CARE HOMES FOR OLDER PEOPLE
Littledale Nursing Home 669 Prince Of Wales Road Sheffield South Yorkshire S9 4ES Lead Inspector
Janice Griffin Unannounced Inspection 15th November 2005 07:30 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 Littledale Nursing Home DS0000021793.V261525.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. 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. Littledale Nursing Home DS0000021793.V261525.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Littledale Nursing Home Address 669 Prince Of Wales Road Sheffield South Yorkshire S9 4ES 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) 0114 261 1644 0114 261 9095 Dr Abdul Majid Khan Mrs Tahir Majid Khan Mrs Janet Cooper Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Littledale Nursing Home DS0000021793.V261525.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 7th July 2005 Brief Description of the Service: Littledale is a 37-bed nursing home on two sites. The main building is a large detached property, which has 30 beds. The other 7 beds are situated in a semi-detached property across the road from the main building. The 7-bed unit is currently closed. The main house is a spacious property; it has one lounge, one dining room and a conservatory. Only one bedroom has an ensuite. Both properties are situated on a main road and accessible to community facilities such as shops, pubs, parks and a post office. Both buildings have small gardens and a car park. Littledale Nursing Home DS0000021793.V261525.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place from 7:30 am to 2:15 pm. As part of the inspection process five-service users, three relatives and six staff, including the manager, were spoken to. A number of records were examined and several areas of the building were inspected. The inspector noted that throughout the inspection staff interacted positively and sensitively with each service user. The inspector would like to thank service users, the relatives, the manager and staff for their commitment to the inspection process. What the service does well: What has improved since the last inspection?
The management of the homes admission and recruitment procedures have improved. The homes complaints procedure has been reviewed and now meets the required standards. The home was clean and tidy. Littledale Nursing Home DS0000021793.V261525.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Littledale Nursing Home DS0000021793.V261525.R01.S.doc Version 5.0 Page 7 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 Littledale Nursing Home DS0000021793.V261525.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Service users individual needs had been fully assessed prior to their admission, and they had moved into the home once it had been agreed that the home could meet their needs. EVIDENCE: Detailed full needs assessments had been completed by the referring social worker for all service users prior to being admitted to the home. Their families had been involved in the assessment process as appropriate. The manager confirmed that service users were only admitted to the home once they were sure that they could meet their needs. Service users were able to visit the home for informal visits prior to their admission if they wished. Service users confirmed that this helped them to get to know everyone at the home and made them feel less anxious. Records checked confirmed that service users families had been very involved in decisions regarding the arrangements. Littledale Nursing Home DS0000021793.V261525.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 11. Service users had an individual plan of care, however, further work is required to ensure that all the service users health care needs are met. The recording of medication administered needs to be improved. Service users told the inspector that they were treated with respect, and the staff respected their privacy and dignity. The inspector observed staff closing doors and speaking with respect when assisting service users. The home had a policy on death and dying. EVIDENCE: Service users said they were consulted about their care plans and they knew that the home kept records, which they were able to look at if they wished. Staff said that care plans were reviewed regularly in consultation with other staff, service users and relatives. One care plan checked did not contain any details of whether the service user had been offered any dental checks. This does not contribute to maintaining the health care needs of service users. Littledale Nursing Home DS0000021793.V261525.R01.S.doc Version 5.0 Page 10 Records were kept of medication received, and disposed of. One service users medication recording sheet had not been signed on one occasion to indicate whether medication had been given or not. This could affect the health and well being of service users. Staff interacted well with the service users, furthermore they were observed closing bedroom, toilet/bathroom doors when attending to service users personal care needs. The service users said this helped to make them feel respected and ‘at home’. The manager said that service users post was only opened if the service user or their representative requested this. This promotes the privacy of service users. Staff interviewed said that they would always sit with service users at the time of death if family were not available. They also said that every effort would be made to ensure that the service users receive appropriate medical attention and pain relieve. Staff would attend the funeral of service users. This allowed the staff to pay their respect to the service user and family and friends Littledale Nursing Home DS0000021793.V261525.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not checked they were checked at the last inspection. EVIDENCE: Littledale Nursing Home DS0000021793.V261525.R01.S.doc Version 5.0 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17 The homes complaints procedure was clear, accessible and contained all the necessary information. Staff had a good understanding of the procedure and timescales involved. Service users were aware that they could complain. Full records of all complaints made were available within the home. The service users legal rights were protected. EVIDENCE: The complaints procedure was available for service users, their relatives and staff. Service users said that they knew that they could complain if they were not happy about anything and that they felt able to discuss any issues or concerns that they may have with the manager and staff. They confirmed that staff were always available and that they were encouraged to talk about anything that troubled them or caused them anxiety. The manager said that two-service user had their legal rights protected by advocates. She also said that if any other service users requested access to advocacy services then she would facilitate the service for them, if requested. Littledale Nursing Home DS0000021793.V261525.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,24 and 26. The location of the home is suitable for its stated purpose. Some rooms need redecorating; some furniture and floor coverings need replacing. Service users bedrooms met individual’s needs in a comfortable and homely way. The layout of the toilets and bathrooms were not adequate. EVIDENCE: Some areas still had damaged decoration, damaged furniture and stained floor coverings, which made some areas look shabby. Some service users did not have a key to their bedrooms. The home did not have enough assisted baths, and the room layout of the toilets did not ensure that there is enough room at either side of toilets to enable access for carers and equipment. This could be a potential safety risk for staff and service uers. Littledale Nursing Home DS0000021793.V261525.R01.S.doc Version 5.0 Page 14 The bedroom doors were fitted with suitable door locks but three service users said that they had not been offered a key to their rooms. Lockable facilities were not provided in all the bedrooms. This does not assure privacy. The service users interviewed said that they were happy with the furnishings in their room. At least two double electric sockets, an easy chairs and a table to sit at were provided in each bedroom. Promoting comfort for the service users. Some of the easy chairs were in a poor condition and looked shabby and dirty. In some bathrooms, the baths were of the domestic type and very low. The toilets did not ensure that there is enough room at either side of toilets to enable access for carers and equipment. This does not ensure that the health and welfare of service users and staff is protected at all times. Littledale Nursing Home DS0000021793.V261525.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 and 30. Service users spoken to said that staff were kind and helpful. The home had a training and development plan and all staff had completed a range of training relevant to their role. The recruitment procedures were sufficiently robust enough to protect the welfare of service users. EVIDENCE: Service users said that staff were always there to help them and they felt safe. Three staff files were checked; the files demonstrated a thorough recruitment process had been followed as required by the regulations. CRB checks had been done and two references obtained, no gaps were noted in staff’s employment history. The homes induction programme met required standard and staff spoken to said it covered such things as safe working practices, the organisation and workers role and the needs of the service users. This promotes the safety of staff and service user. Training needs of care staff were identified via supervision and appraisal sessions. 95 of the staff were trained to NVQ level 2, this demonstrates the provider’s commitment to investing in the staff. Littledale Nursing Home DS0000021793.V261525.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,35 and 38. The service users and staff said the manager was approachable and very professional. Records were in the main up to date and well organised. More care needs to be taken with some health and safety issues and the storage of hazardous substances. EVIDENCE: The manager had a job description that clearly defined her roles and responsibilities and staff were aware of her role. She is committed to ensuring that the home maintains and develops a high standard of care, she had completed regular internal audits on all aspects of the service provided by the home. The financial records of two service users were checked and receipts were available for all transactions made on behalf of the service user. This protects the service user from financial abuse.
Littledale Nursing Home DS0000021793.V261525.R01.S.doc Version 5.0 Page 17 Records were securely stored as required and those checked were accurate and up to date and in good order. Staff and service users confirmed that they had access to the appropriate records as required. The manager stated that there was a programme for the regular servicing and maintenance of all appliances. No fire exits were blocked but one fire door was not closing on its rebate. The key to the laundry was left in the door and hazardous substances were stored in the room. This is a potential safety hazard for service users. Littledale Nursing Home DS0000021793.V261525.R01.S.doc Version 5.0 Page 18 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 2 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 1 X 1 X X 1 X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 X X 1 Littledale Nursing Home DS0000021793.V261525.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP8 OP9 Regulation 13 13 Requirement Service users must have access to dentists at regular intervals. MAR sheets must always be signed to show whether medication has been given or not. The stained damaged furniture must be replaced. Those areas around the home with stained/damaged decoration must be redecorated. The room layout of the toilets must ensure that there is enough room at either side of toilets to enable access for carers and equipment The low baths must be replaced with a suitable assisted type baths. Those service users, who are capable of using a key, must be offered a key to their bedroom door. All bedrooms must have a lockable facility. By 2005 the manager must have NVQ level 4 in management or equivalent. Hazardous substances must be
DS0000021793.V261525.R01.S.doc Timescale for action 01/02/06 16/11/05 3 4 5 OP19 OP19 OP19 23 23 23 01/05/06 01/05/06 01/05/06 6 OP21 OP24 23 16 01/05/06 01/02/06 7 8 9 10 OP24 OP31 OP38 23 9 13 01/03/06 15/08/06 15/11/05
Page 20 Littledale Nursing Home Version 5.0 11 OP38 23 kept in a secure place at all times. All fire doors must fully close on their rebates. 17/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Littledale Nursing Home DS0000021793.V261525.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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