Inspection on 15/07/05 for New Bassett House

This inspection was carried out on 15th July 2005.

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

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

Other inspections for this house

New Bassett House 20/06/07

New Bassett House 11/04/06

New Bassett House 07/12/05

New Bassett House 03/02/05

New Bassett House 04/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE New Bassett House Park Avenue Shirebrook Nr Mansfield Derbyshire. NG20 8JW Lead Inspector Bridgette Hill Unannounced 15 July 2005 09:15 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 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. New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service New Bassett House Address Park Avenue, Shirebrook, Nr Mansfield, Derbyshire, NG20 8JW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01629 580000 01623 588004 Derbyshire County Council Susan Ina Elsden Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 3rd February 2005 Brief Description of the Service: New Bassett House is a home offering 40 places to older persons, which now includes 2 places as part of an intensive assessment or intermediate care project. As well as longer-term care the home offers short-term respite care, which had been used by a number of service users to acquaint themselves with the home before making a final decision about their future. The home is built on one level and is situated in a residential area, near to the town centre of Shirebrook. Arranged on 3 wings the home offers a range of communal rooms to suit different purposes and access for persons with a physical mobility problem is assisted by wide corridors and an open central area. Facilities have been arranged with a domestic style in mind and there is good access to the outside areas of the home. Access to outside professionals is routinely arranged and the home benefits from the active support of a local GP who had assisted to raise the profile of health care in the home New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced one which took place over 5 1/2 hours. During the inspection 2 staff members and 3 residents and 2 visitors were spoken with. Various records including care planning records were examined the findings are recorded in the body of this report. What the service does well: What has improved since the last inspection? What they could do better: There is significant work required to ensure that care plans are in place and that they describe assessed care needs. There was potential that information relating to healthcare needs was not available to staff and that needs would be unmet due to a lack of care plans in the home. Some staff require training in Protection of vulnerable adults and the storage and administration of medicines. New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 6 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. New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 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 standard(s) 1,2 There was sufficient information made openly to service users and their families in order they are informed of their rights. EVIDENCE: A range of information was available in the entrance hallway. This included the Statement of purpose, Service User Guide and inspection report. These contained all required information. The certificate of registration was displayed in the home. This meets a previous requirement. Out of three files examined only one service user had been issued with a Terms and conditions of residency contract. This is an outstanding requirement from previous inspections. New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 9 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 standard(s) 7,8,9,10,11 Insufficient care plans were in place to ensure that staff had necessary information to ensure that service users assessed needs were being met and poor administration of medicines potentially placed service users at risk. EVIDENCE: As part of assessing how standards are being met a sample of three care files were case tracked to examine the outcomes for residents. Other care plans were examined in part to look at specific standards. Care plans and risk assessments were not available for all service users. Of the care plans examined that were available there was poor information on care delivery and they were not descriptive of how all assessed care needs were to be met. Some care plans were missing vital information for example on health needs where one service user had significant medical conditions such as diabetes this was not clearly documented with a plan of care. Risk assessments were not always completed. Risk assessments were available for nutrition and personal handling. There was no tissue viability trigger tool or falls risk assessments in place. Some risk assessments were completed for New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 10 service users for example smoking however these were held within the health and safety file and were not supported by a plan of care in the service users personal file. No records were available of care plan reviews. Care plans did not always contain religious persuasion, preferences and routines, post death wishes, date of admission(s) and there was no record of service users being consulted regarding their plan of care in most files. There were restrictions on liberty for some service users as an electronic bracelet system was available which alerted staff when service users were leaving the building. This was not always documented within a plan of care. Staff told the inspector that where service users were admitted on short-term basis key workers were not always allocated and care plans were not always drawn up. An immediate requirement was issued at the time of the inspection regarding care plans being available, reviewed and the content. Healthcare input from external professionals was recorded but were not always included in the plan of care. This included district nurses, GP’s, dentists and chiropodists. Staff spoken to said there was a good relationship with the district nurses. Some GP’s visited the home routinely each Tuesday as well as for emergency call outs. Poor administration of medicines was observed during the lunchtime medicine round. Multiple pots of medicines were dispensed at the same time into pots with a slip of paper with the service users name on it being placed in each one. No reference was observed to the medication administration records during administration. The trolley was left unattended with pots of pre-dispensed medicines openly accessible on top of the trolley. Staff were observed to take out medicines to more than one service user at a time. Medication administration records were not signed after each administration. Where medication administration records had been hand written these were not signed and verified by staff members. One spelling error was evident. In the controlled drug book the dosage of the drug was not consistently recorded. Where homely remedies were administered this was recorded on a separate sheet so the service users medication administration records was not a concise record of treatments received. This was not in keeping with the policy available in the home. New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 11 Not all staff had received training in the storage and administration of medicines, in particular night staff who had not received any training. A dedicated drugs fridge was available which was temperature checked daily and an up to date drug reference book was available. An immediate requirement was issued at the time of the inspection regarding the safe practice of the administration of medicines. New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,14,15 There was adequate provision of activities though this was not supported by documentation to evidence that activities and leisure time was organised in response to assessed need. EVIDENCE: There was little recorded regarding on care plans regarding preferences and needs regarding social activities. An activities room was available. 15/16 hours of staff time was dedicated weekly to activities. A trip to Skegness was planned and service users spoke positively of this. Some service users said they had their hair and nails done regularly. There was some craft ware around that had been made by service users. There were books and videos available. Service users said they had a choice of meal and one service user said the food had improved since the Manager had been in post. Service users said they had a choice of meal offered to them. Service users appeared to clean and well dressed. New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 13 One service user spoken to received communion in the home each week. New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,18 Information, policies and procedures were in place to any allegations of abuse would be dealt with appropriately however a training package is required to ensure that staff are conversant with these procedures. EVIDENCE: The complaints procedure was in the entrance hallway and included in the Statement of purpose and Service User Guide. One relative said they had not seen this but said they would speak to the Manager if they had concerns which they hadn’t at this time. No complaints were recorded since the last inspection was undertaken. A compliments/complaints book was in the communal area. One compliment had been received since the last inspection. Derbyshire County Councils Protection of vulnerable adults procedures were in place to should concerns be raised. Not all staff had received training in the Protection of vulnerable adults. Letters were available in files to confirm service users were eligible to vote by post. New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 15 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 standard(s) 19,26 The communal areas in the home were homely and service users had access to a number of areas which were well maintained and suitable to meet their needs. EVIDENCE: A range of comfortable and homely lounges were available. Some service users had their particular seats which they preferred and had some of their personal possessions around them including photographs of family and ornaments. The smoking lounge was being redecorated at the time of the visit. Records relating to fire safety checks indicated regular checks and servicing was undertaken. The exterior of the home had seating areas and well planted gardens. Service users were observed to be using this area freely. New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 16 There was no documentary evidence of service users being assessed to hold the key to their bedrooms although one service user said they did have the key. This is an outstanding requirement from previous inspections Records checked indicated regular fire safety checks and servicing of equipment. All areas of the home appeared to be clean and service users and relatives spoke to said they were happy with the standard of cleanliness. Protective clothing was available for staff to use and they were observed using these. New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 There is a well trained staff group at the home who had a good knowledge of the service users however this was not always supported by written information regarding the service users. EVIDENCE: A sample of staff personnel files were examined. These indicated that documentary evidence was not available that all required checks had been completed prior to staff commencing employment. The General Social Care Council Code of Conduct was available for staff to access. There were 21 out of 23 staff in the home who held at least NVQ(National Vocational Qualification) (National Vocational Qualification) (National Vocational Qualification) level 2 in care. This well exceeds the required National Minimum Standard. Service users and relatives spoke of a good atmosphere in the home and of a good staff group who were approachable. Care staff on each shift were supported by a Manager or deputy manager. New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 18 A sample of three staff files were examined to assess recruitment standards. These indicated that there was not documentary evidence available that all required checks and references had been completed. One volunteer was used at the home and as at previous inspections it was unclear if relevant checks had been undertaken to assess the suitability of the person. Staff training records were not examined at this visit and will be inspected at the next inspection. New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,34,35,37,38 Servicing records were in generally good order with only the hoist servicing that was out of date. Records that are required were not always available and management procedures were not in place to audit and identify where gaps were and address these. EVIDENCE: The Manager of the home held a relevant managerial qualification and was said by relatives to be approachable. Records indicated the Manager undertook an annual health and safety audit of the building. The public liability insurance was on display in the office. Records for establishing financial liability were not requested at this visit. New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 20 Some monies were held safely for service users records and balances were checked. These were found to be in good order. Some service user managed their own monies. Service records indicated that gas and electrical servicing had been completed. The servicing of hoists was overdue from the information available. Information on control of substances hazardous to health products was available. Staff on duty could not locate monthly visits made on behalf of the Provider. This is an outstanding requirement from previous inspections Not all records were in place or available as required to by the schedules of the Care Homes Regulations 2001. New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 1 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 4 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 3 x x 3 3 x 2 2 New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 22 YES Are there any outstanding requirements from the last inspection? 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 2 Regulation 5 Requirement The registered provider must provide each service user with a contract that specifies terms and conditions of residence at the home and contains the details included in the Standard and Regulation Old timescale 30.12.03 Where it is practicable residents must be consulted regarding their plan of care and consulted regarding any revision of it Old timescale April 2005 The individual care plans of service users must be improved to reflect the more detailed assessments of needs. Old timescale 30.12.03 Service users care plans must be reviewed ona minimum monthly basis Service users care files must contain all elements listed by Schedule 3 Where there are restrictions on a service users liberty as part of an assessed need this must be documented within a plan of care and reviewed at least monthly If the MAR chart is handwritten or altered by a member of staff Timescale for action 30.9.05 2. 7 15 30.8.05 3. 7 15 4. 5. 6. 7 7 7 15 15 Schedule 3 15 Immediate requiremen t issued seprerately 29.7.05 29.7.05 30.8.05 30.8.05 7. 9 13 (2) 17 (1) (a) April 2005 Page 23 New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Schedule 3 8. 9 9. 9 13 (2) 17 (1) (a) Schedule 3 13 (2) 17 (1) (a) Schedule 3 13 (2) 17 (1) (a) Schedule 3 13 (2) 17 (1) (a) Schedule 3 13 & 18 this must be signed and dated by them. This must then be checked, signed and dated by a second member of staff Old timescale Staff with training in the storage 30.10.05 and administration of medicines must on duty for all shifts It is required that all medicines must be administered safely in accordance with the homes administration policies and procedures Where homely remedies medications are administered these must be recorded on the service users administration record as per the providers procedures The controlled book book must be accurately held and include the name and dosage of the drug Staff must receive training on the protection of vulnerable adults list and the referral procedures for this All staff must training on the protection of vulnerable adults and the locally agreed procedures There must be documentary evidence of Residents being routinely assessed as their ability to hold the key to their rooms and this be offered to them if considered appropriate Old timescale April 2005 Criminal Records Bureau disclosures must be handled in accordance with ‘Criminal Records Bureau Code of Conduct for the handling of Disclosure Information’ Old timescale march 2005 The registered person must ensure that all staff records Immediate requiremen t issued seperately 18.7.05 30.7.05 10. 9 11. 9 30.7.05 12. 18 July 2005 13. 18 13 & 18 July 2005 14. 24 12 30.8.05 15. 29 19 30.8.05 16. 29 17,18,19 Schedule 30.8.04 Page 24 New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 2&4 17. 29 19 18. 33 26 19. 30 & 38 13 & 18 20. 21. 37 37 17, Schedules 2,3,4 15,17, Schedules 2,3,4 23 retained at the home contain the elements described in the Schedules Old timescale 31.8.04 The registered person must develop a local system to indicate the achievement of checks by the Criminal Records Bureau (CRB) Old timescale 31.8.04 The home’s line manager must complete a written report of any visits to the home Staff could not locate these at this visit The registered person must ensure that all staff receive instruction in moving and handling, emergency first aid, and food hygiene Not inspected at this visit Records required by schedules 2,3,and 4 must be available Managerial systems must be introduced and implemented to ensure all records are kept up t date The hoists in the hme must be serviced as per manufacturers guidelines 30.8.05 Old timescale 30.6.04 30.11.04 30.9.05 30.9.05 22. 38 30.8.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 2 8 9 7 Good Practice Recommendations Risk assessments should be intoduced for falls and care plans developed in response to identified risk Risk assessments sho0uld be intoduced for tissue viability and care pland developed in response to identified risk A drug reference book not dated more than one year old should be available All documentation relating to residents care should be C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 25 New Bassett House 5. 6. 7. 8. 7 11 29 29 available in one comprehensive care file (including personal risk assessments) All records relating to residents care should be signed and dated The funeral wishes of service users and/or their families should be ascertained and written into individual case notes. A copy of the Criminal Records Bureau Code of Conduct for the handling of Disclosure Information should be obtained. The registered person should ensure that all volunteer workers are subject to a check by the CRB by September 2004. New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby. DE1 3QT 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 New Bassett House C52 C02 S35586 New Basset House V238640 150705 Stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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