CARE HOMES FOR OLDER PEOPLE
Locharwoods of Birkdale 45 York Road Southport Merseyside PR8 2AY Lead Inspector
Daniel Hamilton Unannounced Inspection 19th May 2006 10:30 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 Locharwoods of Birkdale DS0000066364.V294625.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. Locharwoods of Birkdale DS0000066364.V294625.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Locharwoods of Birkdale Address 45 York Road Southport Merseyside PR8 2AY 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) 01704 564001 Valmar Care Limited Mrs Carol Dacre Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Locharwoods of Birkdale DS0000066364.V294625.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The service must employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 3rd November 2005 Date of last inspection Brief Description of the Service: The Priory is a large two-storey detached property that has been converted into a residential care home. The home is registered to provide personal care and support for up to 19 older people. The property is situated in Birkdale village, which is near to the centre of Southport and all its amenities. There are shops, local bus and train services within close proximity of the home. The Priory has 19 single rooms, which are all equipped with en-suite facilities. Communal space comprises of a dining room at the front of the premises and a lounge to the rear. The first floor rooms are accessible via a passenger lift and a call bell system is in place. There is a large well-maintained garden to the rear of the building and car parking is available at the front of the premises. The Care Home Fee is £392.00 per week. Locharwoods of Birkdale DS0000066364.V294625.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day and lasted a total of 10 hours. Sixteen residents were being accommodated at the time of the visit. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The Registered Provider (Owner), Manager, three staff members, three visitors and seven residents were also spoken to during the visit. Furthermore, satisfaction survey forms “Have Your Say About….” were distributed to a number of residents and / or their relatives prior to the inspection, to obtain additional views / feedback about the home. All the core standards were reviewed and previous requirements and recommendations from the last inspection in November 2005 were discussed. What the service does well:
Since the last inspection, a new owner had purchased the home from the previous Registered Provider (Britannia Healthcare Ltd). The new owner had made significant improvements to the environment and demonstrated a commitment to addressing outstanding requirements and recommendations in order to improve the quality of care in the home. The home had a pleasant and relaxed atmosphere. Residents appeared relaxed and well cared for. Staff were observed to be friendly and attentive to the needs of residents and were seen to spend time talking with residents, offering assistance as required. The home provided a range of information about the home for prospective residents and had established an assessment and care planning system to ensure the needs of residents were identified and planned for. Personal files evidenced good links with health care professionals and a resident said; “It’s a good place and the staff are very caring. They will get a doctor if anyone is unwell.” Staff spoken with were able to provide examples of how they treat the residents with dignity and respect in their day-to-day practice and were seen to offer support to residents in a sensitive manner throughout the day. A resident spoken with reported; “The staff are very thoughtful and caring in their approach.” Residents spoken with confirmed that they thought the staff were good at their jobs and were kind and helpful. Visiting times were flexible and residents had control of their day-to-day lives. Feedback from two residents included; You can have visitors anytime you
Locharwoods of Birkdale DS0000066364.V294625.R01.S.doc Version 5.2 Page 6 want. They are always made welcome” and “No one tells you what you can or cannot do.” A relative reported; Im always popping in. There are no restrictions and I have no complaints.” Meals were well managed and residents received a choice of meals each day. Meals served were nutritious and wholesome and residents spoke highly of the food provided. A resident said; “I could not fault the food. It’s lovely and well presented.” The environment was benefiting from ongoing investment and redecoration. Areas viewed appeared safe and were clean and hygienic. Procedures were in place to control the risk of infection. A resident stated that; “The domestic is great and works hard to keep the place clean.” Sufficient numbers of staff were deployed to meet the needs of residents and the people living in the home were protected by the home’s recruitment policy and practices. Records required under the Care Home Regulations 2001 were in place. What has improved since the last inspection? What they could do better:
Since the last inspection, the manager had updated the pre-admission assessment form however ‘Personal Safety and Risk’ issues had not been included or assessed as part of the assessment process. This matter should be addressed in order to ensure the assessment process is robust. The home must record details of the date that medication is received into the care home in order to account for medication and provide an effective audit trail. Furthermore, declaration forms should be signed by residents (where
Locharwoods of Birkdale DS0000066364.V294625.R01.S.doc Version 5.2 Page 7 practicable) to verify the arrangements for the administration of medication. The competency of staff responsible for handling medication should also be reviewed at regular intervals to ensure best practice. Residents expressed different views regarding the frequency and range of activities provided. For example, some residents reported concerns that the home’s entertainer was no longer visiting the home and that trips had stopped. The home should consult residents about their recreational preferences and expectations and ensure an appropriate response. It was recommended that a copy of the home’s Complaints Procedure be displayed on the home’s notice board to ensure the procedure is clearly visible to residents, staff and visitors to the home. Some staff had not completed training in adult protection. Training should be arranged to raise staff awareness of the different types of abuse and how to safeguard vulnerable adults. Documentary evidence was not available for some training completed and staff had not completed all the necessary Safe Working Practice training as required at the last inspection. These matters must be addressed to verify that staff are trained and competent to undertake their roles. The manager should make arrangements to undertake a qualification equivalent to the National Vocational Qualification in Care at level 4 and the home’s induction programme should be revised, in order to ensure it meets the requirements of the National Training Organisation. At the time of the visit, the results of service user surveys distributed by the home had not been collated / published for interested parties to view and there had been no resident meetings to enable residents to express their views as part of a group discussion for nearly three years. These issues should be reviewed in order to improve consultation and demonstrate that the home is run in the best interests of residents. Overall, appropriate records and receipts were kept for money handled by the manager on behalf of residents however there was one instance were money had been handled and a record had not been maintained for income and expenditure. The manager should maintain records of all financial transactions to provide an audit trail and to ensure accountability. The home must ensure residents’ safety by ensuring that all required safety certificates are available and up-to-date. Furthermore, day staff should receive fire instruction training every six months and night staff every three months. 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. Locharwoods of Birkdale DS0000066364.V294625.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 Locharwoods of Birkdale DS0000066364.V294625.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. The people living in the home had access to key information on the service including the terms and conditions of residency. This enabled prospective residents to determine whether the home was suitable to meet their needs. Assessments of need were undertaken prior to admission, to ensure the needs of prospective residents were identified. EVIDENCE: Pre-inspection records showed that four residents had moved into the home on a permanent basis since the last key inspection. Assessment documentation for two new residents was viewed. Each of the files contained an assessment, which had been completed by the Registered Manager prior to the admission of individual residents. Since the last inspection, the pre-admission assessment form had been updated however the assessment did not include information on ‘Personal Safety and Risk’. One of the files also contained a copy of an assessment completed by a social worker. Feedback from residents and examination of records confirmed that residents had access to information on the home including the Statement of Purpose and
Locharwoods of Birkdale DS0000066364.V294625.R01.S.doc Version 5.2 Page 10 Service User Guide. Furthermore, signed copies (where practicable) of Contracts / Statement of Terms and Conditions were in place. The new Owner reported that new contracts were to be issued to residents within the next two weeks as they related to the Previous Provider. Locharwoods of Birkdale DS0000066364.V294625.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 at least once during a 12 month period. 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 the service. Care plans were in place that outlined how the care needs of residents were to be met. Some Medication Administration Records were not being appropriately maintained to provide an audit trail. This has the potential to place the health and welfare of residents at risk. Care was provided in accordance with the needs, expectations and rights of the people living in the home. EVIDENCE: The manager reported that Care Plans were drawn up following an assessment of individual needs. Personal files were viewed for two residents who had moved into the home since the key inspection. Each file viewed contained a Care Plan, which identified the health, personal and social care needs of residents and the action required by staff to ensure individual needs were met. Care plans seen were personalised, well maintained and had been kept under monthly review. Staff spoken with demonstrated a good awareness of the needs of the people they were supporting and understood their role and the importance of review and updating of care plans.
Locharwoods of Birkdale DS0000066364.V294625.R01.S.doc Version 5.2 Page 12 Supporting documentation including; summary of care needs information, person-centred risk assessments, daily record sheets, health care records, guidance sheets and accident records were also in place. Health care records detailed that residents had access to a range of health care professionals including; general practitioners, hospital staff, district nurses and chiropody appointments. Feedback from residents via Care Home Survey forms and discussion confirmed that residents had access to the medical support they required. One resident reported; “It’s a good place and the staff are very caring. They will get the doctor if anyone is unwell.” Likewise a relative stated; “The home is spot on. The staff are nice and the care provided is excellent.” The home had a medication policy and a copy of the Royal Pharmaceutical Society of Great Britain guidelines for the Administration and Control of Medicines in Care Homes. At the time of the visit, the home’s medication policy related to the Previous Provider. The owner agreed to introduce a new range of Policies and Procedures within the next two weeks. None of the residents self-administered medication at the time of the visit and declaration of wishes with regards to medication were not on individual files. A sample copy was given to the manager for reference. Staff responsible for the administration of medication had completed training and a record of staff authorised to administer medication, specimen signatures and photographs of residents were available. The home used a blister pack system that was dispensed by a local pharmacist. Medication was stored in a locked cabinet, which was bolted to a wall when not in use. There were no controlled drugs in the home on the day of the visit however suitable storage and recording systems were in place. Medication Administration Records (MAR) were viewed for two residents. Records had been signed to record the administration of medication however there was no audit trail, as the date that medication had been received into the home had not been recorded. Since the last inspection, the manager had established a monthly audit system to monitor medication records and stocks. Advice was given that the audit should also review the competency of staff responsible for administering medication. The pre-inspection records detailed that the home had policies and procedures in place regarding the value base of social care. Staff spoken to demonstrated a good awareness of how to promote, safeguard and treat residents with respect, privacy and dignity. Staff were observed to offer support to residents in a discreet and sensitive manner throughout the day. Locharwoods of Birkdale DS0000066364.V294625.R01.S.doc Version 5.2 Page 13 Comments received from residents included; “The staff are very thoughtful and caring in their approach” and “I am treated very well. They respect my privacy and feelings.” Locharwoods of Birkdale DS0000066364.V294625.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. 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 the service. The range and frequency of activities is in need of review in order to satisfy the recreational needs and interests of all residents. Visiting times were flexible and residents retained control of their daily lives in order to maintain their relationships and preferred lifestyles. Meals were well managed and provided in comfort and the people living in the home received a nutritious and appealing diet. EVIDENCE: Since the last key inspection, the home had introduced a new ‘Locharwoods Social Calendar’ that identified a range of activities for residents to participate in during the month. These included; coffee in the village, church services, walks in the community, afternoon tea in the garden, bingo sessions, games, films, baking, music and movement and gentle exercises. The home did not maintain a central record of activities provided or participants and examination of individual ‘Social Activities Logs’ showed that residents had participated in a limited range of activities. Feedback received from residents via Care Home Survey forms provided conflicting information. Some residents reported there were always activities arranged by the home whilst others reported they were never provided. Likewise, residents expressed mixed views about their satisfaction with the activities provided.
Locharwoods of Birkdale DS0000066364.V294625.R01.S.doc Version 5.2 Page 15 Comments included; I’m not interested in the activities anymore”; “The home is starting to provide more activities” and “There are enough activities for me.” Some residents reported concern that the mini bus trips and entertainer had stopped since the last visit. The home supported residents to have access to ministers of religion and church representatives subject to individual religious beliefs. The home’s ‘Statement of Purpose’ highlighted that the friends and relatives of residents were welcome at any time convenient to the resident. Relatives and friends of residents were observed to visit the home during the inspection and residents confirmed that visiting times were flexible. A resident said; You can have visitors anytime you want. They are always made welcome.” Likewise, a friend of a resident said; “I can visit whenever” and a relative stated; “I’m always popping in. There are no restrictions and I have no complaints” The routines in the home were observed as being based around the needs and preferences of the residents and this was confirmed in discussion with residents and staff. A resident spoken with said; “I am very happy. I have control of my own life.” Likewise, another resident reported; “No one tells you what you can or cannot do.” Residents confirmed they were able to bring personal possessions into the home and rooms viewed had been personalised with pictures, ornaments and personal belongings. The home had introduced a new four-week menu that offered a choice of meals for residents. The manager and owner reported that any cultural or special dietary needs would be assessed as part of the home’s assessment process and would be accommodated if a service was offered. The dining room was being redecorated on the day of the visit and meals were being served to residents in the lounge as a temporary measure. Table settings were pleasant with tablecloths, fresh napkins and condiments. Feedback from residents via Care Home Survey forms and discussion confirmed that residents were very satisfied with the meals provided. Comments included; “The food is nice. We get choices for each meal”; I could not fault the food. It’s lovely and well presented” and “The cook is excellent.” Records showed that the Environmental Health Department had completed a routine inspection during February and that the outcome was very good. Only one recommendation was made regarding temperature records. Locharwoods of Birkdale DS0000066364.V294625.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the service. There had been no complaints since the last inspection and residents were confident that if they needed to make a complaint, their concerns would be listened to and acted upon. Some staff required training in adult protection in order to ensure a proper response to any suspicion or evidence of abuse. EVIDENCE: The home had a ‘Concerns and Complaints’ Policy in place and a record of all complaints received was maintained. No complaints had been received since the last inspection. A copy of the ‘Concerns and Complaints’ was included in the Statement of Purpose and Service User Guide. The manager and owner were advised to display a copy in the reception area of the home. Feedback from residents confirmed they felt listened to and that they knew who to speak to and how to complain if they were not happy. None of the residents spoken with during the inspection had any complaints about the home or service provided. One resident said; “It’s a really good home. You can’t fault them” and another reported; “I would tell Stuart [Owner] if I had a complaint.” The home had a copy of the previous Provider’s Abuse and Whistle blowing policies and the manager had obtained a copy of the new local authority adult protection procedures. No additional staff had received training in the Protection of Vulnerable Adults from Abuse since December 2004 and five staff had not completed the training to date. Locharwoods of Birkdale DS0000066364.V294625.R01.S.doc Version 5.2 Page 17 Staff who had completed training in abuse awareness were able to demonstrate a good understanding of the different types of abuse, reporting procedures and their duty of care to safeguard the welfare of vulnerable adults. Locharwoods of Birkdale DS0000066364.V294625.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 at least once during a 12 month period. 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 the service. Although some parts of the environment remained in need of repair / redecoration, the physical appearance of the home was improving and this provided the residents with a safe, clean and comfortable place to live. EVIDENCE: The home employed a handyperson who was responsible for maintaining the environment. Contractors were hired as and when necessary. Records showed that the home’s handyperson undertook a monthly audit of each room in the home to check for hazards and / or maintenance work required. A check of the water temperature at each hot water outlet was also completed, to ensure the temperature was regulated as close to 43°C as possible. The manager and owner reported that all radiators were guarded or were low surface temperature models. A building and fire risk assessment were in place. Locharwoods of Birkdale DS0000066364.V294625.R01.S.doc Version 5.2 Page 19 The home did not have a programme for the routine maintenance and renewal of the fabric and decoration, however the new owner reported that the home would receive ongoing maintenance and refurbishment as required. The dining room was being redecorated during the inspection and arrangements had been made to redecorate the lounge. The pre-inspection questionnaire indicated that various bedrooms and ensuites had been redecorated and this was evident whilst touring the premises. All work identified in the home’s action plan had been completed as required at the last inspection, with the exception of the decoration of two bedrooms and the repair of one en-suite. The new owner reported that he was in the process of addressing the outstanding issues with the previous Registered Provider. Overall, areas viewed appeared to be well maintained and the grounds of the home were pleasant and accessible to residents at the time of the visit. The home had a passenger lift and a call bell system was in place. Residents were observed to have disability aids / equipment to maximise their independence. A risk assessment of the premises had been completed during July 2005, which confirmed that at that time, the necessary disability equipment was available to meet the needs of residents. The manager was aware of the need to ensure the assessment was kept under review. The home had a policy in place for the Control of Infection and data sheets were available for the Control of Substances Hazardous to Health (COSHH). Chemicals were safely stored. The home employed one domestic and areas viewed were generally clean and hygienic. The laundry was appropriately sited away from food preparation areas and was equipped with a washer with a sluice programme, a drier and hand basin. Disposable gloves and aprons were available for staff use. The owner was aware that the laundry floor was in of replacement. Feedback from residents via survey forms and through discussion confirmed the home was kept clean, fresh and hygienic. One resident said; “The domestic is great and works hard to keep the place clean.” Locharwoods of Birkdale DS0000066364.V294625.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the service. Sufficient numbers of staff were deployed to meet the needs of residents. Recruitment practice was robust and safeguarded the people living in the home. Some staff had not completed all the necessary training, to ensure competency in their role and documentary evidence of training completed was not available for some staff, to verify training completed. EVIDENCE: The staffing rota had been revised since the last inspection to reflect the occupancy and dependency levels of residents. At the time of the inspection there were sixteen residents living in the home. Inspection of rotas, direct observation and discussion with the new owner, manager, staff and residents confirmed that three members of staff remained on duty each morning and two in the afternoon. The overlap shift of 3 hours for three days per week had stopped and the two waking night staff had been replaced with one waking night and a sleep in staff member. The new rota enabled the manager or her deputy to be on duty each day of the week. Residents spoken with during the visit confirmed that staff were available to assist them when required. The manager reported that the home employed 12 care staff including the deputy manager. Records showed that only one of the care staff (8.33 ) had a National Vocational Qualification (NVQ) in Care at level 2 or above. The manager reported that a further seven staff (58.33 ) had an NVQ at level 2 or above in care bringing the total number of qualified staff to 8 (66.66 ). This
Locharwoods of Birkdale DS0000066364.V294625.R01.S.doc Version 5.2 Page 21 figure could not be verified because certificates were not in place and some training records were not up to date. One member of staff was working towards the qualification The home had a recruitment policy in place, which covered equal opportunities. Records showed that only one member of staff had commenced employment since the last inspection. The manager had undertaken a thorough recruitment process and had records of interview notes. A Criminal Record Bureau check had been completed and all records required under the Care Home Regulations were in place. Outstanding references that were not available for a member of staff at the last inspection had been obtained. Discussion with staff and examination of records confirmed that new staff received an induction. The home’s induction training did not meet the specification of the National Training Organisation and the manager was advised to update the training / checklist in accordance with Standard 30 of the National Minimum Standards. The home’s training matrix was viewed. At the time of the visit, this did not cover the full range of training completed by staff. Despite a requirement at the last inspection, a number of staff had not completed Safe Working Practice Training or were in need of refresher training. Locharwoods of Birkdale DS0000066364.V294625.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the service. Some aspects of training, consultation and administration within the home require further attention, to demonstrate that the home is run in the best interests of the people using the service. EVIDENCE: The home’s manager (Mrs Carol Dacre) was registered with the Commission for Social Care Inspection. The manager had completed the National Vocational Qualification (NVQ) Level 4 Registered Managers Award. The manager was advised to also complete a qualification equivalent to a NVQ level 4 in Care. Training records showed that the manager also needed to complete some refresher training for some Safe Working Practice topics. Staff and residents spoken with during the inspection spoke highly of the manager and her leadership. A staff member reported; “Carol is very supportive.” Likewise, a resident reported; “The manager is very friendly and takes a genuine interest in our welfare.”
Locharwoods of Birkdale DS0000066364.V294625.R01.S.doc Version 5.2 Page 23 Regulation 26 reports had not been completed as the new Provider visited the home on a daily basis and considered himself to be in charge. The home commissioned an annual external quality assurance assessment which had recently been completed. Furthermore, the owner reported that the home operated an internal quality assurance system and that questionnaires had been distributed to all residents or their representatives during March 2006. Copies were not available for inspection and the results had not been published. No residents meetings had been coordinated since June 2003. Records showed that the manager and owner did not act as an appointee for any of the residents living in the home. Systems had been established to issue invoices to residents for fees, with the exception of three residents who preferred to pay by standing order. Only two residents looked after their financial affairs independently. All the other residents received assistance from relatives or personal representatives. At the time of the inspection, the home looked after the personal allowances of 5 residents. Records were checked for three residents. Two were appropriately managed and records of transactions, receipts and cash balances were correct. In one instance there was no record to account for money received from a resident’s relative to pay for Chiropodist and Hairdressing fees however receipts had been obtained. The manager was advised to record all income and expenditure to ensure an audit trail. The pre-inspection records indicated that equipment within the home received regular maintenance however there was no record for the bath hoist and the manager was unable to locate a recent service certificate. Fire records were also inspected. These showed that the fire alarm system was tested on a weekly basis and emergency lighting and fire extinguishers were tested each month. There was no record of day staff receiving fire instruction training since March 2005 and the fire book did not identify which night staff had received the training. Training records also showed that all staff required refresher training for Fire Awareness and other Safe Working Practice topics as identified in Standard 30. A fire and building risk assessment were in place. Locharwoods of Birkdale DS0000066364.V294625.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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Locharwoods of Birkdale DS0000066364.V294625.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 (2) Requirement The date, quantity and initials of the person receiving medication into the home must be recorded on Medication Administration Records. Documentary evidence of any relevant qualifications of staff must be obtained. Safe Working Practice training must be completed by all staff and refresher training must be completed periodically. [Previous timescale of 03/02/06 not met]. A service certificate for the bath hoist must be obtained. Timescale for action 30/06/06 2 3 OP30 OP38 18 18 (1) (a) 31/07/06 30/09/06 4 OP38 23(2) C 15/07/06 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 2 Refer to Standard OP3 OP9 Good Practice Recommendations The home’s pre-admission assessment should be updated to include Personal Safety and Risk Declaration forms should be completed by residents or
DS0000066364.V294625.R01.S.doc Version 5.2 Page 26 Locharwoods of Birkdale 3 4 5 6 7 8 9 10 OP9 OP12 OP16 OP18 OP30 OP31 OP33 OP33 11 12 OP35 OP38 their representatives to confirm their wishes (where practicable) have been taken into consideration with regard to the administration of medication. A system should be introduced to ensure the competency of staff responsible for administering medication is kept under review. Residents should be consulted about the range and frequency of activities provided. A copy of the Complaints Procedure should be displayed in the reception area of the home. All staff should complete training in The Protection of Vulnerable Adults from Abuse. The home’s induction training should be updated to ensure staff receive training to National Training Organisation specification. The Registered Manager should complete an award equivalent to the NVQ level 4 in Care and ensure that all Safe Working Practice training is up-to-date. Residents should be consulted about the introduction of residents meetings as a forum to obtain feedback about the service provided. The results of questionnaires / service user surveys should be published and made available to prospective residents, their representatives and other interested parties including the Commission for Social Care Inspection. Written records of all financial transactions (income and expenditure) should be maintained for all money handled on behalf of residents or their representatives. Day staff should receive fire instruction training every six months and night staff every three months. Locharwoods of Birkdale DS0000066364.V294625.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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