Inspection on 07/03/06 for Minster Grange

This inspection was carried out on 7th March 2006.

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

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

Other inspections for this house

Minster Grange 30/10/06

Minster Grange 26/09/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Minster Grange Minster Grange Minster Road Stourport on Severn Worcs DY13 8AT Lead Inspector N Andrews Unannounced Inspection 09:23 7 , 9 and 21st March 2006 th th 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 Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 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. Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Minster Grange Address Minster Grange Minster Road Stourport on Severn Worcs DY13 8AT 01299 826636 01299 827180 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) Mrs Monica Arjan McGlynn Trading as Minster Grange Residential Home Mr Arjan Bhoja Odedra, Mrs Shanta Arjan Odedra Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (26), of places Physical disability over 65 years of age (26) Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The partners and their individual duties are those set out in the partnership agreement dated 23 May 2005. 26th September 2005 Date of last inspection Brief Description of the Service: Minster Grange is a large, detached building situated on the main Stourport to Kidderminster road approximately one mile from Stourport town centre. The town provides a good range of social and civic amenities. The home is registered to provide residential i.e. personal, care to a maximum of 26 older people above the age of 65 years who may also be physically disabled and/or have a dementia illness. The property has been adapted for its present use as a care home. There is an enclosed garden at the rear of the premises and carparking facilities at the front of the premises. The service users are accommodated in 16 single bedrooms and 5 double bedrooms. All of the bedrooms except three single bedrooms have an en suite facility. The home has both a passenger lift and a stair lift to enable the service users to have easy access to the accommodation on the first floor. Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine inspection that took place over a day and a half. The person who had been the registered manager had resigned from her post on 13 February 2006. The registered manager of another care home owned by the same registered provider was acting as the manager of the home on a temporary basis. Time was spent with the acting manager and the deputy manager assessing the progress made by the home in implementing the requirements and recommendations arising from the previous inspection. The inspection also included individual discussions with three service users and three members of staff. Various records that the home is required to maintain were inspected and parts of the premises were also inspected. One of the service users with whom a discussion was held said ‘I have a lovely room, a comfortable bed and the food is improving. The food has been very poor. I can’t say that anything is wrong. It’s warm and comfortable. I’m quite happy. The staff are very nice, marvellous. Quite a few staff have left’. Another service user said, ‘The staff are pretty good. You can always have a joke with them. Breakfast has been a bit late recently. The food is not too bad. We leave what we can’t eat. I enjoy what I have.’ A third service user said, ‘The staff are very kind. They speak to us nicely. They’re very cheerful. Sometimes we have to wait because they’re kept very busy. Some of the residents need more attention than others. The staff look after the residents very well but they are very busy. Sometimes the home is short of staff but I’ve never had any complaints. I’m not very keen on the food’. The three service users confirmed that their privacy was respected and that the staff always knocked their bedroom door before entering. They also confirmed that they felt confident about raising any concerns that they might have with the staff. They also felt that any concerns raised would be dealt with quickly and appropriately. The service users confirmed that they were able to get up and go to bed when they wished. Two of the service users said that they enjoyed having breakfast in their own rooms. One of the service users said that she preferred to eat her meals in the dining room. The three service users commented positively on the ‘exercise lady’ who visited the home to carry out music and movement sessions. One service user also said that she enjoyed the ‘sewing lady’ who visited the home once a fortnight. One of the service users said ‘I don’t think that there’s enough going on. Sometimes it’s very boring. When asked what she would enjoy she replied ‘Having someone coming in from outside to talk about a subject’. Two of the service users said that they read books and newspapers. One service user said, ‘The books in the home are pretty old’. One service user said ‘The home is kept very clean’. The staff with whom discussions were held spoke positively about their work and about the home in general. One member of staff commented on the home’s ‘family atmosphere’. She said that the standard of care was good and Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 Page 6 that good relationships existed between the staff and the service users’ relatives. Another member of staff stated ‘I love my job’. She said that she regarded the home as her ‘second family’. She confirmed that there was good mutual support between the staff and said that it was a ‘happier team at the moment’. A third member of staff said that the care was good, the staff were supportive of each other, the home was clean and the service users were ‘well looked after’. Another member of staff also confirmed that the home’s relationship with the service users’ families was good. All three staff expressed their confidence in the new acting manager and said that ‘things had already started to improve’. One member of staff said that she was ‘nervous about change but now things get done’ and the acting manager ‘listens to the staff as well as the residents’. The staff recognised the need for change and expressed their optimism for the future development of the home. One member of staff said that the home was ‘more organised’. She gave the shift pattern where the work was spread more evenly and aspects of the administrative work including care plans as examples to illustrate her point. She said that there was ‘more of a routine’ and that the staff could see ‘things being done properly’. Another member of staff said that she felt that they were ‘being listened to’ and that ‘the communication had improved’. The three members of staff said that staff meetings had been held infrequently in the past. However, they confirmed that a staff meeting had been held recently. All three staff stated that they would welcome the introduction of more frequent staff meetings. The three members of staff confirmed that they had not received a statement of their terms and conditions of employment (contract) from their present employers. It was also confirmed that individual supervision meetings were not being held at the required frequency. In response to a question about what aspects of the service could be improved the staff comments included ‘more variety with the meals’ and ‘a wider choice of food’, ‘more staff training, particularly NVQ training’, and ‘the key worker system is not operating as well as it could’. The acting manager is asked to consider the comments made by the service users and staff, particularly in regard to the food and activities provided, the frequency of the staff meetings and staff supervision meetings and the key worker system and to take appropriate remedial action to address the concerns expressed. The home was inspected against 13 of the National Minimum Standards. Three of the Standards were met, 5 of the Standards were nearly met and 5 were not met. The number of requirements and recommendations had increased since the previous inspection from 21 to 32 and from 4 to 17, respectively. Twelve of the 32 requirements were requirements that had been identified in previous inspections and not yet implemented. Nine of the 32 requirements related to the administration of medication. The number of requirements and recommendations is unacceptably high and detracts from the good work that is being undertaken by a committed and caring workforce. There is an urgent need to appoint a suitable person to Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 Page 7 become the registered manager in order to ensure that all of the issues of concern are addressed and that the full potential of the staff is realised. What the service does well: 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. Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 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 Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 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): 3 An assessment of the care needs of all prospective service users was carried out prior to their admission to the home. However, the assessment form used by the home needed to be amended and improved. EVIDENCE: It was confirmed that prospective service users were admitted to the home only following a full assessment of their care needs. However, the forms that were used by the home were referred to as ‘Care Plan Assessment’. This was potentially confusing and may not enable the staff or other people who have a legitimate interest in the care of the service users to make a clear enough distinction between the assessments and the service users’ care plans. It was confirmed that all of the service users had a care plan. However, in respect of the records that were inspected, it was difficult to distinguish between the assessments and the care plans. An assessment form needed to be introduced that was clear and distinct from the care plan and that covered all of the aspects of care referred to in Standard 3.3. Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8, 9 and 10 The home worked closely with outside agencies in order to ensure that the service users’ healthcare needs were met. However, nutritional screening needed to be introduced for all of the service users. Medicines were, in general, stored safely. However, medication that required cold storage was not stored in a safe manner. Some attention to detail was required, particularly to ensure that medication records are accurate and up to date. Further enhanced training in medication handling was required. This needed to be supported by written, up to date policies and procedures for the staff to follow. The staff were very keen to improve their knowledge in order to ensure that medication is handled safely. The service users felt that their privacy and dignity were respected. EVIDENCE: The home’s response to the five requirements that were made in regard to Standard 7 as a result of the previous inspection was assessed. The first requirement was that all the records that are held about the service users by the home, including the reviews of the care plans, must be maintained at the home and made available on request at all times. The acting manager confirmed that all of the service users’ records, including the reviews of the care plans, were now retained at the home. The requirement had been implemented. The second requirement was that all parts of the service users’ Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 Page 11 care plans must be completed in full and signed by the staff/registered manager. The acting manager stated that the process that was being carried out at the time of the previous inspection of changing the format of the care plans had been completed. However, the previous registered manager had not signed all of the care plans. Therefore, the requirement had not been fully implemented. It was also stated that further work needed to be done in order to bring the care plans up to a better standard i.e. to make them clearer and to include all aspects of care. The wording of the previous requirement has, therefore, been amended to reflect the work that needs to be carried out. The third requirement was that the care staff at the home must review all of the service users’ care plans at least once a month. The acting manager stated that the responsibility for ensuring that this requirement was implemented had been delegated to one of the senior care assistants. It was confirmed that the requirement had been implemented. The fourth requirement was that the service users’ care plans must set out in detail the action which needs to be taken by the care staff to ensure that all aspects of the needs of the service users are met. The requirement had not been implemented and still stands. The fifth requirement was that the service users’ care plans must be agreed and signed by the service users whenever capable and/or their representative (if any). The requirement had not been implemented and still stands. The acting manager described the delivery of personal care by the staff as ‘very good’. Two service users that had recently died had pressure sores. However, they had received appropriate care and pressure relief from the staff under the guidance and supervision of the district nurse. It was confirmed that the staff worked well with other professionals and outside agencies. The staff were ‘aware of what to look for’ in the care of service users who were at risk of developing pressure sores. Appropriate care e.g. turning at regular intervals, and equipment e.g. pressure relieving mattresses, were provided in order to prevent or minimise the risk of further skin breakdown. The continence adviser was in contact with the home. The community psychiatric nurse visited two service users. The home received visits from ‘Mobility Plus’ once a fortnight to hold two-hour sessions of physical activity to music. The acting manager felt that the service users would find the sessions more beneficial if the frequency of the visits was increased to once a week. It was recognised that some of the service users needed to be encouraged to maintain their mobility and independence. It was stated that nutritional screening was not undertaken on admission. However, it was confirmed that the service users were weighed every month. All of the service users were registered with a GP of their choice. A ‘private’ chiropodist visited the home every week. An optician visited the home during the inspection to carry out an annual check of the service users’ eyesight. The service users were referred, via their GP, to the audiology department at Kidderminster Hospital if they needed a hearing test/examination. The acting manager stated that she was in the process of obtaining relevant details/information leaflets for the home on service users’ entitlements to NHS services and how to obtain access to appropriate advice. Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 Page 12 The CSCI Pharmacist Inspector inspected the home’s policy and procedures for the storage and administration of medication. Overall, medication storage was locked and secured in a cupboard and a medicine trolley which were located in a corridor opposite the manager’s office. Controlled drugs were not stored in a controlled drug cabinet at the time of the inspection. However, a cabinet that meets the Misuse of Drugs (Safe Custody) Regulations 1973 was available but it had not been secured to a wall. A suitable area was identified during the inspection and the cabinet was secured to a solid wall. Medication requiring cold storage was inappropriately stored in an unlocked domestic refrigerator located in a dining room. The medication including insulin, eye drops and an antibiotic mixture were stored in the door of the refrigerator together with plastic cartons of milk, margarine and sandwiches. The staff had received some general training from the supplying pharmacy on the correct use of the monitored dosage system and this had led to a change in practice to ensure safe administration to service users. However, the staff would benefit from further enhanced training in medication management. The Managed Care Training Package (Distance Learning) provided by Lloyds Pharmacy had recently been received by the home but none of the staff had started the course. The medication policy was not dated and had not been reviewed or updated. There was a basket containing clear plastic bags labelled with the service users’ names stored in the bottom of the medication trolley. Each bag contained medication for ‘when required’ use and, in some instances, contained only the medication strips, which had been removed from the original labelled pharmacy container. The date of opening of medication (not the Monitored Dosage System) had not been recorded and the balances of medication had not been carried over on the Medication Administration Record (MAR) Charts. Consequently, it was difficult to undertake a full medication audit. Some of the MAR Charts had been hand written by the staff. However, there was no system for double-checking the accuracy of the record. Some omissions were noted on the MAR Charts i.e. there was no signature for administration or there was no documented record of an appropriate code with a reason for the non-administration of medication. Where medication had been prescribed as a variable dose e.g. one or two tablets, none of the staff, apart from one, were recording the amount of medication administered. A Controlled Drug register was available and being used. However, there were some blank lines in the register and no record of any medication administered. The home did not have access to an up to date source of medication information e.g. British National Formulary. In addition, the home did not have all of the Patient Information Leaflets provided with each medication. The care plans of two service users were inspected in regard to medication. Both care plans had a separate section for recording ‘Doctors Visits’ and ‘Nurse Visits’. However, there was insufficient detail to ensure that all of the necessary information regarding medication was recorded and kept up to date. A Notice of Immediate Requirement was issued at the conclusion of the inspection in regard to several matters relating to the administration of medication. Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 Page 13 The principles and practices regarding the service users’ privacy and dignity referred to in Standard 10.1 were discussed. The acting manager stated that the staff promoted these aspects of the service users’ care to a high level. It was confirmed that issues relating to personal care were dealt with discreetly and that the death of service users was handled appropriately. The service users’ comments regarding this aspect of their care were positive (see ‘Summary’ above). It was stated that all of the service users’ bedrooms had been installed with a telephone point. Two service users had their own telephones. However, the home had two mobile handsets that the service users could use to make and receive calls in private. It was confirmed that the service users wore their own clothes at all times and that the staff used the terms of address preferred by the service users. The acting manager stated that the staff induction programme was ‘under review’. She said that it was ‘supportive but needed to be more structured’. It was confirmed that during the induction training the staff were instructed on how to treat the service users with respect at all times. The home had four double bedrooms. One of the double bedrooms had a ‘divider’. Each of the other three double bedrooms had portable screens. Portable screens pose a potential safety hazard to service users and, therefore, fixed screening must be provided. Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 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 and 14 The range of social, religious and recreational activities should be developed in accordance with the service users’ preferences, interests and needs. The service users were able to maintain contact with their relatives and friends as they wished. The service users were encouraged to exercise control over their lives. However, the service users’ guide should include information that will help to ensure their independence and choice. EVIDENCE: The acting manager and deputy manager felt that there was insufficient choice available for the service users at the present time in regard to leisure and social activities. They also felt that the food was of a good standard but that the choice could be increased. The daily routines were flexible and could be changed in order to meet the needs of the service users. The service users were able to enjoy personal and social relationships. It was stated that the service users received a lot of visitors. Unfortunately, the home had a limited amount of space where private discussions could be held. No religious services were held in the home. One service user attended a local community centre once a week. The home received visits from the mobile library service. Outings were arranged during the summer. Art and craft sessions were held but it was felt that the range of activities could be improved. The service users should be consulted about their social interests and the programme of activities arranged by the home. Appropriate facilities and activities should be made available to meet the service users’ interests, preferences and needs. Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 Page 15 The acting manager stated that she intended to introduce a notice board in order to display information about activities. The service users were able to receive visitors at any reasonable time and in private. The service users’ wishes about the visitors they saw or did not see were respected. No restrictions on visits were in place. The relative of one service user visited every Sunday and had lunch at the home. There was no written information available to give to the relatives, friends and representatives of the service users about the home’s policy on maintaining their involvement with service users at the time of moving into the home. Local community groups were not involved in the home. However, a pupil from Stourport High School visited every Friday and two children were shortly due to commence work experience at the home. The service users were encouraged to retain their independence and to maintain control over their own affairs. However, the home handled the personal allowances in respect of all the service users that handed their money over for safekeeping. Some of the service users were encouraged to retain small amounts of money in their purses. None of the service users were receiving the help and support of an advocate at the present time. Information about the local advocacy services should be included in the service users’ guide. Prospective service users were entitled to bring personal possessions with them when they were admitted. A statement to this effect should also be included in the service users’ guide. The acting manager stated that the service users’ guide included a statement regarding the service users’ right of access to the records held about them by the home. Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 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): N/A It was not possible to form an overall judgement as none of the Standards in this section of the report were fully assessed. EVIDENCE: The home’s response to the requirement and recommendation that were made in regard to Standard 16 as a result of the previous inspection was assessed. The requirement was that a record of all the complaints made against the home and the action taken by the registered persons in response to all such complaints must be maintained and made available for inspection at all times with immediate effect. It was confirmed that a complaints folder was now held at the home in which any complaint made against the home could be recorded. A copy of the home’s complaints procedure was kept in the front of the folder. No complaints had been recorded. However, it was stated that a complaint had been made to the home in November 2005 concerning a pair of spectacles for one service user. The details of the complaint had not been recorded. Therefore, the requirement had not been implemented and still stands. A robust and effective complaints procedure is essential in order to ensure the development of an open culture within the home and to underpin the principles of good quality care. The recommendation was that all copies of the home’s complaints procedure should include the telephone number of the Commission for Social Care Inspection. The acting manager confirmed that the recommendation had been implemented. The home’s response to the one requirement and two recommendations that were made in regard to Standard 18 as a result of the previous inspection was assessed. The requirement was that the home’s policy on the protection of vulnerable adults from abuse must be reviewed and, where necessary, Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 Page 17 amended in accordance with ‘No Secrets’ and the guidance contained in this (i.e. the previous) report. On the second day of the inspection the acting manager confirmed that the requirement had been implemented by adapting and amending the same policy and procedure of another home i.e. one of the other homes owned by the registered provider. The requirement was, therefore, regarded as having been implemented. The first recommendation was that the home should obtain a copy of the Department of Health guidance ‘No Secrets’. The recommendation had not been implemented and still stands. The second recommendation was that a policy should be developed and implemented regarding the service users’ money and financial affairs ensuring service users’ access to their personal financial records, safe storage of money and valuables, consultation on finances in private, and advice on personal insurance; and preclude staff involvement in assisting in the making of or benefiting from service users’ wills. The recommendation had not been implemented and still stands. Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 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 The service users lived in comfortable and homely surroundings. However, various improvements were needed to ensure the safety and wellbeing of the service users. EVIDENCE: The premises were accessible, comfortable and homely. However, the home did not have a programme of routine maintenance and renewal of the fabric and decoration of the premises. The carpet in the extension needed a new underlay. The gate at the top of the rear staircase was not high enough to prevent a potential accident i.e. the risk of falling. The gate needed to be raised. A Notice of Immediate Requirement was issued at the conclusion of the inspection in regard to this matter. The acting manager confirmed that arrangements were in hand to ensure that the garden and borders were adequately maintained. The front garden contained a metal structure that no longer served any useful purpose and detracted from the visual amenity of the home. The structure should be removed. The home kept a ‘maintenance sheet’ on which items relating to the environment that needed to be repaired were recorded. The acting manager stated that the Environmental Health Officer had visited the home in January 2006. It was stated that there were no Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 Page 19 outstanding issues that needed to be addressed as a result of the visit. The date of the last visit by the Fire Safety Officer was not known. It was confirmed that a fire risk assessment needed to be carried out and recorded. A Notice of Immediate Requirement was issued at the conclusion of the inspection in regard to this matter. Brookside Fire had serviced the fire extinguishers on 28 February 2006. The home’s response to the requirement that was made in regard to Standard 26 as a result of the previous inspection was assessed. The requirement was that the home’s infection control policy must be reviewed and, where necessary, updated in accordance with the ‘Guidelines for Infection Control in Care Homes’ produced by the Local Health Protection Unit. The requirement was implemented during the period of the inspection. Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 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): 30 A staff training and development programme that meets the National Training Organisation workforce training targets needed to be introduced in order to ensure that the staff are trained to do their jobs. EVIDENCE: The home’s response to the requirement that was made in regard to Standard 27 as a result of the previous inspection was assessed. The requirement was that the staff duty rota must be amended in accordance with the guidance given in this (i.e. the previous) report and a record of whether the staff duty rota was actually worked must be maintained within the home. A copy of the staff duty rota was made available for inspection. It was noted that the details included on the rota still needed to be improved for example, by the inclusion of the surnames of the staff and by making a clearer notation of the position of and the hours actually worked by the staff. The acting manager suggested that the rota could be colour-coded. The requirement had not been fully implemented and still stands. The home’s response to the recommendation that was made in regard to Standard 28 as a result of the previous inspection was assessed. The recommendation was that arrangements should be made for staff to receive training that will enable a minimum of 50 of the care staff to attain a qualification at NVQ level 2 or equivalent by 2005. The recommendation had not been implemented. As the timescale for implementing the recommendation had elapsed, the recommendation now becomes a requirement. Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 Page 21 The home’s response to the three requirements that were made in regard to Standard 29 as a result of the previous inspection was assessed. The first requirement was that two, relevant written references must be obtained before appointing any member of staff with immediate effect. The arrangements regarding the appointment of three staff new staff that had commenced working at the home since the previous inspection were discussed. In regard to one newly appointed member of staff it was noted that two references had been obtained. However, neither of the two references were from a previous employer. In the case of another newly appointed member of staff it was noted that she had commenced employment at the home without any written references having been obtained first. A third member of staff had commenced working at the home for a weekend on a ‘trial’ basis without any references having been obtained. The requirement had not been implemented and still stands. It is essential that at least two, relevant written references are obtained in respect of all prospective staff prior to their commencement at the home in order to ensure the safety of the service users. The second requirement was that the records of the staff that are employed by the home must include proof of the person’s identity. The information held by the home in respect of the three recently appointed members of staff was inspected. It was noted that proof of identity was not available in respect of one of the three staff members. Therefore, the requirement had not been fully implemented and still stands. The third requirement was that disclosure checks from the Criminal Records Bureau must be obtained for all new staff, including prospective staff who have previously undergone a CRB check, before their appointments are confirmed with immediate effect. The acting manager stated that this matter was being given close attention in order to ensure that correct procedures were followed. The requirement had not been implemented and still stands. A Notice of Immediate Requirement was issued at the conclusion of the inspection in regard to this matter. The acting manager was aware that CRB disclosure results were not ‘portable’. It was stated that new checks would be carried out on all existing staff, where necessary, in order to ensure that all the staff had a valid and relevant CRB disclosure. The acting manager stated that the home did not have a staff training and development programme that met National Training Organisation (NTO) workforce training targets. The acting manager said that the home was ‘starting from scratch’ and that all the staff would be asked to undertake induction training on 22 and 30 March 2006. NVQ training would be promoted. The deputy manager intended to commence NVQ level 4 training in September 2006. The acting manager said that she was in the process of identifying and making appropriate arrangements to address the gaps in the mandatory training undertaken by the staff. Not all of the staff received a minimum of three paid days training per year and none of the staff had individual training and development assessments and profiles. Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 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): 31, 33, 35 and 38 A suitable person needed to be appointed to manage the home on a permanent basis. The systems for monitoring the quality of the service and for assuring the standard of care needed to be improved. Satisfactory arrangements had been made for safeguarding the service users’ finances. However, records and receipts should be kept of the possessions handed over for safekeeping. The health, safety and welfare of the service users and staff were promoted. However, there was scope for this aspect of the service to be enhanced by the provision of effective risk assessments. EVIDENCE: The post of registered manager was vacant. The previous post-holder had resigned on 13 February 2006. The registered manager of another home was currently occupying the post of acting manager. The acting manager was competent and was aware of a number of improvements that had to be made in order to ensure that the home meets the National Minimum Standards. The acting manager had already begun to introduce a number of improvements. However, the registered providers must take action to appoint a suitable Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 Page 23 person who will make an application to the CSCI to become the registered manager of the home on a permanent basis. In the meantime, a new Certificate of Registration that does not include the name of the former registered manager will be issued by the CSCI. The job description for the registered manager was not available for inspection. The lines of accountability within the home and with external management were being clarified and reviewed. The requirement that was made as a result of the previous inspection in regard to the training of the now former registered manager was no longer applicable at the present time. The requirement has, therefore, been deleted. It was stated that the home had a quality assurance system. However, the quality assurance system was not in operation at the time of the inspection. Therefore, the requirement that was made in regard to the introduction of a quality assurance system as a result of the previous inspection had not been fully implemented and still stands. It was pleasing to note that the home had an action plan for addressing the requirements and recommendations arising from the previous inspection. However, the home did not have an annual development plan based on a systematic cycle of planning, action, review reflecting aims and outcomes for service users. Questionnaires were available but there was no evidence to show that they had been used effectively or that the results had been analysed or published. There was no evidence to show the home’s commitment to lifelong learning and development for each service user linked to the implementation of their individual care plans. The home had used questionnaires dated 8 February 2006 to obtain the views of family, friends and stakeholders in the community. However, the results had not yet been analysed or used to develop care practice and improve standards. The acting manager was aware of the need to review and, where necessary, amend and update the home’s policies and procedures. The acting manager confirmed that she had already commenced this process. Action had not been progressed within the agreed timescales to implement a number of requirements and recommendations arising from the previous inspection. The service users were encouraged to retain control over their own finances. However, the home had accepted responsibility for handling the personal allowances in respect of a number of service users that had handed their money to the home for safekeeping. The money was used for personal expenses e.g. hairdressing, chiropody etc. Separate records of the money handled by the home in respect of each service user were maintained. The money was kept in individual plastic wallets. The money and the accounts were kept in a lockable facility i.e. a safe. The records were up to date and the accounts that were checked were correct. It was confirmed that no person connected with the running of the home acted as an agent or appointee on behalf of any of the service users. However, records and receipts were not kept of the service users’ possessions that were handed over for safekeeping. Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 Page 24 The home’s response to the requirement that was made in regard to Standard 36 as a result of the previous inspection was assessed. The requirement was that supervision of all care staff must take place at least six times a year and include all aspects of practice, philosophy of care in the home and career development needs. The requirement had not been implemented and still stands. The home’s response to the five requirements that were made in regard to Standard 37 as a result of the previous inspection was assessed. The first requirement was that all records must be available and maintained to meet the requirements of Regulation 17, Schedules 1, 2, and 4 specifically; staff records must be maintained in accordance with Regulation 17, Schedule 4(6). The majority of the records that the home was required to keep were being maintained. Therefore, the requirement was regarded as having been implemented. However, the staff stated that they had not received a statement of their terms and conditions of employment (contract) from the present owners. This issue needed to be addressed. The deficiencies in the record keeping that were highlighted as a result of the inspection are referred to separately in other parts of this report. The second requirement was that the statements of the procedure to be followed in the event of accidents and in the event of a service user becoming missing must be amended in accordance with the guidance given in this (i.e. the previous) report. Copies of both statements were made available for inspection. The requirement had not been implemented and still stands. The statements of both procedures should include a reference to maintaining a clear, detailed and accurate report of any incident that occurs and to the requirement to report any incident without delay to the CSCI in accordance with Regulation 37. The statement of the procedure to be followed in the event of a service user becoming missing should also include an instruction that the matter must be reported to the Police. The third requirement was that fire alarm tests must be carried out and recorded on a weekly basis. The requirement had been implemented. The fourth requirement was that all fire doors must be checked to ensure that they close properly on their rebate and intumescent strips and smoke seals must be checked to ensure that they are maintained in a satisfactory condition at least quarterly. It was confirmed that the requirement had been implemented. The fifth requirement was that visits to the home by the registered provider must take place at least once a month in accordance with Regulation 26 and a copy of the written report on the conduct of the home supplied to the registered manager and to the CSCI. It was noted that the CSCI had received reports made in respect of the home in accordance with Regulation 26, dated 10 October 2005 and 6 February and 6 March 2006. The reports had, therefore, not been supplied to the CSCI consistently each month since the previous inspection in September 2005. The requirement had, therefore, not been implemented and still stands. The acting manager stated that the core training for all the staff was being reviewed and, where necessary, updated. The home’s response to the Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 Page 25 requirement that was made in regard to Standard 38 as a result of the previous inspection was assessed. The requirement was that there must be at least one member of staff on duty at all times, day and night, who is qualified in first aid i.e. the four day First Aid at Work course. The acting manager made information available to confirm that the requirement had been implemented. Risk assessments were in place for all the service users’ individual needs. However, not all of the risk assessments covering the safe working practice topics referred to in Standards 38.2. and 38.3 had been carried out. A Notice of Immediate Requirement was issued at the conclusion of the inspection in regard to this matter. It was confirmed that all hazardous substances were kept in a lockable storage facility. The home’s stair lift and passenger lift had been serviced on 5 August 2005. It was stated that the boilers and central heating system had been recently serviced. However, the servicing certificates were not made available for inspection. The water had been tested for Legionella bacteria on 22 March 2005. PAT testing had been carried out in June 2005. The relevant information and documentation regarding COSHH and RIDDOR were available in the home. The acting manager confirmed that the windows had been fitted with opening restrictors. The home had a health and safety policy. The home maintained a record of all accidents. However, an accident book that complies with the Data Protection Act should be provided. Safety procedures were displayed in appropriate parts of the home. Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 Page 26 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 1 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 2 X X 2 Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 Page 27 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 OP3 Regulation 14 Requirement Timescale for action 30/06/06 2 OP7 15 3 OP7 15 4 OP7 15 5 OP8 13 An assessment form that covers all of the aspects of care referred to in Standard 3.3 must be introduced and used for assessing all prospective and, where necessary, any existing service users. The service users’ care plans 30/06/06 must cover all aspects of care as set out in Standards 7.2 and 3.3 and be completed in full and signed by the staff/registered manager. (Previous timescale 30/11/05 not met). The service users’ care plans 30/06/06 must set out in detail the action which needs to be taken by the care staff to ensure that all aspects of the needs of the service users are met. (Previous timescale 30/11/05 not met). The service users’ care plans 30/06/06 must be agreed and signed by the service users whenever capable and/or their representative (if any). (Previous timescale 30/11/05 not met). A risk assessment of the current 30/04/06 DS0000063833.V285950.R01.S.doc Version 5.1 Minster Grange Page 28 6 OP9 13 7 OP9 13 8 OP9 13 9 OP9 13 10 OP9 13 11 OP9 13 12 OP9 13 13 OP9 13 service users’ nutritional needs must be carried out and recorded, and in respect of all new service users on admission, and regularly reviewed, including risk factors associated with obesity, low weight and any eating and drinking disorders. A separate, dedicated and lockable refrigerator must be obtained for the safe and secure storage of medication requiring cold storage. All the staff that are involved in the administration of medication must undertake further medication management training. All medication must be kept in the original labelled container as supplied by the pharmacy in order to ensure safe handling. The registered person must ensure that a medication audit can be undertaken. The date of opening of all medication must be recorded and any balances remaining at the end of the 28 day cycle must be carried over on to a new MAR Chart. Two members of staff must record the administration of Controlled Drugs (CD) in the CD register. The staff must record the administration of medication in the MAR Charts or use an appropriate code if the medication is not administered. The actual amount of medication administered when the directions are for a variable dose e.g. one or two tablets, must be recorded. The service users’ care plans must be kept up to date and current in respect of medication including any changes, cessation DS0000063833.V285950.R01.S.doc 14/04/06 30/05/06 21/03/06 30/04/06 21/03/06 21/03/06 21/03/06 30/04/06 Minster Grange Version 5.1 Page 29 14 15 OP9 OP10 13 16 16 OP16 17 17 OP19 13 18 OP19 13,23 19 OP27 17 20 OP28 18 21 OP29 17,19 22 OP29 17,19 or addition of medication. The medication policy must be reviewed, amended and updated. Fixed screening must be provided in three double bedrooms in order to enhance the service users’ safety, privacy and dignity. A record of all the complaints made against the home and the action taken by the registered persons in response to all such complaints must be maintained and made available for inspection at all times with immediate effect. (Previous timescale 26/09/05 not met). The gate at the top of the rear staircase must be raised in order to ensure the safety of the service users and to reduce the risk of falling. A fire safety risk assessment must be carried out and recorded in order to ensue the safety of all the service users and staff. The staff duty rota must be amended in accordance with the guidance given in this report and a record of whether the staff duty rota was actually worked must be maintained within the home. (Previous timescale 30/11/05 not met). Arrangements must be made for staff to receive training that will enable a minimum of 50 of the care staff to attain a qualification at NVQ level 2 or equivalent. Two, relevant written references must be obtained before appointing any member of staff with immediate effect. (Previous timescale 26/09/05 not met). The records of the staff that are employed by the home must DS0000063833.V285950.R01.S.doc 30/04/06 30/04/06 09/03/06 15/03/06 23/03/06 30/04/06 31/12/06 09/03/06 31/03/06 Page 30 Minster Grange Version 5.1 23 OP29 19 24 OP30 18 25 OP30 18 26 OP31 8,9,18 27 OP33 24 28 OP36 18 29 OP37 17 30 OP37 17 include proof of the person’s identity. (Previous timescale 31/10/05 not met). An enhanced disclosure check from the Criminal Records Bureau must be obtained for all new staff prior to the commencement of their employment at the home. (Previous timescale 26/09/05 not met). A staff training and development programme that meets National Training Organisation (NTO) workforce training targets must be introduced. All staff must receive a minimum of three days paid training per year (including in-house training) and have individual training and development assessments and profiles. The registered provider must appoint a suitable person to manage the care home who will make an application to the CSCI to become the registered manager. A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (Previous timescale 31/01/06 not met). Supervision of all care staff must take place at least six times a year and include all aspects of practice, philosophy of care in the home and career development needs. (Previous timescale 31/01/06 not met). A valid statement of the terms and conditions of employment (contract) must be issued to each member of staff. The statements of the procedure to be followed in the event of accidents and in the event of a service user becoming missing DS0000063833.V285950.R01.S.doc 09/03/06 30/04/06 30/06/06 30/04/06 30/06/06 30/09/06 30/06/06 30/04/06 Minster Grange Version 5.1 Page 31 31 OP37 26 32 OP38 13 must be amended in accordance with the guidance given in this report. (Previous timescale 30/11/05 not met). Visits to the home by the registered provider must take place at least once a month in accordance with Regulation 26 and a copy of the written report on the conduct of the home supplied to the registered manager and to the CSCI. (Previous timescale 31/10/05 not met). Risk assessments must be carried out and recorded for all safe working practice topics covered in Standards 38.2 and 38.3. 30/04/06 21/04/06 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 3 Refer to Standard OP9 OP9 OP12 Good Practice Recommendations The home should have access to a current and up to date reference source for medication. Two staff should sign and check any hand written additions on the MAR Charts in order to ensure the accuracy of the information. The range of leisure and social activities, choice of food and opportunities for the service users to engage in religious observance should be increased in accordance with the service users’ preferences, abilities and needs. Relatives, friends and representatives of service users are given written information about the home’s policy on maintaining relatives and friends’ involvement with service users at the time of moving into the home. Information should be included in the service users’ guide about the local advocacy services and the service users’ entitlement to bring personal possessions with them when DS0000063833.V285950.R01.S.doc Version 5.1 Page 32 4 OP13 5 OP14 Minster Grange 6 7 OP18 OP18 8 9 OP19 OP19 10 OP31 11 OP31 12 13 OP33 OP33 14 OP33 15 OP33 16 17 OP35 OP38 they are admitted to the home. The home should obtain a copy of the Department of Health guidance ‘No Secrets’. A policy should be developed and implemented regarding the service users’ money and financial affairs ensuring service users’ access to their personal financial records, safe storage of money and valuables, consultation on finances in private, and advice on personal insurance; and preclude staff involvement in assisting in the making of or benefiting from service users’ wills. A programme of routine maintenance and renewal of the fabric and decoration of the premises should be introduced and implemented. As part of the programme of routine maintenance a new underlay should be provided for the carpet in the extension and the metal structure in the front garden should be removed. A job description for the registered manager that enables him/her to take responsibility for fulfilling all of the necessary duties associated with managing the care home should be provided and made available for inspection. The lines of accountability within the home and with the external management should be clarified, understood by all the staff and reflected accurately in the organisational structure as outlined in the home’s statement of purpose. There should be an annual development plan for the home, based on a systematic cycle of planning-actionreview, reflecting aims and outcomes for service users. The results of service user surveys should be published and made available to current and prospective service users, their representatives and other interested parties, including the CSCI. Written evidence should be provided to demonstrate the home’s commitment to lifelong learning and development for each service user linked to the implementation of their individual care plans. The views of family and friends and of stakeholders in the community should be sought on how the home is achieving goals for service users and the information used to enhance good practice. Records and receipts should be kept of all the service users’ possessions/valuables handed over for safekeeping. A book or register that complies with the Data Protection Act and in which all accidents must be recorded should be obtained. Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 Page 33 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Minster Grange DS0000063833.V285950.R01.S.doc Version 5.1 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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