system. Lady Of The Vale DS0000006715.V368283.R01.S.doc Version 5.2 Page 13 From observations made during the visits the residents seemed comfortable and content and the staff were seen to encourage the residents to maintain some independence and dignity. During a partial tour of the home people who could express a view were happy with the care they received and one person said, “The staff are lovely, they look after me very well.” Another relative wrote, “The staff are excellent how they look after my wife. They have the hairdresser to see to her hair at regular periods.” During the visits it was discussed with the management the fact that a high number of people accommodated spent the day in their bedrooms, some of these people had a degree of dementia/confusion and they were seen to be alone for lengthy periods of time. The staff were seen to be generally busy throughout their time on duty and it was of concern as to how these people’s social care needs are met in full. A high number of people over the two floors were seen to need pressure relief monitoring and fluid and dietary intake monitoring. These charts were well recorded and the staff clearly knew their role in relation to completing these. Following a discussion with some of the care workers it was evident they did report to senior staff if a person was not eating and drinking well and some comments were made that the time completing charts has the potential to take them away from spending time with the residents. The senior staff should review and monitor the need for completing these charts and the need for people’s intake to be recorded on a long-term basis. One of the relatives who returned a survey expressed satisfaction with the home saying, “Both my parents have been residents at Lady of the Vale. We have always been impressed with the quality of care it is first class. All the staff are very caring and respectful to all the residents at the home. As a family we only have praise for the staff.” Another person’s relative wrote, “They always contact me about anything they think is important and clearly explain it to me.” Care plans reviewed in relation to wound care showed these to be clearly recorded updated and evaluated on a regular basis. During the inspection the pharmacist inspector looked at how well medicines were handled to make sure that residents were being given their medicines properly. We looked at the policies for medication and found that there were two different policies in use. Neither policy gave staff clear directions on how to handle medication safely. We recommended that the policy and procedures regarding medicines were reviewed and revised. Lady Of The Vale DS0000006715.V368283.R01.S.doc Version 5.2 Page 14 Medicines were stored in safely in the medication rooms, however when the nurses took the trolley to residents to give out medicines, some medicines could not be locked away as they did not fit inside the trolley. It is important to make sure that medicines are stored securely at all times to make sure they are not mishandled. We looked at how well records about medicines were kept. The records about medicines were not accurately completed so it was not always possible to tell if residents had been given their medicines properly. The quantities of medicines held for each resident were not always recorded when the medication came into the home or when it was were disposed of. This made it difficult to tell if medicines had been given as prescribed. Poor record keeping could place residents at risk of being given the wrong doses of medicines. The records could not show that all medicines were accounted for. When medicines cannot be accounted for there is a risk that such medicines could be mishandled. Some medicines were not given properly either because nurses did not follow the prescribers’ directions properly or because medication ran out. We also saw that nurses gave a resident some medication when it was not prescribed for them, by borrowing another resident’s medicine. If medicines are not given to residents as prescribed their health could be placed at risk. The home recognised that some residents want to look after some of their own medicines, however they do not help them to do this safely. The nurses did not check that the residents could look after and take their medicines properly. A risk assessment must be done to check that they can do so safely and ongoing checks must be made and recorded to make sure the residents continue to be safe in handling their medicines. Some strong morphine type drugs (controlled drugs) have to be stored in a special cupboard and extra records have to be kept about these drugs. We found that the records showed that these controlled drugs could all be accounted for. However some of these controlled drugs were not stored correctly, because the nurses had not recognised these medicines as controlled drugs. The manager told us she did not check that medicines were being given properly or being handled safely very often. Most staff have had some medication training but the manager said it was a while ago and in light of the concerns about medication handling would arrange for further medication training to be provided. Lady Of The Vale DS0000006715.V368283.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. Residents find the lifestyle in the home generally matches their expectations and preferences. Some activities/excursions were provided and residents were able to maintain contact with family and friends. Residents were able to exercise choice over their lives and the residents enjoyed the meals they chose. EVIDENCE: The home had an open visiting policy and visitors could be received in the resident’s own room or any of the communal areas of the home. Residents and staff spoken to confirmed this. At the time of these visits there were no residents in the downstairs lounge late morning and none of the residents ate their lunch in the dining room. On the first floor a number of residents ate their lunch from individual tables in front of their comfortable chairs. Staff spoken to said it was the residents choice as all the residents preferred to be in their bedrooms and residents spoken to did not appear clear to be able to express a view regarding this. On the second visit a small group of residents were playing cards and carrying out Lady Of The Vale DS0000006715.V368283.R01.S.doc Version 5.2 Page 16 some activities with a staff member in the dining room. Two of the residents said they enjoyed this very much. There was no formal programme of activities in place however some examples of activities recently carried out involved potting plants, singers and entertainers, exercises, an excursion to a farm and a shopping trip. As raised at previous inspections it was of concern that there is a general lack of stimulation on a daily basis and the televisions were on for lengthy periods of time in resident’s bedrooms. A discussion with the manager highlighted the need for more individual/group activities and some training in meeting the needs of residents with a dementia type illness. Although forms were in place in the care plans to record activities these did not appear to be filled in regularly. A relative replied in the survey saying they felt the care home could improve by “Perhaps providing more activities for residents.” Brief information was in place in two of the care plans looked at to identify the past life experiences of people who use the service and gave some brief information about the persons childhood, working life, relationships, marital status and family dynamics as well as hobbies and past interests. Family members had filled this in and this showed the background, family life and employment history of the individuals. This may assist the staff in understanding the people they are caring for and where possible should be encouraged for all residents. The home supports the residents to meet their religious needs whilst living at Lady of the Vale. One relative wrote, “My mother is even Church of England as I know this has made no difference in any respect”. Attending Mass in the chapel on site on a daily basis was said to be an important part of the daily routine for a number of residents living at Lady of the Vale. Following discussions with residents and staff it was clear that residents are able to exercise some choice and control over their lives. Evidence was seen that residents are able to bring personal possessions into the home. Menus had been developed in line with residents’ likes and dislikes and offered a varied, wholesome and nutritious diet. Residents’ comments were positive in relation to the meals and three residents who expressed a view said the food was good. A choice of meals was available at each mealtime and the chef confirmed that if residents did not want the choices on the menu he would prepare an alternative. Staff were seen to support residents appropriately when eating their meals. Lady Of The Vale DS0000006715.V368283.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can raise concerns by following a readily available complaints procedure and are protected from abuse. EVIDENCE: The complaints procedure was available on display and is included in the Service User Guide to the home. The CSCI had not received any complaints since the last inspection. A concern raised to the manager included a record of how the home had investigated this and had responded to the complainant. There was evidence that the home had a procedure and policy in place for the Safeguarding of Vulnerable Adults and a policy on Whistle Blowing. Staff spoken to during the visit were aware of the action to take in the event of an allegation of abuse. Since the last inspection further staff had undertaken Adult Protection training and this has now been extended to all staff working in the home. Of the eleven relatives/residents surveys returned, all knew how to make a complaint about the care provided. One relative stated, “I do not feel there is anything which could not be resolved by the manager or her deputy.” Another relative wrote, “My father is well looked after and the staff are kind and considerate when I visit and always make me feel welcome. Lady Of The Vale DS0000006715.V368283.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides the people who use the service with comfortable, clean and homely surroundings. EVIDENCE: A partial tour of the home was carried out. The home provides a homely environment with well-maintained grounds. The resident’s bedrooms were seen to be homely, comfortable and personalised with photographs and ornaments. On the days of the inspection the home was clean and free from odours. Some of the bathrooms held a number of creams, shampoos and toiletries. A recommendation was made for these to be held in the individual persons bedroom. Lady Of The Vale DS0000006715.V368283.R01.S.doc Version 5.2 Page 19 Although the home accommodates a number of people living there with a dementia type illness there was no evidence that any orientation aids were in use to aid people living at the home. A discussion with the management showed this could be an area for development to support these residents. Of the eleven residents/relatives who returned surveys all were pleased with the cleanliness of the home. One relative wrote, “The home is a Grade A establishment for care and cleanliness. The staff are friendly and are attentive to my brother’s needs.” Another relative wrote, “This is a very homely environment and I feel like the people are treated as if they are family.” Lady Of The Vale DS0000006715.V368283.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People‘s needs are met by adequate numbers of staff that are suitably trained. Some shortfalls in the recruitment process has the potential to put residents at risk. EVIDENCE: At the time of the site visit the home provided care and accommodation for 37 people requiring nursing care. On the day of the inspection the numbers of staff on duty and the skill mix appeared appropriate to meet the needs of the residents accommodated. Agency staff are used at times to address shortfalls in the staffing levels. The staff stated they felt well supported by the home’s management team, the registered manager was on leave but came in during the visit and the deputy manager was on duty. Domestic, laundry, catering, administrative staff and a maintenance person also supported the staff team. Information gathered from the home’s self assessment showed that of the 26 carers, 15 members of care staff have successfully achieved NVQ level 2 or above and four staff were currently undertaking this. Five staff files were looked at. A requirement was made for the registered person to obtain a statement by the staff as to their physical and mental health. The current application form asks for the medical history of the Lady Of The Vale DS0000006715.V368283.R01.S.doc Version 5.2 Page 21 applicant and not an actual health declaration. Two of the files looked at did not include the person’s education record or full employment history. For a Registered Nurse the person’s career history was not clear and a recommendation was made for the applicant to complete a full CV with their application. A recommendation was made for the manager to check the professional personal identification numbers of the registered nurses on a monthly basis rather than just annually. The files did not include a passport size photograph of the applicant in line with the regulations. The staff files showed no evidence of the programme of induction carried out for new starters. The manager showed us a staff-training booklet, which she said was given to the new staff to work through. A discussion with the manager highlighted that the induction programme for new staff should include the Skills for Care Induction modules. This programme should last for twelve weeks and then be signed off by the trainer and the manager to show the staff member is considered competent and they have received appropriate information to protect themselves and the residents. There was a shortfall in the system in place for staff supervision and appraisals. Staff spoken to could not confirm they received formal supervision on a regular basis. A recommendation was made for the staff files to contain a training and development section. Certificates awarded to staff following fire safety training in April 2008 were still held all together in an envelope rather than held on the person’s file. Although the manager could show that staff had attended certain training courses there was no system in place to show who had received what training, when. Available records showed that most staff had received fire safety training and moving and handling. A recommendation was made for a training matrix to be created to show when staff had attended a particular training course and when this was due to be updated, including mandatory training. Staff spoken to had enjoyed the training in palliative care, which they had completed since the last inspection. The manager provided a list of other training that staff had attended including diabetes awareness, dementia care, mental capacity act, however it was not clear how many staff had attended the particular training course. Two staff members stated that when it came to the day of the training sometimes it was difficult to take the time off to attend the course. Staff were seen to interact with the residents in a pleasant, friendly manner, however one relative expressed some concern that “Occasionally it is difficult to make the care staff understand fully because of the language barriers, for example food requirements.” One relative felt the staff at the home “Are always willing to discuss any issues and residents are always being tended to. Relatives are able to call in at any time.” Lady Of The Vale DS0000006715.V368283.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 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further work is needed to ensure systems are in place so that the home is run in the best interests of the people living there. Shortfalls in the record keeping and in the overseeing of the systems for medication have the potential to put people at risk. EVIDENCE: The registered manager clearly takes her role and responsibilities seriously and is keen to improve and review the service where shortfalls have been identified by the home’s self audit and following this inspection. There are no changes to the management structure of the home. The manager has the relevant qualifications to run and manage a care home. The staff said that the manager was supportive and they did hold meetings Lady Of The Vale DS0000006715.V368283.R01.S.doc Version 5.2 Page 23 however minutes were not recorded. The manager and the deputy manager clearly knew the individual residents and their needs well. The manager and the deputy manager have an open style of communication and they did encourage relatives and residents to express any concerns or issues that need addressing. Two relatives spoken to during the visit were very satisfied with the care of their relatives. Policies and procedures were in place to protect the personal allowances of the residents accommodated. Four resident’s pocket monies were checked and a review of the records held showed these were accurate. Copies of reported accidents/incidents were made in an appropriate logbook. Although the manager was aware of the accidents/incidents a recommendation was made for these to be monitored and a record of any improvements to prevent recurrence or plans to improve practice are made so residents safety is addressed. Evidence provided in the pre inspection questionnaire showed that the equipment and health and safety checks are made on an ongoing basis. A sample of service reports were looked at and this included fire safety records. Although a discussion with the manager highlighted that she did some auditing regarding various aspects of care practices, shortfalls in the medication systems, the care plans, staff files, accident/incident monitoring identified during this visit showed the need to improve these areas and for more regular auditing practices to be carried out. There was no evidence to show that a quality assurance questionnaire had been sent out since the previous inspection and in the AQAA the manager recorded that the home planned to improve and develop the quality assurance tool. An environmental health inspection was carried out on 22nd February 2008. The report showed that there were some areas of non-compliance and a number of recommendations made. The manager confirmed that the issues raised had been addressed in full. Lady Of The Vale DS0000006715.V368283.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Lady Of The Vale DS0000006715.V368283.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15(2)(b) Requirement Care plans must be kept under review and changed as needed so that changes in resident’s care needs are clearly recorded and met. Arrangements must be made for the recording, safekeeping and safe administration, handling and disposal of medication. (The previous timescale of the 29/09/06 had not been met.) 1.All medicines must be stored securely at all times to ensure that medicines are not mishandled. 2.All records regarding medicines must be clear and accurate in order to show that medicines are given properly and can be accounted for. 3. All medications must be administered in exact accordance with the prescribers directions and all residents must have an adequate supply of medication to Lady Of The Vale DS0000006715.V368283.R01.S.doc Version 5.2 Page 26 Timescale for action 30/10/08 2. OP9 13 17/09/08 3. OP9 13(2) 17/09/08 ensure that their treatment is continuous so that residents health is not placed at risk. 4.All medicines must be accounted for by means of an auditable trail and regular audits must be carried out to ensure that medicines are not mishandled. 5.All staff administering medication must be trained to handle medication and are assessed as competent to do so safely. 17/10/08 4. OP33 24(1) The manager must make sure that appropriate systems are in place to check the care practices and to improve the shortfalls identified. 30/10/08 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 OP9 Good Practice Recommendations It is recommended that the policy and procedures regarding medicines are reviewed and revised, to make sure the staff have clear guidelines regarding the safe handling of medicines. The home should ensure residents are consulted about a programme of activities. A record should be made in the individual care plan to show their participation. The registered person should obtain a statement by the staff as to their physical and mental health so they are considered fit to work at the care home. The manager should ensure that an up to date training DS0000006715.V368283.R01.S.doc Version 5.2 Page 27 2. OP12 3. 4. OP29 OP30 Lady Of The Vale 5. 6. OP36 OP29 7. OP38 matrix is available to show when staff had attended a particular training course and when this was due to be updated, including mandatory training and a training plan is developed and followed. The manager should make sure that staff is in receipt of appropriate supervision on a regular basis so that their competencies and training needs are addressed. The manager should check the professional personal identification numbers of the registered nurses on a monthly basis rather than just annually. The files should include a passport size photograph of the applicant in line with the regulations. The manager should ensure that suitable auditing procedures are in place, for example, for care plans, accidents/incidents and medication practices to make sure the people accommodated are safeguarded. Lady Of The Vale DS0000006715.V368283.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Lady Of The Vale DS0000006715.V368283.R01.S.doc Version 5.2 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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