Inspection on 14/06/07 for Longroyds & Pilling House

This inspection was carried out on 14th June 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

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

CARE HOMES FOR OLDER PEOPLE Pilling House Pilling Lane Skelmanthorpe Huddersfield West Yorkshire HD8 9QE Lead Inspector Tracey South Key Unannounced Inspection 14th June 2007 09:10 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 Pilling House DS0000068870.V329097.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. Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pilling House Address Pilling Lane Skelmanthorpe Huddersfield West Yorkshire HD8 9QE 01484 861630 01484 860764 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) Hill Care Limited Mrs Stella T Hunt Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection First Inspection Brief Description of the Service: In September 2006 an application was received from Hill Care Limited to take over both Longroyds House and Pilling House previously owned by Aegis Residential Care Homes Ltd. The application included bringing the registrations of the two separate care homes, Longroyds House and Pilling House, under one registration to be known as Longroyds and Pilling House. In November 2006 Longroyds and Pilling House was registered to provide care and accommodation for up to fifty older people. The accommodation remains as two separate houses and will be referred to, in this report, as “Longroyds and Pilling”. The houses are situated in a rural location, in extensive grounds, in the village of Skelmanthorpe. There is some parking available in the grounds for visitors and there is level access to the entrance of both houses. Skelmanthorpe village has a good selection of shops and community facilities. Longroyds is a period property with a modern extension, which provides single en-suite rooms. The accommodation is on two floors. The first floor is accessed by either stairs or a stair lift. At Pilling the original property has been extended and modernised for its current use that includes a small group of sheltered flats and office space. The accommodation is on two floors. The first floor can be accessed by a passenger lift by people who have difficulty managing the stairs. Some of the original architectural features have been retained, adding character to the accommodation in both houses. The provider informed the Commission for Social Care Inspection on 20/02/07 that fees range from £331.26 to £525.00 per week. Additional charges include hairdressing, papers and magazines, toiletries and personal clothing. Information about the home and the services provided are available from the home in the statement of purpose and service user’s guide. Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out to the home by an inspector on the 14th June 2007. The visit commenced at 09.10am and the inspector left the home at 5pm. During this visit the inspector spoke to some of the people living in the home, some of the staff and the home’s manager. The inspector read care records, audited a sample of medications, reviewed staff recruitment and training records, carried out a brief tour of both houses and observed staff caring for people and serving lunches. Alongside this, the staff at the home also provided information that was requested by CSCI (Commission for Social Care Inspection) about people who live at the home, the staff that work there, the service provided and any incidents or accidents that have occurred. Prior to this visit surveys were sent out to obtain the views of people who live at the home, their relatives and people’s doctors. Seventeen surveys were sent out to people living at the home, six were returned, five of which had been completed. Seventeen surveys were sent out to relatives, eleven were returned. A survey was also sent to the doctor’s surgery used by the majority of people living at the home. The inspector would like to take this opportunity to thank everyone who participated in the inspection process. What the service does well: All people are thoroughly assessed prior to them moving into the home this enables the staff to be sure that Longroyds and Pilling House is suitable for them, as well as giving relatives the assurance that their loved ones needs’ will be met. Care plans are good and describe in detail the level of care and support each person requires to meet their personal, health and welfare needs. This means that staff have the information they need to look after people properly. The atmosphere at both Longroyds and Pilling is warm and friendly. People living there were complimentary about the staff saying there are kind and supportive. People looked well cared for and feedback from relatives’ surveys indicated that they are happy with the care their loved one receives. Surveys sent to relatives included the question, ‘What do you feel the care home does well’. Responses received include, “Always very friendly, pleasant atmosphere. Nice rooms, beautiful grounds and good food”. “I feel that Pilling Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 6 House is a friendly place to visit. All the staff are very polite and helpful”. “At Longroyds the staff are long serving, many from one family, and so create a family atmosphere. They are loving and caring”. Provides a nice quiet homely atmosphere”. “Treats Mom very well – respects her as an individual”. “Keeps an eye on my Dad and look after him”. People appeared to enjoy their meals and staff explained that they have a good idea of peoples’ likes and dislikes in the time they have got to know them. A good variety of meals are provided and specialist diets are catered for when required. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 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 Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are properly assessed prior to moving into the home to ensure that their needs can be met. EVIDENCE: People who are looking for a care home for themselves or their relative/friend are given a Statement of Purpose and a Service User Guide to help them make a decision as to whether this service is right for them. Both of these documents were looked at during this visit and although they contain good information about the service and facilities provided, not all the necessary documents were included. For example, people must be given a copy of the standard form of contract and should also be given details of the relevant qualifications and experience of the registered provider, manager and staff. Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 9 Surveys returned from people living at the home indicated that the majority had received a contract once they had moved into the home, although not everyone could remember whether they had or not. They also felt that they had received enough information about the home before they moved in. Relatives’ surveys indicated that most had received enough information about the home which helped with the decision making as to whether this was the right service for their relative. The manager explained that she assesses people who wish to move into the home to ensure that their needs can be met. She also relies on information submitted by the funding authority that includes a Community Care Assessment carried out by the multi disciplinary team (this may consist of social worker, nurse doctor, physiotherapist etc). There was good evidence that peoples’ needs are being identified prior to them moving in and an initial care plan is based on the information received as part of the pre-admission process. Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 10 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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples’ care plans are detailed and outline the level of support and care each person requires in ensuring their health and welfare needs will be met. Medication systems are well managed and peoples’ rights to privacy and dignity are acknowledged by caring staff. EVIDENCE: Four peoples’ care records were examined in detail. The standard of the care plans is generally very good in that they describe, in detail, the health and welfare needs of each person including the level of support they need from staff. The social care needs of people living at Longroyds had not been written up within the care plan although the information was available in the ‘long term needs assessment’. It would make better sense if the information was translated into the care plans so staff can see at a glance what peoples’ holistic needs are. Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 11 All care plans examined had been reviewed every month and amendments were made to those whose needs had changed. There was good evidence that people including relatives, had been involved in the care planning process. All five of the surveys completed by people living at the home said that they receive the care and support they need. People also indicated that the staff listen and act on what they say and that staff are available when they need them. Relatives’ surveys asked if they felt that the care home meets the needs of your relative/friend. Seven relatives said, ‘always’, four said, ‘usually’. One relative wrote, “my uncle prefers to stay in his own room. He watches TV on a regular basis, and enjoys this. Also he likes to read his newspaper daily”. People living in the home said that they have access to other health care professionals such as doctors, chiropodist, and opticians. Care records also record visits and support given by other health care professionals. Risk assessments have been carried out to identify any risks to the individual. Where a risk has been identified a care plan is produced to minimise the risk. There was one risk assessment that required further details about the preventative measures being used in respect of one person who is at risk of developing pressure sores. The manager was advised of this at the time of the visit. People’s surveys indicated that three people felt they ‘always’ receive the medical support they need, whilst two people felt they ‘usually’ did. The survey returned by the family doctors practice included this comment, “As a district nursing team we find Pilling House communicate well with us. There are no concerns or problems from district nurses”. A sample of three people’s medications was checked during the visit. This showed there to be good systems in place for the recording, storing, administration and disposal of medications. The medication record sheets were neat, tidy and easy to follow. The manager was advised to make sure that the medication policy is easy accessible to staff should they need to refer to it at anytime. People living at the home who spoke with the inspector were complimentary about the staff. They said how kind and supportive staff are. One lady said they are more like ‘friends’ than staff and went on to say how it is a family atmosphere at the home. People said that staff always knocked on their bedroom door before entering and that staff are generally very respectful in terms of peoples’ privacy and dignity. Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 12 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are offered a range of activities and are able to make their own choices about how they spend their time. Meals provided are good, varied and served in a pleasant environment. EVIDENCE: Surveys from people living at the home indicated that three people felt there are ‘always’ activities arranged by the home for them to take part in, whilst two people said there ‘usually’ are. People who spoke with the inspector talked about a number of different activities that take place on a regular basis. A number of people attended an ‘arts and crafts’ session at Pilling House during the afternoon of this visit, whilst over at Longroyds people were entertained by a singer. People appeared to enjoy this and many were heard joining in with the songs familiar to them. A group of ladies spoke to the inspector and talked about how they usually spent their day. They explained that they are able to get up and go to bed when they want and they are free to spend their time as they choose. Staff explained that they try their best to keep people living at the home involved in different activities although it can be difficult at times especially at Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 13 Longroyds when the staffing numbers drop to two between 2-5pm. The homes appear to rely more on outside entertainers such as ‘Active Minds’, singers and the arts and crafts person. Staff spoke about how a number of people go out with their families and that one person recently went on a week’s holiday with her family. Children from the local school visit the home on special occasions, which is said to be an enjoyable event. The manager explained that church services have recommenced and it is intended that the local clergy will visit the home once a month. People living in the home confirmed that there are no restrictions to visiting the home and that their families and friends are able visit at any time. One person said that her son visits regularly and is always made to feel welcome. Relatives’ surveys indicated that the majority felt that the care home helped those living at the home to keep in touch with them. Ten relatives said that they were ‘always’ kept up to date with important information affecting their relative and one relative felt that they ‘usually’ were. The meal being served at the time of the visit looked and smelt appetising and everyone spoken with said the meals are always very good. Dining areas were pleasantly set out. The cook is aware of peoples’ likes and dislikes including the size of portion they prefer. Two people who completed surveys said they ‘always’ like the meals at the home. Another two people said they ‘usually’ do and a further two said they ‘sometimes’ do. One person wrote, “Every Friday fish fingers offered which are too hard to chew and digest. Could steamed fish or fish in parsley sauce etc be given to people who can’t chew or swallow easily?” The manager must ensure that such comments are taken on board. Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 14 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home and their relatives and friends are confident about how to make a complaint. People are potentially at risk as a number of staff have not received training in recognising and dealing with abuse and neglect. EVIDENCE: People living at the home and relative surveys indicated that they know how to make a complaint and although most people didn’t know a named person to approach they said they would speak to any of the staff. Those people who spoke with the inspector were confident that their complaint or concern would be dealt with properly as all the staff are supportive and approachable. Longroyds received one complaint in January of this year, which was responded to appropriately and in accordance with the home’s complaints procedure. In order to ensure that people are properly protected against the risk of abuse and neglect all staff must be suitably trained so they are able to identify and report poor practice including abuse. Twenty-four of the thirty-seven staff employed have completed a POVA (Protection of Vulnerable Adults) workbook. A requirement is made to ensure that all staff are suitably trained within the next two months. Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 15 Information kept in the home about the local authority’s adult protection policy and guidelines was not the most up to date version and the manager was given contact details in order to access this information. Those staff who spoke with the inspector were able to demonstrate a fairly good understanding of how and when they should report incidents of abuse or neglect. Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 16 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, 21 and 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home offers people a homely, comfortable and clean environment but there are areas in both houses in need of redecoration. EVIDENCE: All five surveys completed by people living at the home felt that the home is ‘always’ fresh and clean. A tour of both houses was undertaken which included looking at some peoples’ bedrooms. Both homes, but particularly Longroyds, are starting to show signs of wear and tear and the paintwork on corridors and in some of the communal areas need repainting as they are ‘scuffed’, most probably due to wheelchair damage. There was a leak in the ceiling of the quiet lounge at Longroyds. This will need to be repaired and the ceiling will then require painting to avoid it looking unsightly. One of the assisted baths at Longroyds has been condemned leaving only one assisted bath/shower for the eighteen people who live there. Every effort should be made to resolve this as Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 17 soon as possible to ensure peoples’ personal care needs are not compromised. A number of staff umbrellas were placed on the bath seat of the only bathroom in use. This is not appropriate as it could lead to the spread of infection and neither is it respecting the environment people live in. The bathroom itself is in need of redecoration as it looks old and worn and does not create a warm and inviting atmosphere for people. The registered owner should implement a decorating and maintenance programme to ensure that the décor in both homes is kept to a good standard. As part of relatives’ surveys they were asked how could the care home improve, one person wrote, “Purely cosmetic – it looks dowdy and could do with new fabrics and a coat of paint – and a bit of weeding”. Although there were no unpleasant odours noted during the tour of either home the manager explained that there have been concerns raised by some relatives about unpleasant odours in particular bedrooms. The manager explained that measures have been put in place to combat this and as far as she is aware the families concerned are happy with this. Each house has a laundry in the cellar area. Designated laundry staff are employed at Pilling House but not at Longroyds and care staff are expected to carry out laundry duties. Staff explained how difficult this is at times especially when the staffing numbers reduce to two staff between 2-5pm. The manager explained that she is aware of the difficulties this causes care staff and alternative arrangements are currently being explored. Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 18 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs are generally met by staff who have undergone a thorough recruitment process before they are allowed to work in the home, but the organisation are failing to ensure staff receive the necessary training they need to look after vulnerable people. EVIDENCE: Staffing levels are similar in both homes in that there are three/four care staff who work from 8am until 10pm and two staff work during the night from 10pm until 8am. Care staff are supported by domestic and kitchen staff. The company also employs a handyperson and an administrator who work between the two houses. As already mentioned, the staffing numbers at Longroyds drop to two from 2pm until 5pm every afternoon. The inspector saw first hand the difficulties staff are faced with. For example, a number of people were requesting to use the toilet, one lady got up in her nightwear and was looking for someone to help her get dressed. There had also been an entertainer during the afternoon and once the session had finished people wanted to go back to their own room or a different lounge. The staff were clearly stretched and although they were patient towards people, they could not see to everybody at once and people understandably had to wait until they could be attended to. The staff who Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 19 were on duty explained that it is difficult at times especially when they are expected to carry out laundry duties in an amongst supporting people with their care needs. The ratios of care staff to people living at the home must be determined according to individuals assessed needs and not purely by the number of people living there. The recruitment files of four members of staff were audited in detail and found to contain the required information and recruitment checks. These checks are necessary to help protect people from potentially unsuitable staff. There is currently 37 of the care staff who have NVQ (National Vocational Qualification) level 2 in care. The company should continue to support staff in NVQ training with an aim of having 50 of the carer staff trained to NVQ level 2 or above. This will help ensure trained and skilled members of staff care for people. The manager explained that training is provided by way of training packs that staff read through and then are expected to answer questions on the subject matter. The manager marks the papers and issues a certificate of completion for those staff who have successfully achieved the pass rate. Training packs available include, promoting continence, food hygiene, health and safety, infection control, POVA (Protection of Vulnerable Adults), fire safety and care of the dying. The manager confirmed that all staff left in charge of a shift have received first aid training. There are a number of people who have not received manual handling training. The manager informed the inspector the day after the visit that twenty out of thirty seven care staff employed have received manual handling training although the majority require refresher training as it is over twelve months ago since first completed. Some staff have not received any practice based manual handling training and the registered manager and provider must ensure that this is addressed as a matter of urgency to ensure people’s health and safety is not compromised. New staff receive basic induction training which is more about the organisation than the principles of care practice. The inspector advised the manager of the Common Induction Standards and the Skills for Care standards (this is the national training organisation for care workers). New staff are expected to complete this training within the first twelve weeks of their employment before moving onto the foundation standards. The manager was advised to implement a training matrix, or some other easy means of reference, as it was difficult to establish what training each member of staff had received without the manager having to go through each person’s training file. This will make it easier for the manager to keep up to date with who needs what training at a glance. Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 20 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is generally well managed. However, the absence of appropriate movement and handling training puts people living at the home and staff potentially at risk of injury. EVIDENCE: A requirement has been made to ensure that all staff receive training appropriate to the work they are to perform and where this involves moving people they must receive manual handling training. Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 21 Stella Hunt is the manager for both Longroyds and Pilling House. She has a number of year’s experience of working with older people in a residential setting and in 2006 she successfully completed a NVQ level 4 and the Registered Manager’s Award. Since then she has completed a NVQ in Team Leading. Staff were positive about their manager saying she is approachable and supportive. The staff at Longroyds explained that the manager has taken time out to get to know them and has spent time with each person on a one to one basis, as part of their supervision. The manager organised a staff meeting in April 07, which gave staff the opportunity to come together as one team and discuss operational and general matters about the home. The manager intends to have regular staff meetings and one to one supervision sessions with all staff. To date there has been no quality assurance systems implemented and the manager was not aware of the company’s intentions in respect of quality monitoring. To ensure that the home is run in the best interest of people who live there it is important that there is some form of self-monitoring that takes place at least annually, and is based on seeking the views of people who are associated with the home. The operations manager visits the home every month in accordance with Regulation 26 of the Care Homes Regulations 2001. The purpose being to check that the home is operating well and time is spent talking with people who live at the home as well as staff to gain feedback on how the home is managed. Some people have small amounts of personal money that is held safely at the home by staff. Records are available to show when money is deposited on behalf of people. The records show the individual cash balance for each person and how their money is used on their behalf, including receipts for goods and items purchased. Three peoples’ finances were checked during the visit and were found to be correct. There was good evidence in place to indicate that health and safety checks including the maintenance of equipment take place. Regular fire safety checks are carried out; the person responsible for recording fire drills must ensure that they record each member of staff in attendance. All staff should attend at least two fire drills each year. Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 22 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 3 8 2 9 3 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 2 2 X 2 X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/a 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 OP18 Regulation 13 Requirement Timescale for action 30/08/07 2 OP19 23 Arrangements must be made to ensure all staff receive appropriate training to prevent people being harmed or suffering abuse or being placed at risk of harm or abuse. A redecoration programme is 30/07/07 required to ensure that all parts of both homes are reasonably decorated in order to provide people with a safe and wellmaintained environment. The ceiling in the quiet lounge at Longroyds must be repaired and redecorated. The condemned bath hoist must be repaired/replaced to ensure peoples’ personal care needs are not compromised. The registered manager and provider must review staffing levels to ensure there are sufficient numbers of staff on duty at all times, in particular between 2-5pm, to meet the needs of peoples living in the home. All care staff must receive DS0000068870.V329097.R01.S.doc 3 OP21 23 30/08/07 4 OP27 18 30/07/07 5 OP30 18 30/08/07 Page 24 Pilling House Version 5.2 training appropriate to the work they are to perform and where this involves moving people they must receive manual handling training. All new staff must receive structured induction training to ensure they do their job safely and effectively. 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 OP1 Good Practice Recommendations The statement of purpose needs to include the name and qualifications of the registered provider. The service user guide needs to include a copy of the standard form of contract and should also include relevant qualifications and experience of the registered provider, manager and staff and views of the people living at the home. The risk assessment identified during the visit to the home needs to include greater detail about the preventative measures in place, that is, the specialist equipment being used to prevent pressure sores developing as well as visual observations. The manager should ensure that the comment made in peoples’ surveys about offering steamed fish is acted upon. Staff should refrain from using the downstairs bathroom at Longroyds for storing their personal belongings. Work should continue with a view to having 50 of care staff with NVQ level 2. The manager should implement a training matrix to keep up to date information about the training undertaken by staff. 2 OP8 3 4 5 6 OP15 OP26 OP28 OP30 Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Pilling House DS0000068870.V329097.R01.S.doc Version 5.2 Page 26 - 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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