Inspection on 22/05/07 for Owston View

This inspection was carried out on 22nd May 2007.

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

Owston View 31/05/06

Owston View 11/10/05

Owston View 26/10/04

Owston View 26/04/04

Owston View 26/08/03

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Owston View Lodge Road Carcroft Doncaster South Yorkshire DN6 8QA Lead Inspector Marina Warwicker Key Unannounced Inspection 22nd May 2007 09:00 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 DS0000031963.V332042.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. DS0000031963.V332042.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Owston View Address Lodge Road Carcroft Doncaster South Yorkshire DN6 8QA 01302 723368 01302 729167 None NONE Doncaster Metropolitan Borough Council 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) Mrs Susan McNair Turton Care Home 36 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (24) of places DS0000031963.V332042.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st May 2006 Brief Description of the Service: Owston View is a purpose built care home for older people situated on Lodge Road Carcroft, in a residential area close to many local facilities. It is also on the bus route to Doncaster. The home provides care for 24 older people in the main part of the home, and a further 12 people who have a mental infirmity in a specialist unit known as The Croft. The Home also provides a day care service for up to 8 people. Fees range from £330.00 - £ 490.00 per week, and additional charges apply to hairdressing, specialised toiletries, and magazines etc. There was a lack of information about the facilities to people living at the home and also to those who visit in the form of the Statement of Purpose and the Service User Guide. DS0000031963.V332042.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was carried out on Tuesday 22nd May 2007 between 9am and 5pm. Fifteen people who use the service were consulted and seven staff were spoken to. A further sixteen service users/ relatives, Fifteen staff were contacted by post to obtain feedback about the service. Comments received from the surveys have been included in the body of the report. Time was spent observing and interacting with staff and the service users. The manager was present during the inspection. The premise was inspected which included bedrooms of service users and the communal areas inside and the outdoors. Samples of records such as the care plans, medication records, some service reports and staff recruitment and training files were checked. I would like to thank the people who live at Owston View, their relatives, the care staff and the managers for their contribution towards this process. What the service does well: The people have their needs assessed and a contract drawn to tells them about the service they will receive and the rights they have whilst they live in the home. The principles of respect, dignity and privacy are put into practice by the staff so that the people living at the home are comfortable and confident that they are correctly supported and cared for. People who use service are able to make choices about their life style, and are supported to develop their life skills. People at the home receive a wholesome diet. People who use the service are able to express their concerns and have access to a complaints procedure. The physical design and layout of the home enables people who use the service to live in a safe and comfortable environment, which encourages independence. DS0000031963.V332042.R01.S.doc Version 5.2 Page 6 Externally the home has extensive grounds, and there are facilities for residents and visitors to walk around and also to sit out, where a number of benches and garden furniture are available. What has improved since the last inspection? What they could do better: The registered manager needs to make available an up-to-date statement of purpose setting out the aims and objectives of the home and provide a service user guide so that people are able to find out about the suitability of the service. The registered manager must ensure that all the people who are using the service have an appropriate and up to date care plan reflecting their needs. The care staff must receive formal training in end of life care so that they are able to make sure that the people receive appropriate care and the families get the attention and support they require. All the people who live in the home must be consulted; including those reside in the EMI unit (or their representatives) with regard to the activities programmes. The activities organised must be in relation to recreation, fitness and healthy living. The activities must be changed according to the seasons. All staff working at the home must attend formal training in Protection Of Vulnerable Adults and they must be familiar with the whistle blowing policy. The manager must ensure that the staff are competent in dealing with allegations of abuse and familiar with the homes policies. The manager must ensure that an additional stand aid hoist is purchased to meet the needs of the people who live at the home. The staffing numbers must reflect the assessed needs of those who receive the service. This must include the day care users. The manager must operate a thorough recruitment procedure to safeguard the people who use the service. The manager must ensure that all staff working at the home are trained and competent to do the jobs they are employed to do safely and appropriately. The induction programme must be reviewed to reflect the present Skills for Care Standards. DS0000031963.V332042.R01.S.doc Version 5.2 Page 7 The management must introduce an effective quality monitoring system based on seeking the views of the people who use the service. The quality monitoring must be used to measure whether the home is meeting its aims and objectives. The registered manager must ensure that safe working practices are operational by making sure that all the staff working at the home have attended mandatory training such as moving & handling, health & safety, fire safety, food hygiene, Infection control and First aid. 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. The summary of this inspection report can be made available in other formats on request. DS0000031963.V332042.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 DS0000031963.V332042.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4&5 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Prospective people and their representatives who wish to use Owston View do not have access to the information such as the statement of purpose and the service user guide so that they are able to make an informed decision. However, by visiting the home and consulting the people who live at the home the prospective residents are able to decide whether the home is able to meet their needs. The people have their needs assessed and a contract drawn to tell them about the service they will receive and the rights they have whilst they live in the home. DS0000031963.V332042.R01.S.doc Version 5.2 Page 10 EVIDENCE: The manager did not have copies of the statement of purpose and the service user guide so that the inspector was able to check the aims, objectives and the facilities made available to the people living at Owston View. Information belonging to three people living at the home was checked. The three people had signed copies of the Terms & Conditions displayed in their bedroom. All three people had documentation in their care plan of the needs assessments undertaken prior to them moving into the home. The placing authorities had carried these out. Five people and three staff were consulted. They hoped that the manager made sure that the staff collectively had the necessary skills and experience to deliver the appropriate care. The feedback from the relatives and staff said that the staff encouraged trial period of stay before agreeing to settle permanently at the home. DS0000031963.V332042.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,910&11 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The health and personal care that people receive at Owston View is based on their individual needs. The present care plans need review and revision. The principles of respect, dignity and privacy are put into practice by the staff so that the people living at the home are comfortable and confident that they are correctly supported and cared for. EVIDENCE: The three care plans checked had most of the required information. However, it was difficult to find the information due to the lay out. Some sections were not completed; therefore the information was not complete. The care programme approach would be beneficial to people living at this home especially those who were infirm and needed help with orientation of place, time and recognition of their past life and experiences. The care DS0000031963.V332042.R01.S.doc Version 5.2 Page 12 programme approach would achieve a greater consistency and continual improvement in the standards of practice provided through involvement of the social and health care related staff. This approach enables maximum use of user involvement and multidisciplinary input. The present care planning style needs to be reviewed. Four staff and five people living at the home said that they had been involved in the planning of their care. Two people said, “The staff ask me whether I want to have a bath and help me if I need. They are good at prompting us”. “I am quite able to ask for help. I decide what I want to do”. The manager and the care staff said that they sought professional advice with regards to continence and tissue viability from the community nurse specialists. All the people living at the home had access to their own general practitioner. There was evidence of people attending hospital appointments in their care plans. Designated staff were responsible for medication management at the home. These staff had received training and had been deemed competent by the manager. On the day of the site visit one person was self-administering medication. That person had suitable space and lockable facilities to store medicines. Three Medication Administration Sheets were checked and the medication storage and management processes were discussed with the deputy manager. The staff adhered to the home’s medication policy. During the staff interview it was evident that the staff monitored the condition of the people and if concerned they sought help from the general practitioner or the district nurse. During the site visit it was noted that the staff addressed the people respectfully. The people were dressed in clothing, which was appropriate, and they looked clean and comfortable. The pop socks worn by one of the people were too tight causing swelling of the lower limbs. This was pointed out to the manager and it was rectified immediately. The feedback from the relatives and people using the service confirmed that the care staff gave them privacy and dignity at all times. Although the staff said that they had looked after people dying and supported the families, none of the staff have had formal training in end of life care and bereavement counselling. During staff interviews it was ascertained that they were interested in having formal training in end of life. DS0000031963.V332042.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14&15 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People who use this service are able to make choices about their lifestyle, and are supported to develop their life skills. Social, cultural and recreational activities are not available on a regular basis hence the home does not meet the individuals’ expectations. This is due to the lack of availability of support staff. People at the home receive a wholesome diet. EVIDENCE: On the day of the site visit there were no visible activities offered to the people. It was a lovely sunny day and none of the people at the home were encouraged to go out into the garden or go out for a walk. People were seated around the communal areas. They were asked by the inspector what they did all-day, One person said, “I am happy to sit and do nothing.” DS0000031963.V332042.R01.S.doc Version 5.2 Page 14 Another said, “It would have been good to go out but there isn’t anyone around to take us out.” “The staff are too busy doing their jobs.” Another person said, “Well they can do a lot for us but that depends on their priority?” The surveys had the following comments. “Activities are very enjoyable.” “Not enough staff and not enough stimulation.” “There are no activities on a daily basis.” The staff said that more outings could be organised if they had more staff. The family and friends were seen visiting the people and they were able to have privacy if they so wished. The manager said that the people either manage their own finance or their families take responsibilities. The three people tracked had their finance managed by their sons and daughter. The breakfast and dinnertime was observed. The people were given a choice of meals and the kitchen staff served the meals attractively. The care staff helped people who needed assistance in a discreet manner. The care staff sensitively handled those people who had difficulty having meals with the other people. These people were offered alternative areas to have their meals. I had lunch with the people at the home. The lunch was attractively served and was tasty. The cooks and the kitchen assistants not only prepared the meals but also served the lunch and were involved at mealtimes. Some comments received from the surveys were; “Meals are at set times and a list is displayed on the notice board outside the dining room. Those unable to comprehend are helped by staff.” “Usually meals are good.” “ We try and include all the residents including those in the EMI units to have their meals in the main dining room.” DS0000031963.V332042.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17&18 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People who use the service are able to express their concerns and have access to a complaints procedure. Their rights are protected by the home’s policies. The care staff working at the home are not formally trained in the Protection Of Vulnerable Adults including whistle blowing. Lack of staff training and awareness of neglect, abuse, inhuman or degrading treatment and deliberate negligence could lead to the staff placing themselves and the people living at the home at risk of abuse and neglect. EVIDENCE: The home’s complaints policy was accessible and the staff said that they had read the policy. A record was kept of the complaints received by the home. There had been four complaints and there was documentation showing that action had been taken to rectify them. Discussions took place with regards to using the findings of the investigations as a way of making people aware of the home’s policies and also using them as areas for learning and development for staff. This would move away from staff feeling that the management adopt a ‘Blame Culture’ when complaints were raised. “ The managers issue policies and they ignores the polices themselves.” The staff feedback stated that they had not had training in Protection Of Vulnerable Adults and they were not sure of the whistle blowing policy and how DS0000031963.V332042.R01.S.doc Version 5.2 Page 16 it was applied. The staff training records were also checked, and there was no evidence that training had taken place after September 2004. There had been a mixed feedback to the way the management dealt with complaints and concerns. Some comments were; “ The friction between the care team and the management causes problems when dealing with complaints”. “The care staff are angels and they sort out any problems.” “ Complaints are there for the management to blame staff and not to help them learn from it and help staff. Arrange for experienced staff to do hands on care and show how it should be done.” Some of these comments were shared with the manager on the day of the site visit. The people living in the main house said that they have the freedom to vote and either they went to the local voting station or use the postal voting system. It was ascertained through feedback that the staff or their representatives helped those who lacked capacity to make such decisions. The care staff said that they would use an advocacy service if they found out that a person living in the EMI unit needed an independent support/advice. DS0000031963.V332042.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25&26 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The physical design and layout of the home enables people who use the service to live in a safe and comfortable environment, which encourages independence. However, the people would benefit by the home exploring the possibility of ensuite toilet facilities in each bedroom. Externally the home has extensive grounds, and there are facilities for residents and visitors to walk around and also to sit out, where a number of benches and garden furniture are available. EVIDENCE: The premise was checked during the tour of the home with the manager. The grounds were kept tidy, accessible and attractive. There were pleasant sitting areas, lounges and a dining room for the people to use. These areas were well DS0000031963.V332042.R01.S.doc Version 5.2 Page 18 used by the people and their visitors. The bedrooms did not have ensuite toilet facilities. The majority of people had commodes in their bedrooms and the inspector was told that the commodes were used at nighttimes for the convenience of the people who live at the home. There were toilets near the bedrooms and the shared areas. There was sluicing facilities for cleaning the commodes. The staff said that due to the increase in the dependency levels of the people entering the home they needed another stand aid. They also said that the commodes used by the people were old and some were unsafe and unsteady therefore the commodes need to be replaced. Every room had a call system which was accessible to people occupying the room. The rooms were single occupancy. The individual bedrooms were personalised according to the occupants’ liking. Several bedrooms had personal belongings and the care staff recorded these in the individuals’ care records. Rooms were individually ventilated and there was emergency lighting throughout the home. The premise was kept clean, hygienic and free from offensive odours. The staff were familiar with the policies on control and the spread of infection. DS0000031963.V332042.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29&30 People who use this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The care staff in the home have not received essential training at the appropriate intervals and therefore it is questionable whether they have the competencies in caring for those who use the service. The staffing numbers to support the people who use the service, which also includes the people who access the day care service, is not sufficient. Therefore it is not in line with the terms and conditions of those who are permanent residents at Owston View. EVIDENCE: This outcome area was judged using the feedback from the surveys, consultation with the people who use the service and the staff as well as checking the records kept by the home with regards to staff recruitment, training and supervision. Four staff recruitment files were checked. The following gaps were noted. • Three files did not have any evidence of induction training. • There was no evidence of face to face interviews and job offers to staff. • Two staff did not have two written references and the same staff did not have full employment histories. DS0000031963.V332042.R01.S.doc Version 5.2 Page 20 • • • • Three staff did not have evidence of satisfactory CRB checks, although the manager assured me that all staff including the volunteer has had satisfactory CRB checks. Two staff did not have signed copies of their Terms & Conditions of employment. Two staff did not have any identification on their files. There was no evidence of health declarations from the staff or evidence of occupational health check clearances. The registered manager was involved during the checks and was aware of the gaps in the information. The four staff training files checked confirmed that Not all the staff have had mandatory training in fire safety, health & safety, moving & handling, Infection control, Protection Of Vulnerable Adults and dementia awareness. An immediate requirement notice was issued to the registered manager to ensure that the above training is provided for all care staff within a set time scale. This is to safeguard the people who use the service and the staff. However, some care staff had received training on mental health, foot care, care planning, optical testing and nutritional needs in the elderly. The lack of care staff on duty was seen by the relatives and the care staff as causing difficulties when delivering support to the people and therefore affecting the smooth running of the service. The following comments were received with regards to staffing from the people who use the service and the visitors. “Not enough staff on the shop floor.” “Cleaners are often taken off their duties to cover care staff sickness. This is one of the reasons for the standards dropping.” “Deputy manager always encouraged us to go on courses and complete the NVQ training.” On the day of the site visit there were one registered manager, one care manager and 5 care staff on duty. One of the carers was on 1:1 duty observing one resident and this left 2 care staff for 21 people. Of these 21 people one person was to be transferred to a nursing home since the needs and the dependency level warranted this. Therefore the staffing levels did not compliment the needs of the people. On the whole the staffing levels need to be looked into so that the people receive the level of care they require and pay for. Additional staff should be employed to take care of Day care people. The management need to stop using domestic staff to make up the numbers of care staff. This has been commented in the surveys. DS0000031963.V332042.R01.S.doc Version 5.2 Page 21 The staff were divided as below on 22/05/07. Owston View Older persons unit Occupancy 22 The Crofts EMI unit Occupancy 12 Staff on duty 3 Care staff 1 Care manager (Shared between the units) 2 Care staff 20 Permanent (One receiving 1:1 care) 1 Respite 1 Day care service user. 10 Permanent 1 Respite 1 Day care service user DS0000031963.V332042.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36&38 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The management and administration of the home is based on openness and ensuring the home is run in the best interests of the people who occupy it. There are some issues with regards to the management approach and showing respect to those who work at the home. The home did not have a comprehensive quality assurance system to monitor the service provided. Therefore the management are not fully aware of the views of the people who access the service and the staff who work at the home. EVIDENCE: The registered manager is a knowledgeable person with several years of experience in the care sector. Senior care staff supports her so that an appropriate standard of care could be delivered. DS0000031963.V332042.R01.S.doc Version 5.2 Page 23 The management have had meetings with the staff and with the people who use the service. The management said that the same people attended these meetings. The feedback to the surveys from the people who live at the home, their relatives and the staff highlighted the value of seeking opinions individually in a non-threatening anonymous way. The following were some of the responses received. “I like living here, I feel safe and supported by staff I am very satisfied.” “My mother is settled and I am happy to see her so well.” “ No activities. Cleanliness is average.” “No Supervision, just paper exercise.” “ Relationship between the staff and the managers are strained at times because staff workload and differences of opinions. The management need to revise the ration of 2 staff to 22 residents.” “ I am very happy here. My family live near by and they visit me and I cannot complain. “My mother usually looks well every time I see her and her general health has improved considering her age.” “ May be better toilet facilities; instead of old commodes why not make it more comfortable and clean by putting ensuite.” The annual development plan was agreed with the council and on the day of the site visit repairs and replacement to the structure were being carried out. The manager said that when staff handle peoples’ monies written records of all transactions were maintained. However, most people handle their own monies or their representatives managed the monies for them. The staff said that the frequency and the quality of supervision was dependent upon the supervisor. The staff in the main were happy and comfortable with the way they received supervision. All four staff files checked had copies of their supervision records. The manager and the staff knew that they had to keep records and report all accidents, incidents of illnesses, any deaths, any allegations of abuse and misconduct to the Commission for Social Care Inspection. The registered manager said that she took action to safeguard the health and welfare of the people who live and work at the home. However, the lack of staff training in health & safety, moving & handling, Infection control and first aid indicated that the staff were not formally prepared to safeguard them selves and also those whom they take care of. This has been highlighted under staff training. The induction foundation training of staff also needs to be updated to meet the Skills for Care standards. DS0000031963.V332042.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 1 3 3 3 2 3 2 3 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 3 X 2 X 3 3 X 2 DS0000031963.V332042.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4,5,6 Requirement The registered manager must make available to people who use the service and the prospective users an up-to-date statement of purpose setting out the aims and objectives of the home and also provide a service user guide so that people are able to find out about the suitability of the service. The registered person must ensure that all the people who are using the service have an appropriate and up to date care plan to suit their needs. Previous timescale.30/06/06 Timescale for action 27/07/07 2 OP7 15 07/09/07 3 OP11 18 07/09/07 The care staff must receive formal training in end of life care so that they are able to make sure that the people receive appropriate care and the families get the attention and support they require. At least 50 of care staff to receive the training by the stated time scale and the rest by 11/12/07. DS0000031963.V332042.R01.S.doc Version 5.2 Page 26 4 OP12 16 5 OP18 18 6 OP22 7 OP27 16 18 8 OP29 19, Schedule2 9 OP30 18 All the people who live in the home must be consulted; including those reside in the EMI unit (or their representatives) with regard to the activities programmes. The activities organised by the management must have regard to the needs of those who live at the home and must be in relation to recreation, fitness and healthy living. A programme of activities must be in place by the stated time scale. The activities must be changed according to the seasons. All staff working at the home must attend formal training on Protection Of Vulnerable Adults and they must be familiar with the whistle blowing policy. The manager must ensure that the staff are competent in dealing with allegations of abuse and familiar with the homes policies. The manager must ensure that an additional stand aid hoist is purchased to meet the needs of the people who live at the home. The staffing numbers must reflect the assessed needs of those who receive the service. This must include the day care users. The manager must operate a thorough recruitment procedure to safeguard the people who use the service. The manager must have all the information stated in regulation 19 and the schedule 2 of the Care Home Regulation 2002 on each staff employed by the home. The manager must ensure that all staff working at the home are DS0000031963.V332042.R01.S.doc 27/07/07 27/07/07 27/07/07 26/06/07 26/06/07 27/07/07 Page 27 Version 5.2 10 OP33 24 11 OP38 12,13,16 trained and competent to do the jobs they are employed to do safely and appropriately. The induction programme must be reviewed to reflect the present Skills for Care standards. The management must introduce 27/07/07 an effective quality monitoring system based on seeking the views of the people who use the service. The quality monitoring must measure whether the home is meeting its aims and objectives. The registered manager must 19/10/07 ensure that safe working practices are operational by making sure that all the staff working at the home have attended mandatory training such as moving & handling, health & safety, fire safety, food hygiene, Infection control and First aid. Immediate requirement notice issued on 22/05/07. Training to be completed by the stated time scale. DS0000031963.V332042.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 OP24 2 OP28 Refer to Standard Good Practice Recommendations The individual accommodation i.e. bedrooms should have safe commodes or the management should explore the possibilities of en-suite toilet facilities. The registered manager should ensure that a minimum ratio of 50 of staff should be trained to NVQ Level 2 or equivalent. Previous time scale 30/10/06 DS0000031963.V332042.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000031963.V332042.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. 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