Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 24/02/06 for Monks Haven Residential Home

Also see our care home review for Monks Haven Residential Home for more information

This inspection was carried out on 24th February 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The staff on duty at the time of the inspection were polite, courteous and appeared to have developed caring relationships with the people in their care. The Inspector observed residents taking their lunchtime meal, which appeared to be enjoyed by all. The meal was nicely presented and good portion sizes were served. The Acting Manager was willing to talk in a constructive manner about how problems identified during the inspection could be resolved. Residents are encouraged to celebrate their birthdays and special festivities are arranged for residents` 100th birthdays. Birthday cakes and buffet teas are provided on such occasions. The Acting Manager recently made arrangements for local schoolchildren to visit the Home and talk with residents about their past lives. Arrangements are made to celebrate special occasions such as Christmas and Easter. Residents were recently consulted about the contents of the Home`s menus. Some of the bedrooms visited were pleasantly decorated and well maintained. An electronic organ and piano were available for use by visiting entertainers.

What has improved since the last inspection?

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Monks Haven Residential Home 55-57 Beverley Terrace Cullercoats Tyne & Wear NE30 4NX Lead Inspector Glynis Gaffney Unannounced Inspection 10.40 24 , 27 and 28 February and 2nd March th 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 Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Monks Haven Residential Home Address 55-57 Beverley Terrace Cullercoats Tyne & Wear NE30 4NX Telephone number Fax number Email address Acting Manager 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) 0191 252 1957 Geoshine Limited Care Home 33 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (23) of places Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th August 2005 Brief Description of the Service: Monkshaven is situated on the sea front at Cullercoats and is a larger older style adapted building. The Home provides residential care for 33 older people, for whom up to 10 may have dementia care needs. Nursing care is not offered. Bedroom accommodation is spread over three floors. There are 26 single bedrooms of which three have en-suites. Three double bedrooms are also available. There is a passenger lift to the first and second floors. However some bedrooms, bathrooms and toilets can only be accessed via a small number of steps. The following communal facilities are also provided: two lounges and a dining room; two bathrooms and one shower; nine toilets; a kitchen and adjoining utility rooms. The Home has a small paved area to the front which was attractively presented. There was also a yard area to the rear of the building. Street parking was available. Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced, took place over 12 hours and involved two inspectors. The premises were inspected, as were a sample of care records and a selection of other records, policies, and procedures. What the service does well: What has improved since the last inspection? The Acting Manager had purchased a number of cash boxes, which will be fitted in all bedrooms to provide residents with a lockable facility. The Acting Manager had prepared a cleaning rota and now requires his domestic staff to record what cleaning tasks have been completed during their shift. Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 6 The Acting Manager had: • • • • • • • • Revised the Home’s Statement of Purpose and Service User Guide to include the necessary details; Completed his first quality review of the care and services provided at Monkshaven; Made arrangements for a Co-Director to visit Monkshaven on a regular basis to monitor the Home’s performance; Taken action to improve the quality of information held in residents’ care records; Completed preventative health care risk assessments for each resident to promote their well-being; Prepared an initial training plan based on staffs’ identified training needs; Purchased an activity pack which will enable staff to provide more appropriate activities for residents with dementia care needs; Begun to prepare more specialist Care Plans for residents with dementia. The following improvements had been made to the premises: • • • • • • • • • • • • • • • • • Problems with external drainage had been resolved; Bedrooms 15,16, 26 and 29 had been redecorated; The window frame in bedroom 28 had been re-painted; New window restrictors had been purchased and were being fitted at the time of the inspection; Blinds had been purchased for all toilets and bathrooms and were being fitted at the time of the inspection; The floor covering in toilet 9 had been replaced; New carpets had been fitted in some bedrooms; The emergency lightening near bedroom 8 had been fixed; Rotten window frames had been replaced. External window frames to the rear of the building on the first floor had been re-decorated; All radiators were guarded; A new washing machine and dryer had been installed; A range of kitchen equipment had been provided such as a microwave, a water boiler and a fridge/freezer; New commodes, bed linen, towels and sit-on weighing scales had been purchased; New seating had been purchased for the lounge areas; A ground floor toilet had been redecorated; New pictures had been purchased and hung throughout the Home; New signage had been fitted on bathroom and toilet doors. The Home’s Cooks had been provided with relevant information about the nutritional care needs of older people. An application to register a Manager for the Home was submitted to the Commission. Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 7 The Home’s Medication Policy had been revised to include the required information. An up to date drugs reference book had been purchased. 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. Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 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 Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. The Home’s Statement of Purpose and Service User Guide provide prospective residents with sufficient information to enable them to make an informed decision about whether to live at the Home. The arrangements for obtaining Care Management assessment and care plan information prior to a resident’s admission into the Home were unsatisfactory. This could result in staff not having access to the information needed to safely meet residents’ needs. EVIDENCE: Following legal action taken by the Commission to ensure that prospective residents are provided with satisfactory information about Monkshaven, the Acting Manager had revised the Home’s Statement of Purpose and Service User Guide to include the required details. The Acting Manager had taken steps to ensure that residents’ care records contained the required details following legal action taken by the Commission. Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 10 However, not all of the care records examined contained a Care Management Assessment. The Acting Manager gave an undertaking to ensure that the required information is obtained and, where this is not possible, to record this in the care records of the residents concerned. Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9. Although progress had been made with ensuring that residents’ care records contained the required information, further improvement was still required. Failure to ensure that residents’ care records contain the required information could result in staff not being clear about how residents’ needs are to be met. Preventative health care risk assessments had been completed and assist staff to promote residents’ well-being. Suitable medication policies and procedures were in place and protect residents from potential harm. EVIDENCE: Following legal action taken by the Commission in December 2005 to ensure that residents’ care records contained the required information, a detailed audit of 22 residents’ care records was undertaken. Although there was sufficient evidence to confirm that action had been taken to comply with the legal Notice issued by the Commission, it was identified that further Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 12 improvements were still required, as some care records did not contain the following details: 1. The name, address and telephone number of residents’ Care Managers; 2. The name of each resident’s Key Worker; 3. Written evidence that each resident had received a copy of the Home’s Statement of Purpose and Service User Guide; 4. A copy of the original Care Management Assessment and Care Plan; 5. A copy of the most recent Care Management review report; 6. Written evidence that each resident had been provided with the opportunity to access a dentist and an optician. The name and address of each resident’s dentist and optician; 7. Signed and dated risk assessments; 8. Signed and dated social care and dental health care assessments; 9. Next of kin addresses. The Acting Manager was able to provide evidence that residents had recently received chiropody and optical care. However, details of when residents had received chiropody care had not been transferred to their individual care records. Risk assessments aimed at preventing the development of skin and nutritional care problems were in place for each resident. One resident’s Oxygen Therapy Care Plan had been updated to ensure that it covered the recommended areas. The Home’s Medication Policy had been revised to include the required information. Staff at the Home had access to an up to date medication reference book. Arrangements had been made for those residents over 75, who take four or more medicines, to be referred to their GP for a medication review. However, there was no written information to support this. Temperature checks of the area within which the medication trolley was kept, had not been completed. Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Improvements had been made to the way in which social activities were provided within the Home and there were more opportunities for stimulation through leisure and recreational activities. Suitable arrangements were in place to support residents to maintain contact with their families and friends. Residents were encouraged and supported to make decisions about everyday matters. This allows residents to retain as much control as possible over how they live their lives. Residents were provided with a well-balanced diet that offered choice, variety and which promoted their health and well-being. EVIDENCE: A social care assessment and care plan had been completed for each resident. The Acting Manager was in the process of updating residents’ social care assessments to ensure that information held in the Home was accurate and up to date. Dr George had recently purchased an activity pack for use with residents with dementia care needs. Four staff had undertaken training in how Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 14 to provide suitable activities for people with dementia care needs. However, it was noted that: • • • A Social History had not been completed for each resident; Some of the objectives included in residents’ social care plans were very general. However, Dr George said that residents’ social care plans would be revised once he had updated each person’s social care assessment; Although monthly reviews of residents’ social care plans had taken place, the information recorded by care staff was sometimes vague and limited. The Acting Manager confirmed that a programme of weekly activities had recently been drawn up and would shortly be publicised within the Home. A local Minister provides religious services on a monthly basis and a hairdresser visits the Home once a week. Residents spoken with confirmed that the Acting Manager and his staff team always make their families and friends feel welcome. They said that visitors could be seen in private or join residents in the lounge and dining areas. A policy outlining the Home’s approach to enabling residents to maintain contact with family and residents was available. None of the residents spoken with could recall the Acting Manager placing any restrictions upon their visitors. It is the Home’s Policy to support residents to maintain control of their own financial affairs. The Acting Manager said that lockable facilities and day-today support with managing personal monies and valuables would be provided where needed. Residents are permitted and encouraged to bring their own personal possessions with them when moving into the Home. A number of bedrooms were visited and it was evident that residents had been encouraged to personalise their own private spaces. Since the last inspection, the Home’s cooks had been given information about those residents considered to be at nutritional risk and details of their food preferences. Arrangements had been made for one of the Home’s cooks to undertake qualifying training in catering. A nutritional policy setting out the Home’s approach to nutrition and the provision of food was not available. Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. A satisfactory complaints procedure was available. that their views and opinions were listened to. EVIDENCE: Generally residents felt A Complaints Procedure was available and it included details of how to refer a complaint to the Commission. A copy of the procedure was located in each resident’s bedroom. A summary of the Complaints Procedure was also included within the Home’s Service User Guide. Since the last inspection, the Commission has received one anonymous complaint about inadequate levels of staffing within the Home. This complaint was investigated as part of the August 2005 Announced Inspection following which a staffing agreement was reached with the Acting Manager. Compliance with the agreement reached is monitored during each visit to the Home. At the time of the inspection, the required levels of staffing were in place. The Home had not received any complaints since the last inspection of the Home. Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Although the condition of the kitchen, and the standard of hygiene within it, were inadequate, the Acting Manager had made plans to resolve the problems identified at the time of the inspection. The condition of paintwork, furniture and flooring in some areas of the Home was inadequate and did not provide residents with a satisfactory environment in which to live. The remaining premise related standards were satisfactorily met. EVIDENCE: A programme of routine maintenance and renewal of the fabric and decoration of the premises was not available. However, the Acting Manager is in the process of preparing a plan which will set out the work that needs to be undertaken over the next 12 months, including those matters referred to below: Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 17 • Toilet 1: there was no lampshade or window covering; • Toilet 4: the window frame was grimy and in a poor decorative condition. The floor covering did not fit properly around the toilet bowl; • Toilet 6: the floor covering did not fit properly around the toilet bowl. The window frame was grimy; • Bedroom 2: there was a very strong and unpleasant odour. The carpet was stained in places. There was a small hole in the back of the door; • Bedroom 6: there was no window restrictor. The carpet was stained in places. The chest of drawers was in a poor condition; • Bedroom 7: there was a very strong and unpleasant odour. The carpet was stained in places; • Bedroom 11: the veneer on both chests of drawers had come away in places; • Bedroom 13: the carpet was very stained. The bedside cabinet and chest of drawers had a worn appearance; • Bedroom 15: there was no window restrictor. The carpet was stained around the washbasin area; • Bedroom 17: the carpet was very stained; • Bedroom 23: there were cracks to the ceiling. The wall behind the wash basin was also cracked in places. The carpet was very stained. The bedside cabinet had a worn appearance; • Bedroom 24: the window frame was grimy and the paintwork was lifting in places. There was a very strong and unpleasant odour. There was no window restrictor; • Bedroom 26: the chair was soiled and contained a number of cigarette burns. The bedside cabinet was grimy; • Bedroom 29: the bedside cabinet was in a poor condition. The carpet was stained. A handle was missing off the wardrobe; • Bedroom ?: there was no window restrictor. The carpet was very stained. The paintwork on the wall around the wash basin, the back of the door and the window frame was grimy and flaking in places; • Small lounge: one of the armchairs was very worn. Two others had a soiled appearance; • Red corridor carpet: the red corridor carpet on the ground, first and second floors was both grimy and ‘bleached’ stained in places. The Acting Manager had made arrangements for the carpet to be cleaned. However, an area of corridor carpet recently shampooed still looked grimy. Although a cleaning rota had been prepared since the last inspection, it did not provide sufficient detail of the cleaning tasks to be undertaken and of the products to be used. The concrete surface in the rear yard was uneven. The Acting Manager has been advised that the yard area should not be used until the surface has been made even and safe. Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 18 Following an inspection of the kitchen areas, an ‘Immediate Requirement Notice’ was served requiring the Acting Manager to remedy the concerns referred to below: Back Pantry: 1. 2. 3. 4. The marble shelving was grimy; Plastic containers used to store foodstuffs were grimy; The floor was grimy; The window frame, to the left hand side of the pantry, was dusty and grimy; 5. Disused items of equipment were being stored in the pantry, i.e. two deep fat fryer containers and a water boiler; 6. There were grease marks on the ceiling; 7. The wall tiles were grimy in places; Fridge Freezer Room: 1. A large chest freezer was awaiting disposal; 2. The wall tiles were grimy in places; 3. The kitchen unit cupboards were grimy. The shelf had collapsed in one of the cupboards checked. Items stored in the cupboards were grimy; 4. The shelving in a large wooden ceiling to floor cupboard used to store pots and pans was grimy. The surface was worn in places making it difficult to clean; 5. The upright fridge was grimy. The covering to the top of the fridge was worn making it difficult to clean the surface; Main kitchen: 1. The kitchen units were grimy; 2. The edging between the wall and the washbasin had disintegrated in places. It was also discoloured; 3. The stainless steel framework situated under the wash basin was grimy; 4. The hot trolley was grimy. The external surface, and the wall tiles to the side, and behind the hot trolley, was greasy and grimy. There were food particles and grime on the floor underneath the hot trolley; 5. The rubbish bin did not have a lid; 6. The paintwork to the kitchen door was flaking in places. The door was also grimy; 7. The kitchen window and fan were grimy; 8. The mop bucket was very dirty. Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. The Home had sufficient numbers of staff on duty to cater for the number of residents accommodated and their assessed needs. Sufficient numbers of qualified staff were not employed within the Home, which could result in staff not having the skills, qualities and knowledge needed to deliver a good quality of care. However, satisfactory arrangements had been made for staff to commence both qualifying and ongoing training. The arrangements for vetting staff were unsatisfactory and this has the potential to place residents at risk of harm. EVIDENCE: Since the last inspection visit, occupancy levels within the Home have decreased. At the time of the inspection, 20 residents were accommodated. The levels of staff provided were in line with those recommended by the Department of Health. The staffing agreement set out below has been agreed with the Acting Manager: Number of residents 20 to 22 Numbers of care staff 3 Management Points of cover information RM supernumerary DS0000032467.V258323.R01.S.doc Version 5.0 Page 20 Monks Haven Residential Home 23 24 25 3 3 3 or 4 26 3 or 4 27 4 RM supernumerary RM supernumerary RM 4 staff to be supernumerary provided at key times where one or more residents require two care staff to assist with personal care. Key times – 8am to 1pm and 5pm to 8.pm. RM 4th member supernumerary of staff to be provided during key times. RM supernumerary It was also agreed that: • • The Acting Manager’s hours would be extra to the care staff scheduled on duty for each shift; The above staffing levels would be reviewed and increased where necessary and that this might mean providing extra staff to those numbers set out in the above. The rotas examined did not include staffs’ full names and the actual hours worked by the Acting Manager. Although 50 of the care team had not obtained a relevant care qualification, arrangements had been made for four more staff to undertake the required qualifying training. A system was not in place that provided an overview of the training staff had received and the training they required. Four senior staff had nearly completed a 12-week Medicine Awareness training course. A further three staff were undertaking a 12 week Dementia Care training package and five staff had recently received continence care training. Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 21 Personnel records for all staff working at the Home were available at Monkshaven. The Home’s application form had been updated to require applicants to declare any convictions held. A sample of staff personnel records examined were found to be satisfactorily maintained with one exception. There was no evidence confirming that staff had received a copy of their job description or the General Social Council’s Code of Conduct for Employees. Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 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. There had been an improvement in the way in which the Home was managed. However, the Acting Manager was not suitably qualified and experienced. An Annual Development Plan was not available. This creates the potential for a ‘piece meal’ and unfocussed response to work that needs to be undertaken to improve the quality of care and services provided at Monkshaven. Staff had not received adequate training in key areas, which has the potential to place them, and the residents they care for, at risk of harm. Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 23 EVIDENCE: In October 2005, Dr George took on the full time role of Acting Manager and has applied for registration with the Commission. Over the last 18 months, he has gained experience in managing a care home, and had on an occasional basis, worked as a carer as part of the shift compliment. However, he had not worked in any other position within a care home. The Acting Manager had not undertaken recent training in key areas, such as manual handling, basic food hygiene and health and safety. His First Aid certificate was out of date. Although the Acting Manager had not undertaken recent dementia care training, he attends regular workshops arranged by the Dementia Care Network. The Acting Manager had obtained a relevant management qualification, but does not have a care-based qualification relating to the care of older people. However, Dr George had worked as a medical doctor in the field of geriatric care. Regular reviews of the quality of care and services offered at Monkshaven had not been undertaken, and as a consequence, this resulted in the Commission taking enforcement action. Following enforcement action, the Acting Manager completed an initial quality audit, and at the time of this inspection, was in the process of completing the Home’s first Annual Development Plan. As part of this process, residents and their families were asked to complete quality questionnaires. However, arrangements had not been put in place to seek the views of the staff team and other professionals involved with the Home. Arrangements had been made for staff to receive certificated fire training. But First Aid and Basic Food Hygiene training had yet to be arranged for those staff requiring an update. Staff had received Infection Control training. Two recently appointed staff had not yet received Manual Handling training. Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 1 X X X X 2 2 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 x 2 X X 2 Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Acting Manager(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement Ensure that a summary of the Care Management Assessment is obtained before a resident moves into the Home. Take action to obtain the above information in respect of existing residents where this is possible. Ensure that residents care records contain a copy of the Homes own pre-admission assessment. (This requirement has not been checked as there have been no new admissions into the Home since the last inspection visit.) Ensure that each resident’s care record is updated to include the following details: 1. The name, address and telephone number of their Care Acting Manager; 2. The name of their Key Worker; 3. Written evidence that they have received a copy of the Home’s Statement of Purpose and Service User Guide; Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 26 Timescale for action 31/03/06 2. OP3 14 13/03/06 3. OP7 14 and 15 31/03/06 4. OP9 13(2) 4. A copy of their original Care Management Assessment; 5. A copy of their most recent Care Management review report; 6. Written evidence that they have been provided with the opportunity to access a dentist and an optician; 7. The name and address of their dentist and optician; 8. Signed and dated risk assessments; 9. Signed and dated social care and dental health assessments; 10. The name and address of their next of kin. Ensure that: • 03/04/06 5. OP15 16(2) 6. OP19 16(2) A record is kept of when the Home requests a medication review for each resident; • Weekly checks of the air temperature of the room in which the drugs trolley is stored are undertaken. Prepare a policy which sets out 03/04/06 the Homes approach to dietary assessment and nutritional care. A copy of the policy should be forwarded to the Commission for comment. The Acting Manager must ensure 12/03/06 that: Back Pantry: 1. The marble shelving, floor, window frame, wall tiles and plastic containers used to store foodstuffs are cleaned; Disused Kitchen equipment is removed; The ceiling is painted; 2. 3. Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 27 Fridge Freezer Room: 4. 5. 6. Disused Kitchen equipment is removed; The wall tiles and kitchen units are cleaned; The kitchen unit with a broken shelf is repaired and the items of equipment within it are cleaned; The shelving in the large wooden cupboard are cleaned; The upright fridge (2) is cleaned; 7. 8. Main kitchen: 9. 10. 11. 12. 13. 14. 15. 16. 7. OP19 23(2) The kitchen units are cleaned; The edging between the wall and the washbasin is replaced; The stainless steel framework situated under the wash basin is cleaned; The hot trolley, the surrounding walls and floor are cleaned; The rubbish bin is provided with a lid; The door is cleaned and repainted; The kitchen window and fan are cleaned; The mop bucket is cleaned. 01/04/06 Ensure that the Home’s cleaning rota covers the following areas: • • • • • The lounge areas and the furniture contained within them; The hairdressing room; The laundry; The utility area to the front of the kitchen; The office; Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 28 • • Regular shampooing of the Home’s carpets and curtains; Window cleaning. Ensure that the Home’s cleaning rota states what products are to be used for what cleaning tasks. A copy of the revised cleaning rota must be forwarded to the Commission. Ensure that the carpets in bedrooms 6 and 13 are replaced. Ensure that: • • Toilet 1: a lampshade is provided and a window covering fitted; Toilet 4: the window frame is cleaned and re-painted. The flooring should be replaced; Toilet 6: the flooring is replaced. The window frame should be cleaned; Bedroom 2: the carpet is either cleaned or replaced. The door should be repaired and re-painted; Bedroom 6: a window restrictor is fitted. The carpet must be cleaned and replaced if necessary. The chest of drawers must either be refurbished or replaced; Bedroom 7: the carpet is either cleaned or replaced; Bedroom 11: the chest of drawers is either replaced or refurbished; Bedroom 13: the carpet is either cleaned or replaced. The bedside cabinet and chest of drawers must either be refurbished or replaced; Version 5.0 Page 29 8. 9. OP24 OP26OP25 OP24OP19 16(2) 16(2) & 23(2) 13/04/06 01/06/06 • • • • • • Monks Haven Residential Home DS0000032467.V258323.R01.S.doc • • • • • • • • • Bedroom 15: a window restrictor is fitted. The carpet must be cleaned. The bedroom door must be repaired and then repainted; Bedroom 17: the carpet is either cleaned or replaced; Bedroom 23: the ceiling cracks are repaired. The ceiling must be redecorated. The carpet must be cleaned. The wall behind the washbasin must be repaired and redecorated. The bedside cabinet must either be refurbished or replaced; Bedroom 24: a window restrictor is fitted. The window frame must be cleaned and re-painted; Bedroom 26: the chair is either cleaned or refurbished. The bedside cabinet must be cleaned; Bedroom 29: the bedside cabinet is either refurbished or replaced. The carpet must be cleaned. A missing wardrobe handle must be replaced; Bedroom ?: a window restrictor is fitted. The carpet must be cleaned. The wall around the wash basin, the back of the door and the window frame must be re-decorated; Small lounge: the armchairs are either refurbished or replaced; Red corridor carpet: the carpet is either cleaned or replaced. (August 2005 Announced Inspection Report.) Version 5.0 Page 30 Monks Haven Residential Home DS0000032467.V258323.R01.S.doc 10. OP26 16(2) Ensure that: Action is taken to eliminate the unpleasant odours in bedrooms 2, 7 and 24; • The ‘Continence Care’ trigger checklist provided by the Commission is completed in respect of residents occupying the above bedrooms. Ensure that the Homes rota includes staffs full names and the hours worked by the Acting Manager. Ensure that 50 of the care team have undertaken qualifying training. (August 2005 Announced Inspection Report.) Ensure that the following information is held on staff files: An identification photo. (May 2003 Inspection Report) Verification of identity; • Evidence that staff have been provided with a written job description. (August 2005 Announced Inspection Report). The Acting Manager must: Obtain a relevant care related qualification; • • 04/04/06 11. OP27 18 04/04/06 12. OP28 18 31/12/06 13. OP29 7, 9 and 19 04/04/06 14. OP31 9 04/04/07 15. OP31 9 The Acting Manager must: Undertake refresher training in the following key areas: Manual Handling; First Aid; Basic Food Hygiene; Health and Safety; Dementia Care. 01/07/06 16. OP33 24 The recently completed quality review must be reviewed and DS0000032467.V258323.R01.S.doc Version 5.0 Page 31 Monks Haven Residential Home updated on an annual basis. The views of staff and professional visitors to the Home should be sought and used to inform the quality review process. Specific survey questionnaires should be designed for this purpose. 17. 18. OP33 OP38 24 13(2) An Annual Development Plan must be prepared and a copy forwarded to the Commission. Ensure that: • All staff have received refresher training in the following key areas: First Aid; Basic Food Hygiene. 01/07/06 04/04/06 01/07/06 (This requirement was first issued following inspections in October 2004 and August 2005. Failure to comply with this requirement within the given timescale will result in the Commission taking enforcement action to ensure compliance.) • All new starters have received training in Manual Handling. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Acting Manager/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Use the Commission’s ‘care records checklist’ to ensure that residents’ care records contain the required details. DS0000032467.V258323.R01.S.doc Version 5.0 Page 32 Monks Haven Residential Home Complete a number of checklists each month to provide evidence that residents’ care records have been checked on a periodic basis. 2. 3. 4. OP7 OP9 OP15 Ensure that the drugs trolley is secured to the cupboard wall when not in use. Prepare a policy outlining how frequently the menus are to be updated, how this should be undertaken and who should be involved. Ensure that the menus provide residents with an opportunity to have two portions of fruit and dairy products each day. Ensure that a hot meal choice is available at the tea-time meal. Arrangements should be made to ensure that residents placements are reviewed on a six monthly basis. Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 33 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Monks Haven Residential Home DS0000032467.V258323.R01.S.doc Version 5.0 Page 34 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!