Inspection on 05/09/06 for Olivet Christadelphian Care Homes

This inspection was carried out on 5th September 2006.

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

Olivet Christadelphian Care Homes 14/08/08

Olivet Christadelphian Care Homes 30/11/05

Olivet Christadelphian Care Homes 19/07/05

Olivet Christadelphian Care Homes 07/01/05

Olivet Christadelphian Care Homes 15/06/04

Olivet Christadelphian Care Homes 17/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Olivet Christadelphian Care Homes 17 Sherborne Road Acocks Green Birmingham West Midlands B27 6AD Lead Inspector Lisa Evitts Unannounced Inspection 5th September 2006 09:25 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 Olivet Christadelphian Care Homes DS0000024873.V310515.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. Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Olivet Christadelphian Care Homes Address 17 Sherborne Road Acocks Green Birmingham West Midlands B27 6AD 0121 683 8700 0121 683 8701 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) Olivet@cch-uk.com Christadelphian Care Homes Mrs Margaret Alison Maylin Care Home 60 Category(ies) of Dementia - over 65 years of age (60), Old age, registration, with number not falling within any other category (60), of places Physical disability over 65 years of age (60), Sensory Impairment over 65 years of age (60), Terminally ill over 65 years of age (60) Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The number of beds is 60, of which 31 may be for nursing care and 29 for residential care Males and females over the age of 65 years That one named service user under the age of 65 can be accommodated and cared for within this home for reasons of old age 30th November 2005 Date of last inspection Brief Description of the Service: Olivet provides nursing and residential care for up to 60 persons of 65 years of age or above and the service is exclusively offered to those of the Christadelphian faith. The home is situated on a site that also provides sheltered housing and operates as part of the Christadelphian Nursing and Residential Care Organisation and has other establishments around the country. There is sufficient off road parking for 27 vehicles as well as a dedicated space for the visiting GP. The home has an attractive enclosed garden area to the rear of the property, which resident’s have access to. The premises are close to public transport links to the city centre and within walking distance of a range of local amenities. Nursing and residential areas are located in separate wings of the building; the nursing area is a recent build and has a dedicated section for care of those suffering from dementia. Construction work is currently being undertaken to provide an extra five-dementia care beds. The home has three shared rooms with en-suite facilities. The remaining single rooms, with the exception of one room have en-suite facilities and these have recently been upgraded to include a walk in shower facility. Each wing has a lounge and there are a number of dining and bathing areas, the home also has on site kitchen and laundry facilities. The home has hoists and pressure relieving equipment available to meet the assessed needs of the residents at the home. There are assisted toilets and bathrooms available and corridors are wide and spacious and enable residents to move around the home freely with any mobility aids they require. Entrance to the home is via reception. Out of hours there is a phone available Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 5 and numbers to ring to gain access to the home and this ensures that staff are aware of who is entering the building, and this promotes the safety of residents. In the reception area, there are many biblical leaflets and copies of the homes Statement of Purpose and Service User Guide. Comment forms are also available for visitors to the home to complete if they wish. The current scale of charges for the home is £660 - £905 per week for nursing care and £360 - £480 for residential care. Additional charges include hairdressing, chiropody, toiletries and newspapers. Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced fieldwork was undertaken by two inspectors over eight hours and was assisted by the Registered Manager and General Manager. There were 56 residents living at the home on the day of the inspection. Information was gathered from speaking with the residents and staff, from observing care staff perform their duties and from examining care and health and safety records. Medication procedures were reviewed. Staff personnel files were sampled and a partial tour of the building was undertaken. Prior to the inspection the manager had completed a pre inspection questionnaire and returned it to CSCI, and this gave some information about the home, staff and residents that was also considered. One immediate requirement was made on the day of the inspection and a satisfactory response to this was received a week after the inspection took place. What the service does well: The home provided prospective residents with information and the opportunity to spend time at the home in order to decide if they would like to live there. In addition to this comprehensive pre admission assessments are completed to ensure that the home can meet the assessed needs. The home provides a clean and comfortable environment in which to live and visitors are made to feel welcome. Residents are able to choose if and when they go out, one resident stated, “I’m free to come and go as I choose” and this ensures that residents are able to make their own choices. Staff training is arranged to ensure they have the appropriate knowledge to work competently within their role. There are robust procedures in place for recruitment of staff and this safeguards residents from harm. Personal allowances can be safely held by the home if requested by the residents. Residents are well supported by the care staff to meet their health, welfare and personal needs. Comments from residents included: Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 7 “We are all of the same religion which is the most important thing” “I’m very happy here” “We are well blessed with doctors, dentists, chiropodists and opticians” “I spend most of my time in the lounge, I like the company” “The staff get my visitors a cup of tea” “Food is very good, we have a choice” “Food is normal, they do their best” “We have nothing to complain about here” “The gardens here are beautiful” “I’ve got everything I need” “The nurses and staff treat us extremely well” “The staff are very respectful here” What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Olivet Christadelphian Care Homes DS0000024873.V310515.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 Olivet Christadelphian Care Homes DS0000024873.V310515.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): 1,2,3, & 5 The quality outcome of this area is excellent. This judgement has been made using available evidence including a visit to the service. The home provides prospective residents and their representatives with relevant information about the home, and this enables them to make an informed decision about the homes suitability. Residents are issued with a contract to ensure that they are informed of terms and conditions of their stay at the home. The home completes assessments and gathers pre admission information and this enables the home to ensure they can meet the needs of the prospective resident. Residents are invited to spend time at the home, enabling them to make a choice about whether or not they may wish to live in the home. EVIDENCE: The home has a service user guide and statement of purpose, which contain relevant information about the home. These are available in large print format and this assists prospective residents who have visual impairment to access the information required to make an informed decision about the homes Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 10 suitability. It is recommended that the home consider use of audiotapes to provide the information for prospective residents with sensory impairments. A current registration and liability insurance certificate are on display in the reception area of the home and this ensures that anyone using the premises can see them. Each resident is issued with a statement of terms and conditions of residency and this includes the room number to be occupied and fee. The home has an eight - week trial period that gives the resident time to experience living at the home in order to help them to decide if they would like to stay as a permanent resident. Comprehensive pre admission assessments are completed prior to the resident being admitted into the home and this ensures that the home is able to meet the needs of the resident. Prospective residents are encouraged to visit the home prior to making a decision about whether they would like to live there. The home manager discussed a prospective residents admission and a variation to the homes current registration, plans were discussed for the resident to come and visit the home at different times and to stay for an overnight visit and this is commendable as it will ensure that the home can meet the needs of this resident and enable the resident to make an informed choice. Residents who currently reside in the sheltered housing join residents at the home for meals as they choose and this enables them to feel secure in this environment. Should their condition deteriorate and assessment be required for permanent residency within the home, residents would already know staff and residents making any transfer a comfortable process. Comments from residents included: “I’m very happy here” “I come over for lunch everyday to see my friends” “We are all of the same religion which is the most important thing” Olivet Christadelphian Care Homes DS0000024873.V310515.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 & 10 The quality outcome of this area is good. This judgement has been made using available evidence including a visit to the service. Resident’s health and personal care needs are well met by the staff. Care plans have improved and provide staff with sufficient detail to meet the individuals assessed needs. Improvements are required to the management of medication to ensure that it is safely administered to residents. EVIDENCE: Each resident has a care plan written. This is an individualised plan about what the person is able to do independently and states what assistance is required from staff in order for the resident to maintain their needs. Care plans and daily records are produced on a computer. Each member of staff has a password and this prevents entries from being changed. Care plans were generally detailed and provided information for staff to follow. Some specific information such as the type of incontinence aids required was not always recorded and therefore staff would not know what to use. There were some good details such as ‘speak slowly’ and ‘ensure call pendant is worn’ and ‘use lidded beaker’. There was also evidence of personal likes and Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 12 dislikes being recorded and an example of this was “Does not like to wear tights or stockings, wears knee length socks” and this ensures that resident’s likes are maintained. There was evidence that care plans were reviewed and updated by staff to ensure that current information was reflective of the care required, however this was not monthly as required and the home must formalise a monthly system for monitoring this. There was no evidence of residents or representatives involvement in the review or planning or care on files reviewed and the home must provide evidence if the resident or families do not wish to be involved in this process. There was evidence of nutritional screening and falls risk assessments taking place. Manual handling assessments gave details of any equipment to be used to assist residents such as “use handling belt with two carers, will rock on the count of three and stand using gutter frame”. This provides good details for staff to follow. Residents can retain their General Practitioner (if in agreement) on admission to the home and this ensures that residents receive continuity of care if they choose. There was evidence that residents see external healthcare professionals such as a Parkinson’s nurse specialist, chiropodist, dentist, speech therapist and optician. The home employs Physiotherapy assistants to work with residents to maintain or improve their current level of mobility. One resident said, “We are well blessed with doctors, dentists, chiropodists and opticians” Daily progress notes were detailed and gave details about physical condition, mental health and how the resident had spent their day. They also included details of any professional visits and the outcome. Progress of treatment prescribed was also recorded which shows that the staff are monitoring changes in condition. Residents seen were well presented and appropriately dressed for the time of year. The management of medication was reviewed and required some improvements to ensure that audits could be completed. On the residential unit, the following was found: •Not all variable doses were recorded. •Handwritten Medication Administration Records (MAR) had not been signed and there was no evidence of confirmation of the prescription. •Prescription creams were not signed for when administered. Good practices were that medications were signed in for upon receipt into the home and photocopies of prescriptions were kept for confirmation. There was Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 13 good written confirmation of resident’s warfarin doses, which minimises the risk of mistakes occurring. Some staff are due to commence distance-learning courses regarding medication and this will ensure that staff have the knowledge to administer medication safely. On the nursing unit: •There was no carry forward system in place therefore it was not possible to complete an audit. •There were two different lists in place for reasons for not giving medication and it was confusing which list was being used. •Not all drugs were signed for upon receipt. •Not all medications were signed for when administered. The medication policy was reviewed and requires updating to reflect the procedures for disposing of medication on the nursing unit. Olivet Christadelphian Care Homes DS0000024873.V310515.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 & 15 The quality outcome of this area is excellent. This judgement has been made using available evidence including a visit to the service. Residents are able to exercise choice over their daily lives and the activities that they choose to participate in which promotes their individuality and independence. Residents receive a wholesome and varied diet, which meets any special dietary needs. EVIDENCE: The home was due to interview for an activities coordinator to be appointed. This position will be full time and the successful candidate will coordinate activities through the home. The general manager felt that there are not enough activities on offer and plans to work with the co-ordinator to improve activities and documentation of activities. In the corridor there are photographs on display of garden parties held in the summer and a large wall freeze was on display, which children from a local holiday club had produced. Activities currently on offer include games, arts and crafts, scones and strawberry mornings, coffee mornings, hymn singing, movement to music, painting and paper crafts. There were monthly bible classes arranged and Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 15 daily bible readings. There is a communion service every Sunday afternoon for those residents who wish to attend. A number of residents go out to their own church and this promotes their independence and contact with the local community. The hairdresser visits once a week for residents who wish to participate in this activity. The home has an open visiting policy which means residents can see their visitors at anytime they choose. Comments from residents included: “We had a garden party” “Activities take on all forms” “I spend most of my time in the lounge, I like the company” “The staff get my visitors a cup of tea” “I’m free to come and go as I choose” “I visit my friends in their flats” “I could get involved with the activities if I wanted to but I don’t want to” “My key worker takes me out shopping” “I go to church on Sunday and the staff get me ready in the wheelchair” During the tour staff members were observed talking with residents in their rooms and one staff member was reading a postcard to a resident and this ensures that residents are stimulated. Menus were reviewed and these identified a range of nutritious meals and the residents had been involved in the reviewing of the menus. The menus had been re printed and included pictures to help residents identify the choices available. The menu clearly identified the alternatives available to the main meal and two choices are offered at teatime. Fresh fruit is always available and was placed in baskets throughout the home for residents to take as they choose. Milky drinks and biscuits are available before bed and there are facilities to make toast or sandwiches if residents request these. Pureed meals were available for residents with swallowing difficulties and these were appropriately served. Food was cooked for residents who required special diets for medical reasons. No diets were required at the present time for cultural requirements however staff knew how to meet these needs should the need arise in the future. Records of food eaten by residents are kept and this enables the staff to monitor dietary intake and take appropriate actions for residents who may require assistance. Comments from residents included: “We are very well fed” “Food is very good, we have a choice” “I like the choice of food” “Food is normal, they do their best” Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The quality outcome of this area is excellent. This judgement has been made using available evidence including a visit to the service. The complaints procedure is comprehensive and is accessible to residents and their representatives should they need to make a complaint. There are robust systems in place to protect residents from abuse. EVIDENCE: The complaints procedure is on display on notice boards throughout the home and is available to anyone who needs to make a complaint. It is recommended that this procedure is available in large print to assist residents or representatives with visual impairments. CSCI had received one complaint since the last visit to the home and this had been forwarded to the provider to investigate. Good documentation was available pertaining to the concerns raised and a copy of this was sent to CSCI. The home had not received any other complaints but had received a number of ‘thank you cards and letters’. Comments from these included: “Thank you for all the love, care and attention given” “Mom is so happy, settled and well cared for” “Olivet ought to be held up as a model of the ideal” “You have made every effort to respect wishes and dignity” Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 17 Resident’s comments included: “We have nothing to complain about here” “Would talk to the staff nurse if I had a problem” “Would talk to Margaret or my key worker if I was unhappy” The welfare committee visit the residents and address any concerns raised, however it was also pleasing to see that there were details available for external advocacy agencies should the residents require this service. This is commendable as such services assist residents and their families to exercise personal autonomy and choice over their lives. The adult protection policy was reviewed and was very comprehensive, including contact details for Social Care and Health and CSCI. There have been no adult protection concerns raised pertaining to Olivet and staff have received training in Adult Protection to ensure they have the knowledge to deal with any allegations appropriately. The home has a Whistle blowing policy to ensure that staff have the knowledge to protect clients/service users without fear of any reprisals. Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 & 26 The quality outcome of this area is excellent. This judgement has been made using available evidence including a visit to the service. Olivet provides a homely, comfortable and clean environment to live in, where residents are relaxed and secure. Resident’s rooms are individualised and the home provides facilities to meet individual needs. EVIDENCE: A partial tour of the building was completed and areas seen were homely in style, clean and odour free. Furniture, fixtures and fittings are all of a high standard and this promotes a comfortable environment for residents to live in. Corridors throughout the home are wide and have handrails in place and this assists residents who require assistance or the use of mobility aids to move freely around the home. Hoisting equipment and pressure relieving equipment is available for residents who are assessed as requiring this assistance. Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 19 The garden area was secure and very well maintained. A decking area gives access to a platform lift so that residents in wheelchairs can also access the garden. Tables and benches were available for residents to use if they chose to sit in the garden area. There are a number of assisted bathrooms and shower facilities throughout the home, which meet the identified needs of residents. All bedrooms except for three have shower facilities. Toilets had liquid soap and handrails as required. There are bookcases in the corridors and seating areas, so that residents can choose where they would like to sit and browse through the books if they wished to do so. Some redecoration of the home had taken place and new dining tables were on order. This ensures that residents are provided with a clean and homely environment in which to live. Residents bedrooms reviewed were found to contain personal possessions, which reflect their age, gender and culture and this ensures that the residents have as comfortable surroundings as possible. One resident spoken with had a telephone in her room and this facility can be arranged for other residents if they choose, which enables them to make calls as they wish. One resident who wandered around the home had had a buzzer installed into the bedroom door, which would alert staff during the night if she vacated the room and this assists with minimising risks to the residents safety. During the tour some mops were noted to be stored in buckets and not inverted and a staff member was observed feeding a resident without wearing an apron and this does not ensure that the potential for cross infection is minimised. It was recommended that the Health Protection Team Infection Control Nurses should be invited in to complete an audit and advise where improvements could be made. There are currently construction works in progress as one wing of the home is having an extension of five beds. This is to create further dementia care facilities. The courtyard has been planned in a square, which will allow residents the opportunity to wander around the unit safely. A sensory garden is also planned. The area was safely sealed off to prevent any injury to residents. One resident said, “They are building five more rooms but its not bothering me”. Comments from residents included: “I have a room of my own, the cleaners clean it for me” “The gardens here are beautiful” “I’ve got everything I need” “The cleaners come and clean my room everyday” Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 The quality outcome of this area is excellent. This judgement has been made using available evidence including a visit to the service. Adequate staffing levels are maintained at the home to meet the identified needs of the residents. There is a robust recruitment system in place, which ensures that residents are safeguarded from harm. Staff undertake relevant training to ensure that they are competent to do their jobs. EVIDENCE: In addition to care staff the home also employs laundry, housekeeping, kitchen and maintenance staff, to ensure that all needs of the residents are maintained. Staffing rotas were reviewed and identified adequate numbers of staff on duty. There has been some use of agency staff, however these staff have been given at least two shifts supernumerary to ensure they have received an induction and are orientated into the home. Where possible the home uses the same members of agency staff to ensure continuity for the residents. The home currently has no staff vacancies. The home currently has 61 of care staff that have achieved NVQ Level 2 in care and this ensures that there is a skilled workforce caring for residents in the home. Comments from residents included: “The nurses and staff treat us extremely well” “The staff are very respectful here” Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 21 “Very warm staff” “I think the staff are doing their best for me” “The staff come and help me quickly if I use my call bell” “Staff are wonderful to me” Four staff files were reviewed and were found to contain POVA (protection of vulnerable adults) and CRB checks, references and application forms. Comprehensive interview notes had been recorded. Two files did not have any identification photographs on file and this is a requirement. All staff that have been at the home for three years have just had a repeat Criminal Records Bureau check completed and this continues to safeguard the residents from harm. The most recent person to be employed at the home had completed an induction into the home and was working through the Skills for Care induction. There was evidence that staff had received training in adult protection, person centred care, dementia care, practical approaches to eating well in dementia care, diabetes, fire, food hygiene, first aid, infection control, manual handling, wound care and parkinson’s disease. There was evidence of training places booked for nutrition in care and PEG study days. Some members of staff were attending training for diabetes on the day of the fieldwork visit and confirmed what training they had received. One member of staff spoken to said, “Training is very good, we are all way over for our registration”. This ensures that a skilled and competent workforce cares for residents. Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, & 38 The quality outcome of this area is excellent. This judgement has been made using available evidence including a visit to the service. The Registered Manager ensures that a good standard of service is provided at the home and that the home is run in the best interests of the residents. There is a robust procedure in place for the management of resident’s personal monies. Maintenance checks and comprehensive staff training ensures that the health, safety and welfare of residents is protected. EVIDENCE: The Registered Manager is a Registered Nurse with much experience of caring for older people and has a Diploma in the Management of Care Services. Since the last fieldwork visit to the home a General Manager has also been appointed, so that the Registered Manager can concentrate her time on care practice. The appointment of the General Manager is also forward planning as the Registered Manager is to retire next year, and this is a positive step taken Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 23 by the organisation to ensure that there is competent staff in place to continue to run the home in the residents best interests and with little disruption. The current manager has organised all files and documentation in a logical and consistent way and this will also assist a new manager to find information easily. One staff member spoken to said, “The management are very good, if we can justify the need for new equipment or training, we get it” The Organisation produces a six monthly comprehensive audit based on Care Homes Regulations. Senior managers undertake monitoring visits and details of these visits are sent to CSCI as per Regulation 26. There are no resident questionnaires at the present time but welfare and visitors questionnaires are encouraged to be used and these were available in the reception area of the home. The home has plans for an independent audit and a fellow home is piloting a new quality assurance system. There were also plans to introduce a residents meeting and letters were in the process of being organised to invite relatives and residents to the meeting. This shows that the home is continuing to improve and seek the views of residents and visitors as to how the home is run. Departmental and staff meetings are also held and this gives staff the opportunity to discuss any concerns or bring forward any new ideas in an open and inclusive atmosphere. The management of resident’s personal monies was reviewed and balances checked were found to be correct. Residents on the residential unit are encouraged to handle their own finances while able as this continues to promote their independence. Residents have a separate page for recording their monies on the computer and a paper copy is also held. External managers audit personal monies to ensure they are correct. Receipts were available but were not numbered so it was not possible to complete an audit. There were no signatures for money received and there were no receipts available for residents who had purchased sweets as ‘the sweet lady’ held these. It is recommended that two signatures are obtained for money received and that receipts are obtained for all purchases made. This will safeguard both residents and staff. Maintenance records and safety certificates were available and included checks on assisted bath hoists, electrical wiring, gas safety, hoists, lift and legionella. Checks on portable appliances were being carried out on the day of the fieldwork visit to ensure they were safe to use. Weekly fire alarm tests and emergency lighting check records were seen and the fire alarm was being serviced on the day of the fieldwork visit. There was Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 24 evidence that fire drills have taken place and names of staff attended had been recorded. Fire extinguishers had been serviced and the fire risk assessment had been recently updated. This ensures that equipment if in full working order and that staff have the knowledge to act appropriately to safeguard residents in the event of a fire. Accident records were reviewed and were very detailed with outcomes. The manager reviews all accident forms and a trustee also audits them each month, and this will assist to minimise further risks to residents from occurring. Any unexplained injuries are reported to CSCI as per Regulation 37. During the tour COSHH (control of substances hazardous to health) products were found to be in the sluice room and not locked away and these could pose a risk if accidentally swallowed by residents. An immediate requirement was left with the manager for these products to be stored securely at all times. Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15(1)(2)( c) Requirement Timescale for action 28/11/06 2. OP7 15(2)(b) Residents and/or their representatives must be involved in the agreeing of care plans. (Previous timescales of 31/10/04, 07/05/05, 31/10/05 and 28/02/06 not met) All resident care plans must be 31/10/06 reviewed at least monthly and this must include a written review of the care needs. (Previous timescales of 22/10/04, 07/05/05, 30/09/05 and 31/01/06 not met) Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 27 3. OP9 13(2) Quantities of all medicines received and balances carried over from previous MAR charts must be recorded. (Previous timescale of 20/07/06 and 31/01/06 not met) Variable dose medication must be recorded. Handwritten MAR charts must be signed and confirmation of prescription recorded. Prescription creams must be signed for when administered. All drugs must be signed for when administered. The medication policy must be updated to include the process for disposal of mediactions on the nursing unit. Protocols for “when required” medication should be written and should include reasons for administration, dose, maximum daily dose and dose intervals in addition to the need to record the outcome. Examples of mediactions that require written protocols are rectal diazepam, benzodiazepines and antipsychotics. (Previous timescale of 31/02/06 Not assessed on this occasion) Staff files must contain an identity photograph. COSHH products must be stored securely at all times. 03/11/06 4. OP9 13(2) 30/11/06 5. OP9 13(2) 30/11/06 6. 7. OP29 OP38 19 Sch 2 13(4) 13/10/06 05/09/06 Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 28 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 OP1 OP16 OP26 OP35 Good Practice Recommendations It is recommended that the home consider the use of audiotapes for the statement of purpose and service guide. It is recommended that the home consider producing the complaint procedure in large print format. It is recommended that the home invite Infection Control Nurses to complete an audit. It is recommended that a system for the numbering and subsequent logging of individual receipts for items purchased out of resident’s personal allowances is introduced. Signatures should be obtained for all monies in and out of the accounts. (Previous recommendation) Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Olivet Christadelphian Care Homes DS0000024873.V310515.R01.S.doc Version 5.2 Page 30 - 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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