Inspection on 11/09/06 for Musmajas

This inspection was carried out on 11th September 2006.

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

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

Other inspections for this house

Musmajas 06/10/08

Musmajas 19/05/08

Musmajas 05/11/07

Musmajas 21/03/06

Musmajas 13/07/05

Musmajas 11/08/04

Musmajas 17/05/04

Musmajas 27/08/03

Musmajas 17/06/03

Musmajas 29/08/02

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

CARE HOMES FOR OLDER PEOPLE Musmajas Priory Hall Wolston Nr Coventry West Midlands CV8 3FZ Lead Inspector Deborah Shelton Key Unannounced Inspection 10:30 11 & 20 September 2006 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 Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Musmajas Address Priory Hall Wolston Nr Coventry West Midlands CV8 3FZ 02476 542701 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) Latvian Welfare Fund, Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 21st March 2006 Brief Description of the Service: Musmajas is a care home set in its own grounds approximately 1 mile from the village of Wolston. The property is owned by the Latvian Welfare Society and was developed into a care home to serve the Latvian community in the Midlands. The home can accommodate up to 18 service users in single room accommodation. Accommodation is sited in the large manor house and surrounding bungalows. Musmajas provides personal care to frail elderly people most of whom originate from Latvia. The home’s staff consists of English and Latvian speaking carers who can also converse in English. No intermediate or specialist care is offered at this home. Service users with nursing needs are cared for by the visiting community nurses. Medical services are provided by the local GP practice. The current scale of charges is £315 - £334 per week. Additional charges are made for outings (other than shopping), chiropody, hairdressing, dry cleaning and newspapers/magazines. Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following are the findings of an unannounced inspection visit that took place between the hours of 10.30am and 7.10pm on Monday 11 September 2006 and between the hours of 9.15 am and 11.00am on Wednesday 20 September 2006. The manager was on duty along with two care assistants, two catering and two administration staff. Sixteen people were living at Musmajas. Three residents were ‘case tracked’. This involves finding out about the individual’s experience of living in the care home by meeting with them, talking to them and their families (where possible) about their experiences, looking at their care files, looking at their environment, discussions with staff on duty and reviewing staff training records to ensure training is provided to meet resident’s needs. Documentation regarding staffing, health and safety, medication and complaints was also reviewed. The inspector was introduced to a majority of the people that live at Musmajas and conversations were held with seven people. Some of the residents at this Home do not speak English whilst others speak English as their first or second language. Latvian/Polish speaking staff assisted the inspector to speak to some of the residents who did not speak any English. There were no visitors at Musmajas during the inspection, however, Commission for Social Care Inspection comment cards have been received and comments made are included in this report. The inspection process enabled the inspector to see residents in their usual surroundings and see the interaction between staff and residents. The inspector dined with those residents who chose to eat their meal in the dining room. The Home were without a manager for approximately six months until a replacement could be found. The new manager commenced his employment in June 2006 and is working hard to learn the procedures and working practices as well as trying to implement some new ideas. What the service does well: The atmosphere at Musmajas is relaxed and friendly. Residents appeared at ease in their surroundings and some were pleased to show the inspector their bedrooms and other communal areas. Staff were friendly and helpful and appeared to have a good working relationship with each other and with residents. Residents all commented that Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 6 the staff were kind, patient and would do anything for you. Some of the comments received by residents regarding life at Musmajas are as follows: “I am totally happy here, the food is good, sometimes there is too much” “staff are all friendly and helpful, nothing is too much trouble” “I am lucky to be here” “staff are lovely, there is always lots of hugs and kisses, everyone is friendly” “everything I need I have, I have no worries, its fantastic here” Detailed below are some of the comments received by relatives on the Commission for Social Care Inspection comment cards: “the staff at Musmajas in Wolston are wonderful, I could not wish for my father to be in a better environment. He is always well cared for”. “I find the carers very kind and caring” “the staff are lovely” Residents have an increased sense of wellbeing through their positive relationships with staff and the relaxed and friendly atmosphere at the Home. What has improved since the last inspection? The newly appointed manager has the list of issues identified at the last inspection and has started working towards addressing some of these issues. A programme of refurbishment and renewal of the fabric and decoration is now available and this records maintenance and refurbishment activities for the year. Work has also started on the refurbishment of the first floor toilets. These are due to be finished shortly. All staff apart from one now have criminal records bureau checks (CRB). The manager is searching for a new company to undertake these checks on behalf of Musmajas. It was a requirement of the last inspection that a manager be recruited. The Home were without a manager for approximately 6 months. A new manager is now in post and is in the process of applying to become the registered manager with the Commission for Social Care Inspection. Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 7 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. Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3, 6 is not applicable Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Without a suitable Statement of Purpose or Service User Guide potential residents are unable to make an informed choice about where they live. Pre-admission assessment processes do not fully identify the needs of a resident; this gives rise to a risk of Musmajas not being able to meet individual needs. EVIDENCE: The Home has yet to develop a Service User’s Guide. The manager was able to find a copy of the Statement of Purpose, which is not finalised. The manager was advised to refer to the National Minimum Standards and Regulations for details of information to be included in these documents. This is an issue that has been raised at previous inspections. The Statement of Purpose and Service User’s Guide should clearly set out the objectives and philosophy of Musmajas and provide clear information about the Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 10 Home. Currently prospective residents and their families have insufficient information on which to make a considered choice of Home. The care file of the most recently admitted resident was reviewed. The resident was admitted from a Care Home out of the area and the placement was arranged by the resident’s social worker. The newly appointed manager did not conduct a pre-admission assessment on this occasion and no paperwork was forwarded by the resident’s social worker. Brief details were obtained and the placement agreed. A care plan was developed upon admission to the Home. The main reason for the placement at Musmajas was due to the Latvian speaking staff who would be able to communicate with the resident. The manager showed the inspector an assessment form which can be used to record basic information regarding the needs of the potential resident. The standard form does not contain detailed enough information to enable staff to develop care plans or identify the resources needed for an individual prior to their admission. This is particularly important for those residents who are self funding and who do not have assessment and care management care plans provided by their social worker. Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in the outcome group is adequate. This judgement has been made using available evidence including a visit to this service. Residents are mostly protected by the systems in place regarding health and personal care. Lack of information in care plans means that health care needs could be missed. Systems and practices regarding storage and administration of medicine are good. Residents are treated with respect and their rights to privacy and dignity are maintained. EVIDENCE: Three residents were “case tracked on this occasion. This included looking at the individual care files for each of these residents, chatting to them, looking at the bedroom and other accommodation which they use, discussing their individual care needs with staff and reviewing medication records. Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 12 Standardised documentation is used in care files and the information was easy to read and understand. Care plans were basic and did not contain sufficient information regarding identified health or personal care needs. Each file contained a basic daily routine, a core care plan, various risk assessments, details of medical visits and daily entries recorded by staff. Care plans did not give sufficient instruction to staff on how to meet individual needs. The manager stated that the current system of passing on information is via the staff “hand over”. Staff said that they do not use care files on a daily basis however they are available for review if needed. Details regarding health, personal care needs and changes in health are discussed by staff at the end of each shift and information is “handed over” to the staff coming on duty. Residents are at risk of not having their health and personal care needs met if care plans do not contain enough detail. The core care plan is reviewed on a monthly basis and changes in health are recorded on review notes. There was no photograph of the resident on their file to aid staff with identification. One care file indicated that the resident had psychological needs, however there was no care plan to address the need. There was therefore no evidence that staff would be able to meet this resident’s psychological needs. Various risk assessments were in place, two relating to the risk of developing a pressure area. One of these risk assessments graded residents “at risk” or “no risk”. One risk assessment seen assessed the resident “at risk”, there was no care plan or any other details recording the action that staff are to take to reduce the risk of developing a sore area. This resident may therefore be at risk of developing a sore as there is no documentary evidence to demonstrate that staff are taking the appropriate action to reduce the risk. Written information had been provided by a family member regarding the special needs, likes and dislikes of one resident. There was limited evidence that staff were complying with the requests made. Manual handling and nutritional risk assessments were in place and reviewed on a regular basis. The preferred names of residents are recorded along with details of religion, likes and dislikes and information regarding social and leisure activities previously undertaken. Care files contained evidence that residents have regular contacts with GP, optician, chiropody and dentists. Residents said that they see the GP when ever they need and confirmed that the chiropodist visits regularly. Two people spoken to confirmed that their health care needs are fully met and stated that Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 13 they had no concerns regarding the ability of staff to be able to meet these needs. The management of medication was reviewed, this involved looking at medication storage, stock levels and records such as medication administration records (MAR), receipt and disposal records. At the first visit to the Home on 11 September there was no controlled drugs register which must be kept in order to comply with legislation. At the visit of 20 September the manager had purchased a register and was going to start to complete information. The MAR chart had not been completed on one occasion to demonstrate that a resident had received their medication. There was no photographs of residents on MAR charts or the weekly medication storage boxes. This is a good practice measure that reduces the risk of staff administering medication to the wrong resident. The manager reported that they receive a good service from the GP and pharmacy and that there are no problems with the medication systems in use. Staff were seen to treat residents with respect and dignity. Those residents spoken to said that staff are always kind, they knock on bedroom doors, respect your privacy and maintain your dignity, particularly when completing personal hygiene such as showering. Two of the male residents were asked if they had a choice of male or female carer to complete personal hygiene tasks. Both responded that they preferred assistance from male carers and confirmed that this takes place on a majority of occasions. Both gentlemen were happy with the arrangements in place. Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The current arrangement for activities and entertainment are limited and so therefore do not provide adequate recreation or motivation for residents which may result in boredom and low self-esteem. Residents are encouraged and supported to maintain contact with their family, friends and local community resulting in supporting their social skills and increase in their mental well being. Lack of choice regarding food and daily activities can reduce resident’s self esteem. Meals are well presented, wholesome and provide residents with a nutritious and balanced diet. EVIDENCE: There is no activity programme in place, no activity organiser and no evidence in care files that any regular activities take place. All of the seven residents, who were able to express a preference, stated that they did not wish to undertake any activities. Residents were asked if they liked to play games, Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 15 watch TV or read books. It was noted that there are both English and Latvian books in the conservatory and some said that occasionally they read and talked about other residents who also like to read. All said that they like to sit outside and chat amongst themselves or with staff. One resident said “I am old, I eat, I sit and chat, what more do you want”. A majority of residents said that they had no interest in watching the television apart from the news. Some said that they have newspapers to read. During both days of the inspection residents were sitting outside chatting amongst themselves. Residents were asked what they do in the winter months and most said that they stay in their bedrooms. This could lead to social isolation. The manager has some ideas for introducing small-scale activities and initially encouraging a few residents to join in. One comment received from a relative on the Commission for Social Care Inspection comment card related to a lack of activities, “more activities, mostly able bodied sitting about all day everyday in summer. Winter just stuck in their rooms! Makes for long days”. Community contact is maintained through the various functions that take place in the main halls at Musmajas. Residents are invited to join in or watch. Some of those spoken to mentioned these and two particularly talked about the car boot sale that previously took place in the adjacent fields. Residents said that they enjoyed having visitors and going out with them. They said that they have visitors on a regular basis and confirmed that they are made to feel welcome and are offered drinks. There were no visitors at the Home on the day of inspection. The inspector dined with residents in the lounge. The meal served was appetising and well cooked. The dining room was pleasantly laid out. Residents came into the dining room at their own pace and were served their meal immediately, they were therefore not waiting a long time seated at the dining table before being served their meal. There were seven residents who had chosen to eat in the dining room, others were eating outside in the gardens as it was a sunny day and some were eating in the bedrooms through choice or medical conditions that made it difficult to eat elsewhere. During a conversation with the administrator it was noted that residents have a choice of meal on a daily basis. Menus forwarded with the pre-inspection questionnaire record that a choice of two meals is available. Meals were discussed with five residents, all said that the food was good and that there is plenty to eat. However, none were aware that there is a choice of meal. Residents said that most mornings for breakfast there is porridge and occasionally bacon and eggs and every day you are brought your meal on a plate. When questioned they confirmed that they are never given anything to eat which they do not like but they are not told what is for dinner. Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 16 The inspector sat at the dining table with a lady and a gentleman. The lady asked a member of staff if the desert was ice cream, the staff member confirmed that the desert was angel delight and encouraged the resident to try it. The resident left the table without eating any desert. This resident was therefore not offered a choice. All meals were served plated and the inspector did not see anybody eating anything apart from liver and onions. Staff spoken to said that residents are told what is available for dinner but are not offered a specific choice of meals. The kitchen looked orderly and clean. The Home have recently acquired their “Gold Star” food hygiene award. There was a cook and a catering assistant on duty. The cook was knowledgeable about the special dietary needs, likes and dislikes of residents. Both English and Latvian meals are prepared and buffets and cakes are provided on special occasions such as birthdays. Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate systems are in place to handle complaints and service users are confident that any concerns would be listened to and acted upon. Adult protection arrangements in place do not protect residents from harm and need further development. EVIDENCE: Neither the Home nor the Commission for Social Care Inspection have received any complaints about Musmajas. Residents said that they had no concerns and were happy with everything, however if they had any concerns they would speak to the manager or a member of staff. A copy of the complaints procedure was seen, this requires updating as it contains out of date information i.e. telephone number. The manager confirmed that he would amend this immediately. A complaint log book is available, however as no complaints have been received this is blank. There have been no adult protection issues at this Home. Staff were seen to interact well with residents and residents confirmed that staff treat them with respect and dignity. Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 18 There was no documentary evidence to demonstrate that staff have received training regarding the Protection of Vulnerable Adults. Some staff were not fully aware of the action to take if abuse is suspected at the Home. The Home’s whistle blowing policy requires updating as it contains out of date information such as telephone numbers. The Home are trying to find a new organisation to undertake criminal records bureau (CRB) checks on their behalf. One member of staff has no Protection of Vulnerable Adults or CRB check. Residents are being put at risk by employing staff and enabling them to work shifts before appropriate checks have been undertaken. Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 19 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, 21 and 26 The quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. The home is in need of improvements to provide a well-maintained environment with sufficient and suitable equipment and facilities, which ensure safe and comfortable surroundings are provided for all residents. EVIDENCE: Musmajas Care Home consists of three bungalows and an old manor house. Certain areas of the Home require updating and other areas re-decoration. Work is required in the dining room as the ceiling is badly stained and a plaster repair completed on the wall requires making good to the standard of the remaining walls. There is a lounge with TV and bar, a conservatory and a small lounge in one of the bungalows. Residents confirmed that the Home is always clean and tidy. The quality of the furnishings varied but in general were satisfactory. Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 20 Some residents were seated outside in the gardens during a majority of the inspection. Residents said that they enjoyed sitting outside in the quiet and chatting. The gardens are large and well maintained and staff had put up an awning to shield some residents from the sun. Other chairs were placed under trees that also gave some sun protection. There is a block of toilets outside of the main buildings which residents use when they are in the gardens. The bedrooms of those residents being “case tracked” were reviewed as well as three others. Bedrooms had been personalised with pictures and ornaments. Some of the furnishings, carpets and wall coverings are old, getting worn and should be included in the Home’s new programme of refurbishment. An unpleasant odour was noted in one bedroom, this room is now vacant and the Home are trying various methods to remove the odour. No odours were noted in any other areas of the Home. Radiators throughout the Home are protected to prevent the risk of burns to residents. There is no shaft lift to gain access to the first floor of the main building. A stair lift is available for use. Residents whose bedrooms are located on the first floor were seen using the stair lift without problem. Work has started on the toilet block on the first floor but further work is to be undertaken. The manager confirmed that this should be finished shortly. The large windows with small balcony outside mentioned in the last inspection report were open on the day of inspection. This presents a risk to residents and measures must be taken to remove any risk of accident. A number of doors leading to communal areas were being wedged open with items such as metal ashtrays. This is not safe as the fire safety of these doors is compromised if they are wedged open. The security of the bungalows was discussed. Bungalows are locked at night from the outside. Staff have a master key and confirmed that they complete hourly checks throughout the night. Residents are able to exit from the inside by turning two separate small handles. One resident tried to open the door herself but was unable. The manager was advised to discuss the safety of these doors with the fire service. Staff were observed throughout the inspection process wearing disposable gloves and aprons and following the Home’s infection control procedure. Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 21 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 quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. The numbers of staff are not sufficient to meet the needs of residents accommodated in the home, which could result in a reduction of the care provision. The management of staffing issues such as limited amounts of mandatory, service user focussed training and insufficient induction for new staff potentially puts resident’s at risk. The recruitment practices in the home are not sufficient to ensure the support and protection of the residents. EVIDENCE: Staff work set shifts between the hours of 8am – 8pm and 8pm – 8am. A number of staff live on the premises and one per night offers additional “sleep in” assistance to the “waking” member of night staff. Duty rotas show that on some days two staff work between 8am – 8pm and on others there are three. Each night one waking member of staff and one sleep in staff are on duty. In addition to this the manager works Monday – Friday 8am – 4pm. Catering staff are also employed. Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 22 It was noted at the last inspection of the Home that staff had little time to spend talking to residents and residents’ needs are met in a task-orientated way as opposed to holistically. This was also observed during this inspection. Staff are currently undertaking non care (cleaning and laundry) and care duties and do not appear to have the time to provide meaningful activities for residents. However, it was noted that a cleaner has been employed and is due to start shortly. The employment of a cleaner will allow staff to focus on care duties and may free some time for additional interaction with residents. One comment received by a resident on the Commission for Social Care Inspection comment card relating to staffing is detailed below: “In my opinion it is the best Care Home in Warwickshire. I do not know if or where one would find a better one. The staff are always sensitive. Maybe it is a condition of employment”. Currently only one member of staff employed has obtained NVQ level 2, four other staff are due to start this course in September 2006. Evidence that staff are enrolled on this course was seen. The staff files of all of those employed were reviewed to identify whether up to date criminal records bureau (CRB) checks have been obtained. Records demonstrated that all staff apart from one have a CRB check. The manager confirmed that unfortunately the company who had previously undertaken the CRB checks on their behalf is no longer operational. This member of staff is newly employed and the manager is searching for another organisation to undertake the CRB check. The manager was informed that staff should not work shifts until they have CRB check undertaken. Without receipt of POVA and CRB checks the Home are unable to demonstrate that they are employing suitable staff and are possibly putting their residents at risk. The inspector was shown an induction file that is available for use by newly appointed staff. Induction standards were developed by Warwickshire Care Services and are in line with the National Training Organisation’s requirements. Staff files seen contained a basic induction package which would not meet the National Training Organisation’s requirements. A training matrix has been developed which records staff names and training courses undertaken. The dates of the training are not recorded. It is therefore difficult to see (without looking through each individual staff file, which is extremely time consuming) whether training is up to date. From the matrix seen it was noted that not all staff have received up to date mandatory training. Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 23 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, 36 and 38 The quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. The newly appointed manager has a good understanding of the areas in which the home needs to improve. There is no evidence to demonstrate that systems are in place to ensure that the quality of the service provided meets the needs and expectations of the Service users who live at the Home. Lack of supervision and training could lead to unsafe working practices There are no procedures in place to manage residents’ monies and valuables so their interests are not effectively safeguarded. Not all health and safety issues have been addressed to ensure that residents live in a safe environment. This puts residents at risk of harm. Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 24 EVIDENCE: The new manager started his employment at the Home approximately three months ago. Prior to this the Home were without a manager for approximately six months. Certain management issues such as staff supervision and training have slipped. The new manager is aware of the issues to be addressed and is working towards addressing any outstanding issues that are within his power. Quality assurance systems and practices were discussed. It was noted that a satisfaction survey was sent to relatives in May 2006. The results of the survey have not been correlated. There is no formally documented system of ensuring that the quality of the service provided meets the needs and expectations of residents. There are no resident’s meetings, no relatives meetings and no documented audits. The manager said that he completes room audits on a daily basis but does not keep any documentation. The manager feels that the main way in which the Home ensure that the service meets peoples expectations is by daily communication. The manager feels that staff have an excellent relationship with residents and spend time chatting on a daily basis to make sure everything is going OK. During discussions with the administrator it was noted that personal allowance and other financial matters are handled by relatives or advocates for all residents apart from one. The administrator assists one resident with his financial affairs. There were no records on the premises at the time of inspection as they had been sent to an external auditor. The score previously given to this area will remain until evidence is available to demonstrate that this issue has been addressed. The manager was unaware of his responsibility regarding staff supervision and confirmed that there has been no staff supervision recently. Various records were reviewed to ensure that the Home promote health and safety. A legionella test was last undertaken in December 2005 and another test has been organised for December 2006. The hoist for used for moving residents has not been serviced since 2003, it was informed that the hoist is not currently being used. This must be serviced and tested before use with any resident. An external company provided fire training for nine staff in October 2005. Warwickshire Fire Service are apparently visiting the Home at the end of September to provide further training. It was difficult to see from records whether all staff have up to date fire training. A service contract for the stair lift was available dated February 2006. Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 25 Six monthly fire drills are undertaken. Fire alarm weekly tests and emergency lighting monthly tests have not been completed since August 2006. As mentioned previously in this report doors were being wedged open with various objects such as metal ashtrays. The security of the bungalows and the inability of residents to be able to exit the bungalows without assistance is also an issue to be discussed with the fire service. Insufficient testing of fire safety equipment and poor fire safety practices potentially puts residents at risk. Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 x 2 X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 x 2 X X 2 Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 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 OP1 Regulation 4, 5Sch 1 Requirement The registered person must ensure that there is a suitable Statement of Purpose and service user’s guide available for existing and prospective residents. (Outstanding since 7 July 05) 2. OP3 14(1)(a) The registered manager must ensure that all residents receive a full assessment prior to admission. A copy of the completed assessment must be available in care files. 23/10/06 Timescale for action 04/12/06 3. OP7 15 Care plans must set out in detail, 23/10/06 the action needed to be carried out by care staff to ensure all aspects of the health; personal and social care needs of resident are met. This must include details of any equipment needed to deliver their care. 4. OP8 14, 15, 17 The registered person must 23/10/06 Sch. 3, ensure that all residents have full assessments of potential risks to their health and, where a DS0000004256.V307109.R01.S.doc Version 5.2 Page 28 Musmajas risk is demonstrated, an appropriate plan of prevention must be devised. These risk assessments must be assessed monthly and changes in risk factors clearly recorded. (Outstanding since 21 March 06) 5. OP12 16 The registered person must ensure that there are organised activities that meet the residents’ social, cultural and interest needs. (Outstanding since 21 March 06) 6. OP14 12 The registered manager must ensure that evidence is available to demonstrate that residents have a choice regarding daily life including meals. 20/11/06 20/11/06 7. OP18 12, 13, 18 The registered person must ensure that all staff receive training in the protection of vulnerable adults (Abuse Awareness) (Outstanding since 21 March 06) 20/11/06 8. OP19 13 23 The registered provider and manager must ensure that all parts of the Home are in good decorative order and well maintained. The registered provider must ensure that the bathroom and toilet area on the first floor is reorganised and refurbished as soon as possible. An action plan with timescales must be forwarded to the commission. (Outstanding since 21 March 06) 04/12/06 9. OP21 23 04/12/06 Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 29 10. OP27 18 The registered person must, having regard to the size of the care home, the statement of purpose and the number and needs of the service users, ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. The Home is required to achieve a minimum ratio of 50 of staff trained to NVQ level 2, all care staff must be registered on a TOPSS certified training programme. The registered person must ensure that staff files contain evidence that a Criminal Record Bureau (CRB) check, Protection of Vulnerable Adult (PoVA) check and satisfactory references are obtained before a staff member starts working in the home. (Outstanding since 21 March 06) 20/11/06 11. OP28 18 04/12/06 12. OP29 19Sch 2 23/10/06 13. OP30 18 The manager must ensure that there is a staff induction and ongoing training and development programme which meets the National Training Organisation workforce training targets. The registered manager and owner must ensure that the management systems and practices in place are suitable to meet the needs of residents. The Registered Person must introduce systems which will effectively monitor and audit DS0000004256.V307109.R01.S.doc 20/11/06 14. OP31 12 04/12/06 15. OP33 24 04/12/06 Musmajas Version 5.2 Page 30 working and care practice in the home. These procedures must be ongoing. (Outstanding since 21 March 06) 16. OP35 16, 20 The registered person must maintain suitable records of service users’ personal monies held for safekeeping. The registered person must ensure that suitable locks or restrictors are installed on the large windows to the landing of the main house. (Outstanding since 21 March 06) 18. OP38 13 The Manager must ensure that all issues that relate to the health and safety of staff and service users detailed in the main body of this report are addressed as a matter of priority i.e. fire safety issues. 23/10/06 20/11/06 17. OP38 13, 23 23/10/06 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 Refer to Standard OP9 Good Practice Recommendations Consideration should be given to including photographs of residents on Medication Administration Records for ease of identification. Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Musmajas DS0000004256.V307109.R01.S.doc Version 5.2 Page 32 - 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. 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