Inspection on 21/12/05 for Mother Redcaps Nursing Home

This inspection was carried out on 21st December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Mother Redcaps Nursing Home 27/10/09

Mother Redcaps Nursing Home 29/06/08

Mother Redcaps Nursing Home 24/05/07

Mother Redcaps Nursing Home 04/12/06

Mother Redcaps Nursing Home 19/05/06

Mother Redcaps Nursing Home 16/05/05

Mother Redcaps Nursing Home 21/10/04

Mother Redcaps Nursing Home 19/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Mother Redcaps Nursing Home Lincoln Drive Egremont Promenade Wallasey Wirral CH45 7PL Lead Inspector Julie King Unannounced Inspection 21st December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mother Redcaps Nursing Home DS0000020940.V274043.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. Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mother Redcaps Nursing Home Address Lincoln Drive Egremont Promenade Wallasey Wirral CH45 7PL 0151 639 5886 0151 630 2295 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) Business & Marketing Consultants Limited Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51), Physical disability (2) of places Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 51 older persons may be accommodated of whom no more than 2 adults shall be in the category PD and 1 named adult under 65 years of age. Provide accommodation for two named service users for personal care OP (PC). 16 May 2005 Date of last inspection Brief Description of the Service: This care home is a three-storey purpose built nursing home, situated on Egremont Promenade overlooking the river Mersey, and offers nursing care for 51 older persons. A lounge/dining room is provided on each floor with televisions, videos, piano, and music centres available. The home is double glazed throughout and ramp access is available at the front entrance. A lift serves all floors. All accommodation offered is in single rooms and the majority have the benefit of en-suite facilities. A selection of bathrooms, showers and toilets are provided on each floor and assisted bathing facilities are available. The small front and side gardens are well maintained and car parking is provided at the front of the building. Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 7 hours and was undertaken because of recent complaints about lack of care in the home, and ongoing staffing shortages. The lead inspector was accompanied by Regulatory Manager Paul Gillespie, Regulatory Inspector John McCabe, Regulatory Inspector Les Smith and Pharmacist Inspector Maggy Howells. There has been no response or compliance with outstanding requirements from previous inspections. A full tour of the premises took place, and staff and care records, along with medication records, were inspected. The inspectors spoke to all staff on duty, plus most service users and some visitors. What the service does well: What has improved since the last inspection? What they could do better: Mother Redcaps needs to meet all outstanding requirements from the previous inspection report, plus meet all requirements identified in this report. It is essential to meet these to ensure the health, safety and welfare of all service users and staff. Any failure in meeting statutory requirements and legally binding regulations may result in the Commission considering enforcement action. Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 Page 6 Mother Redcaps needs to improve in all areas. All record keeping, including service user’s pre-admission assessments, care planning, medication management, audits, risk assessments and staff files require improvement. The overall standard of care needs improving, and the staffing levels especially at night, require urgent rectification to help ensure the safety and welfare of all service users. Medication management is another area that requires immediate improvement, and caused such concern on the day of this unannounced inspection that an immediate improvement requirement notice was served on the home by the pharmacy inspector. A report containing the findings of the specialist pharmacy inspector will be produced as a separate document in due course, and an unannounced follow up inspection will be undertaken to assess compliance. 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. Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5. The homes Statement of Purpose and Service User Guide does not provide enough information for prospective service users so they can be clear about the services the home provides to meet their care needs. The lack of specialist care training for care staff may lead to unsafe care practice and could therefore compromise the safety of both service users and staff. EVIDENCE: The Statement of Purpose and Service User Guide are out of date and do not contain all the required documents and information as specified under regulations 4 and 5 of The Care Homes Regulations 2001. This was a requirement of the previous inspection. The home was also displaying an inspection report on the main information board from October 2004, which has been superseded by the May 2005 report, which contains numerous requirements. Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 Page 9 Twenty service users were case tracked as part of this inspection, including recently admitted service users. Some of the service users had been admitted to the home with varying degrees of cognitive impairment (dementia). The home’s present pre admission assessment document is inadequate and does not contain enough information about the impact of cognitive impairment on a service user, nor does it mention thought disorders, disorder of perception, challenging behaviours, wandering etc which are common symptoms in the Dementia illnesses. The home needs to review and amend the present document to include more information on cognitive impairment, psychosocial aspects of the service user, before admission to the home. Care staff (Nurses and carers) spoken with on the day of the inspection said, since the new manager was appointed to the home there had been very little specialist training organised for care staff. One carer said she had been to a study day on bereavement, which was provided free by the local undertakers. Specialist training is needed for all care staff to ensure that the assessed and changing care needs of the service users are met. Specialist training should include dementia, stroke, diabetes, challenging behaviours, pressure area care, etc. Each prospective service user is invited to visit the home and spend some time there, before they make a decision to move in. The visit includes viewing the accommodation available, the communal rooms and services available, and meeting with other service users and staff. Contracts / terms and conditions of stay are available for service users, whether privately, or state funded. Mother Redcaps Nursing Home DS0000020940.V274043.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): 7, 8, 9, 10 & 11. Service user’s individual health, personal and social care needs are not clearly recorded, and consequently care staff are not provided with adequate information they need to meet each service user’s care needs. Medication management is poor, potentially placing service users at risk. EVIDENCE: Care plans lacked consistency both in format and content. There were errors of omission on all case files examined ranging from name missing to complete documents left out. The dependency levels of the service users appear to be underestimated by the registered nurses (RNs), especially with regard to the current care planning documentation which includes RN input and involvement in actual care delivery. There was a care planning checklist available for all clinical items to be completed on admission and this was invariably incomplete. Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 Page 11 There is a sheet available for GPs to record visits and relevant actions, and in one case this was also being used to record visits by professions allied to medicine, with the result that it was difficult to read and collate information. Service users are allowed to smoke in their rooms, but in all cases looked at there were no risk assessment for this potentially hazardous activity. Dependency profiles were inaccurate, and staff admitted to completing these based on what they felt was achievable with current staff levels and not what was required to ensure appropriate levels of care based on assessed needs. There was a lack of understanding by qualified staff who were spoken to in respect of the difference between the assessment carried out by the long term care team for registered nurse input is invariably ‘Medium Dependency,’ and the dependency level that they were required to assess. This incorrect use of the care documentation has resulted in most of the service users being classed as medium dependency, when their daily reports strongly suggest high dependency. There were no care plans in place for psychological care and dementia in particular. One service user was stated to be aggressive and violent at times but there was no other documentation for this particular aspect of care, nor was there any policy readily available to guide staff in risk managing this service user. Specialist multidisciplinary healthcare team (MDT) input, specific to the needs of this service user was also lacking. Evaluations on care plans and risk assessments, such as Waterlow (tissue viability), nutrition, continence, etc; were inadequate. Examples were seen on some care plans as having no evaluation since Oct 2005. Basic clinical observations, such as temperature, pulse, blood pressure, etc; were not always carried out; and one file examined showed that no observations had been made since April 2005. Medications were very poorly managed and an immediate requirement for improvement was issued. The specialist pharmacist inspector will produce a separate pharmacy report in due course. Personal support in the home is offered in such a way as to promote and protect the service user’s privacy, dignity and independence. Staff were observed knocking on service user’s bedroom doors prior to entering, and service users spoken to told the inspectors that “most of the girls are nice”. The service users also told the inspectors that staff in the home were always courteous, respectful, and maintained their privacy and dignity when giving personal care. Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 Page 12 All service users in the home can access their NHS entitlements, such as opticians, dentist, etc; and care staff (if staffing levels allow) escort the service users to their hospital appointments. Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 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 & 15. Service users social, cultural, religious and recreational interests and needs are not being met; potentially leading to feelings of boredom and frustration amongst the service users. The food offered at Mother Redcaps is good, helping to ensure a wholesome and varied diet for all service users. EVIDENCE: On admission to the home service users are asked about their choices and preferences as regards food, past social life and hobbies. This information is used by care staff to plan diets and activities for the service user. A carer has been assigned to organise the activities for the service users in the home. An activities program is posted in the main hall of the home. Service users, relatives and carers who spoke to the inspectors said there were very little organised activities for service users as the carer had to do care duties because of shortage of staff. Carers and female service users told the inspector that there had been no hairdresser coming to the home, as the management of the home had not paid the fees for some months. Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 Page 14 Some of the female service users spoken to were upset as they were not sure they would have their “hair done” before the Christmas holidays. Carers did say that would make every effort to try and do the ladies hair before Christmas day. The carer undertaking activities needs considerable training and guidance as to why and how suitable activities are offered to service users, and the importance of documenting information on how service users participated in activities. Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 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, 17 & 18. The lack of progress regarding staff training in adult protection, plus minimal senior staff knowledge about the Protection of Vulnerable Adults (POVA) regulations undermines the management of the homes ability to sufficiently safeguard service users. The complaints procedure is inadequate, potentially leaving service users at risk. EVIDENCE: A complaints policy and procedure is displayed in the main foyer of the home, and a record is kept of most, not all, concerns or in-house complaints that are raised. The complaints procedure has contact details of the local CSCI. Since the previous inspection both the home and the CSCI have received complaints about this service, some of which have been upheld. Some service users and relatives spoken to told the inspectors that they were not always sure that if they had any concerns, they would be listened to and acted upon, or taken seriously. The ongoing lack of, or minimal staff training and development in adult protection is an un-met requirement from the previous inspection report. The inspectors were informed that service users have the opportunity to vote in local and national elections, and there is no religious or political persuasion in the care home. Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 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 & 26. Since the previous inspection the standard of décor within the home has deteriorated, with no signs of improvement through maintenance or future planning. The home does not therefore, present as a homely and comfortable environment for all service users. EVIDENCE: During this unannounced inspection the inspectors walked around the interior of the building, examining all communal and most service user areas. There was a smell of urine on the corridors and some bedrooms. Many of the service user’s bedrooms were also showing signs of wear and tear, and again décor had deteriorated in standard a great deal since the last inspection. Some of the rooms seen had torn wallpaper; others had malodorous and stained carpets as well as torn bedding. Damaged paintwork was also common in most bedrooms on the top floor. Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 Page 17 The tour of the building was undertaken with a staff member who had been at the home for some time. During the tour they told the inspector that they were “ashamed of the home”. The major environmental concerns are as follows: Protective bumpers on bed rails were soiled in 2 rooms. Bed rails in use in 3 rooms with no protective bumpers in place. One room had 1 bed rail fitted the other side of bed being against the wall and radiator. One room had bed rail brackets fitted but no bed rails. Door to cleaning materials store cupboard was off its hinges. The fire escape on the top floor was cluttered with wheelchairs and storage boxes – the inspector required that this was cleared immediately. Two rooms had badly marked carpets. Several rooms had items of furniture e.g. wardrobes stored in the en-suite to make more space available in the room to enable a hoist to be used. Two rooms had items of bed linen (1 a duvet and 1 a pillow) kept on top of the toilet in the en-suite, and on the middle floor two out of the available three shower rooms were not in use due to ongoing work. External clinical waste bins were also seen to be overflowing, and general waste skips in the car park were full, with numerous items of rubbish and furnishings dumped on the ground. Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. The recruitment and training policies and practices of the home are not robust, and the appropriate checks on staff are not being carried out. This does not adequately safeguard the service users from risk or harm. EVIDENCE: Examination of the staffing rota evidenced a high use of agency and bank staff, on both days and night duty. The rota also evidenced high sickness levels amongst staff, and a relatively high turnover of staff in general, particularly night duty. A number of staff personnel files were examined, and most were found to be lacking in basic requirements such as specialist care, or ongoing training. Some files had inadequate documentation and records regarding the recruitment of staff, including references, CRBs and POVA checks. Records of staff training lack detail and do not evidence the competence of staff to do their jobs. The specialist care training needs of staff must be reviewed to ensure the health, safety and well being of all service users. The service users assessed and collective care needs should be reflected on the levels of qualified and care staff on duty at any given time. Given the lack of up to date dependency ratings for all service users, it was not possible to ascertain that the current staffing arrangements adequately provide sufficient Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 Page 19 care for all service users at all times. The Commission will be discussing this serious area of concern with the provider as a matter of urgency. Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 37 & 38. There is ineffective leadership, guidance and direction to staff from the home’s management, leading to low staff morale and a high staff turnover. The standard of record keeping, regarding care plans, staff records, risk assessments and accidents is inconsistent in quality and content, and does not adequately safeguard residents. EVIDENCE: The manager is a first level nurse who has now been in post since March 2005, and has previously managed a care home. The manager has applied to the Commission to commence registration procedures. Visitors who spoke to the inspectors said since the new manager was appointed the morale of all staff had fallen, and quality staff had left the home because of the attitude and lack of commitment to the home by the manager. Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 Page 21 The visitors also said that the manager was hardly in the home, sometimes she came in to work at 10.30am and left at 2.30 pm, and staff did not always know where she was. On the day of this unannounced inspection, the manager arrived at the care home at 10.30am, but prior to that the nurse in charge of the home could not contact her. Care staff alleged that the acting manager was not approachable, victimised staff, and had produced two very negative and threatening letters to staff about their conduct in work time. Staff at the home said that they felt the home was “going under” because of the lack of commitment to the home from management. Carers had faxed the owner of the home, informing him of their concerns as regards to staffing levels and the way the manager was conducting the home. At present the home has vacancies for Registered Nurses and care staff. The manager suggested to the inspectors that the staffing shortages and low morale in the home was the fault of the owner, who disregarded her requests for an increased budget for staff. Staff members spoken to stated how much the home had deteriorated. Staff shortages were a particular problem. One person informed the inspector that trained staff had been instructed by the matron ‘not to work on the floor but to concentrate on their paperwork. Staff morale is very low; one staff passed the comment that “if matron only comes in when she feels like it you can’t expect the staff to show any commitment”. This comment was also replicated by other staff members. Audits for care plans, accidents and medications were seen, but these were out of date and clearly had not been acted upon. The manager stated that staff supervision was under way, however one example of supervision was observed, and seen to be very poorly recorded, and was inadequate in quality and content. Again, this is an area of noncompliance from the previous inspection. The provider’s representative had not given documented support and supervision to the manager, thereby limiting the manager’s effectiveness in her role. The lack of monitoring and support to the manager is a serious weakness which needs to be addressed in order to ensure that the leadership provided at the care home is adequate. This will also help to ensure that the Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 Page 22 manager can be effective in her role – this is a key component of the internal quality assurance processes, assisting the care home to meet National Minimum Standards Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 Page 23 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 2 3 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 2 18 1 2 2 2 2 3 2 3 2 STAFFING Standard No Score 27 1 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 1 X X 1 1 2 Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 Page 24 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. Standard Regulation Requirement The registered person must compile a Statement of Purpose, which is to include all the items as listed in Schedule 1 of The Care Homes Regulations 2001. Previous timescale of 30/06/05 not met. The registered person must produce a Service User Guide that is to include all the items as listed under this regulation. Previous timescale of 30/06/05 not met. The registered person must produce a care plan for each service user (service user) that must be kept relevant and updated on a regular basis. Previous timescale of 30/06/05 not met. The registered person must ensure that all staff receives adequate training regarding the prevention of abuse for vulnerable adults. Previous timescale of 30/07/05 not met. The registered person must ensure that the care home is in a DS0000020940.V274043.R01.S.doc Timescale for action 1 OP1 4 28/02/06 2 OP1 5 28/02/06 3 OP7 15 28/02/06 4 OP18 22 28/02/06 5 OP19 23 30/02/06 Mother Redcaps Nursing Home Version 5.1 Page 25 6 OP26 16 7 OP27 18 8 OP29 19 9 OP30 18 10 OP32 12 11 OP33 24 12 OP3 14 good state of repair and reasonably decorated at all times - and must put right all the items identified in this report. Previous timescale of 30/07/05 not met. The registered person must keep the care home clean and odour free at all times. Previous timescale of 30/06/05 not met. The registered person must ensure that there is sufficient staff on duty at all times. Previous timescale of 30/06/05 not met. The registered person must obtain all the documents and records for all persons employed, and must have CRB and POVA checks for all staff prior to employment. Previous timescale of 30/06/05 not met. The registered person must ensure that all staff receives training appropriate to the work they perform. Previous timescale of 30/06/05 not met. The registered person must ensure that good professional relationships are established between management, staff and service users. Previous timescale of 30/06/05 not met. The registered person must ensure appropriate quality assurance process is commenced with the involvement of service users and their representatives. Previous timescale of 30/06/05 not met. The registered person must ensure that a holistic pre admission assessment is recorded on all prospective DS0000020940.V274043.R01.S.doc 31/01/06 21/12/05 21/12/05 28/02/06 31/01/06 31/01/06 31/01/06 Mother Redcaps Nursing Home Version 5.1 Page 26 13 OP4 12, 14 & 15 14 OP8 12 15 OP9 13 (2) 16 OP12 12 17 OP14 12 18 OP16 22 19 OP17 12 service users prior to admission into the care home. The registered person must ensure that all the assessed needs of all service users are fully met and documented at all times. The registered person must ensure that suitable provision is made for all service users regarding pressure sore prevention and treatment at all times, and that adequate pressure relieving equipment is available as needed. The registered person must ensure that adequate arrangements are made for the recording, handling, safekeeping, safe administration and disposal of medications received into the care home. This must be acted upon immediately as discussed at the time of the interview. The registered person must ensure that all service users are enabled, as they so wish, to participate in fulfilling activities of their choice – and these offered activities must be recorded whether or not they are participated in. The registered person must ensure that all service users are enabled to exercise autonomy and choice over their lives, and can choose to have activities such as hairdressing, etc; as they wish and need. The registered person must ensure that there is an adequate complaints procedure, fully accessible to all service users and their representatives, which must include all points as listed under this regulation. The registered person must ensure that the care home is DS0000020940.V274043.R01.S.doc 31/01/06 31/01/06 21/12/05 31/01/06 31/01/06 31/01/06 31/01/06 Page 27 Mother Redcaps Nursing Home Version 5.1 20 OP20 16 21 OP21 16 & 23 22 OP22 16 23 OP24 16 24 OP28 18 25 OP31 9 26 OP36 18 27 OP37 17 28 OP38 13 conducted in a manner that respects the rights of all service users at all times. The registered person must ensure that the furnishings are of a suitable and adequate standard in all areas of the care home. The registered person must ensure that all en-suites are accessible to the service users and not blocked with wardrobes or hoists either belonging to the service user, or someone else. The registered person must ensure that there are suitable and sufficient aids and adaptations throughout the care home, accessible to all service users. The registered person must ensure that there is suitable and sufficient furnishings of adequate standard available for all service users, and must replace or repair the furnishings found to be in a poor state of repair. The registered person is required to ensure that suitably qualified staff are on duty at all times. A person shall not manager the care home unless they have the qualifications, skills and experience necessary for managing the care home. The registered person must ensure that all staff are appropriately supervised, and records of this are kept. The registered person must ensure that all the records as specified in Schedules 1, 2, 3 & 4 of The Care Homes Regulations 2001 are available in the home at all times, up to date and accurate. The registered person must ensure that all risks to the DS0000020940.V274043.R01.S.doc 31/03/06 31/01/06 31/01/06 31/03/06 31/01/06 31/01/06 31/03/06 31/03/06 28/02/06 Page 28 Mother Redcaps Nursing Home Version 5.1 29 OP7 14, 15 & 18 30 OP12 18 31 OP26 16 (2) 32 OP19 23 (4) 33 OP21 16 & 23 34 OP31 43 35 OP31 7 36 OP31 10 service users, staff and visitors are clearly identifed and appropriate action taken on their findings – refer especially to lack of records re checking bedrails. The registered person must ensure that all qualified nurses are appropriately trained and competant to carry out service user dependency scorings which acurately reflect each invdividual servic user. The registered person is required to ensure that the activities person is provided with training appropriate to the work they are to perform. The registered person must make, after consultation with the local Environmental Health authority, suitable arrangements for the disposal of general and clinical waste. The registered person must keep all fire exits and escapes clear and fully accessible at all times. The registered person must ensure that adequate numbers of bathing facilities are available for all service users at all times. The registered person must comply with requirements and regulations as specified, within the given timescales – failure to do so shall be an offence. A person shall not carry on a care home unless he is fit to do so – refer to previous outstanding non-compliances with requirements, and requirements as above. The outstanding requirements must be met within the stated timescales – failure to comply may lead the Commission to take enforcement action. The registered provider and the registered manager shall, having DS0000020940.V274043.R01.S.doc 28/02/06 28/02/06 28/02/06 21/12/05 28/02/06 28/02/06 28/02/06 31/01/06 Page 29 Mother Redcaps Nursing Home Version 5.1 37 OP33 24 38 OP34 25 regard to the size of the care home, the statement of purpose, and the number and needs of the service users, carry on or manager the care home with sufficient care, competance and skill. The registered person must establish and maintain a system for improving the quality of care 28/02/06 provided at the care home, including the quality of nursing. The registered person must carry on the care home in such a manner as is likely to ensure that the care home will be 28/02/06 financially viable for the purpose of achieving the aims and objectives set out in the statement of purpose. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard OP7 OP8 OP38 No. 1. 2 3 Good Practice Recommendations It is recommended that all significant conversations between qualified staff and service users representatives are clearly recorded. It is strongly recommended that all accidents, falls and untoward incidents are clearly audited and recorded by the homes management at least monthly. Additional risk assessments and checklists related to equipment and environment would help safeguard service users. Mother Redcaps Nursing Home DS0000020940.V274043.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor 10 Duke Street Liverpool L1 5AS 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. 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