Inspection on 21/11/07 for Petteril House

This inspection was carried out on 21st November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Petteril House 18/02/09

Petteril House 03/09/08

Petteril House 23/05/06

Petteril House 12/10/05

Petteril House 20/05/05

Petteril House 01/11/04

Petteril House 23/06/04

Petteril House 18/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Petteril House Lightfoot Drive Harraby Carlisle Cumbria CA1 3BN Lead Inspector Marian Whittam Unannounced Inspection 21st November 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Petteril House DS0000036543.V346150.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. Petteril House DS0000036543.V346150.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Petteril House Address Lightfoot Drive Harraby Carlisle Cumbria CA1 3BN 01228 606393 01228 606402 petteril.house@cumbriacc.gov.uk www.cumbriacare.org.uk Cumbria Care 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 Helen Harrison Care Home 38 Category(ies) of Dementia - over 65 years of age (17), Old age, registration, with number not falling within any other category (37) of places Petteril House DS0000036543.V346150.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home is registered for a maximum of 38 service users to include: up to 38 service users in the category of OP (older people not falling within any other category) up to 17 service users in the category of DE(E) (Dementia over 65 years of age) Two service users may share a bedroom of at least 16 sqm usable floor space only if they have made a positive choice to do so, when one of the shared spaces becomes vacant the remaining service user has the opportunity to choose not to share, by moving to a different room if necessary. 23rd May 2006 3. Date of last inspection Brief Description of the Service: Petteril House is a residential care home registered with the Commission for Social Care Inspection to provide care and accommodation for up to thirtyeight people over 65. The home is owned by Cumbria County Council and run and managed by Cumbria Care. The home is located on the outskirts of Carlisle and is close to local shops and public transport routes. The property is a two storey building and is equipped with a passenger lift to assist residents to access accommodation on the first floor. Accommodation is provided in four living units, each with its own sitting and dining area and small kitchen. One living unit specialises in providing care to people with dementia. There are toilets and bathing facilities close to all accommodation provided for residents. The home is set in its own grounds and has car parking available at the front of the property. Fees charged to residents include care, accommodation, meals and laundry. Fees are charged weekly and currently range from £326.00 - £434.00 per week, depending on the level of care a resident requires. Residents pay separately for their own toiletries, newspapers and hairdressing. Information about the services provided and fees charged is included in the home’s statement of purpose and service users’ guide. Petteril House DS0000036543.V346150.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit that forms part of a key inspection took place over one day and we (The Commission For Social Care Inspection, CSCI) were in the home for a total of 6 hours. Information about the service was gathered in different ways: • An Annual Quality Assurance Assessment document completed by the manager identifying what the service does well and what could be improved. • Interviews with residents, visitors and staff on the day of the visit. • Completed questionnaire survey forms from residents, relatives and medical professionals coming into contact with the home. • Letters sent to CSCI about the service • The service history. We looked at care planning documentation and assessments to ensure the level of care provided met the needs of those living in the home and made a tour of the building to inspect the environmental standards. Staff personnel and training files were examined and medication records and handling. A selection of records required by regulation was examined. . What the service does well: The home provides a homely atmosphere and people living there are able to bring in their own things from home such as pictures, ornaments and suitable items of furniture to make their rooms more homely and personal. All the bedrooms in the home are for single occupancy. We observed staff to have a good rapport with residents and their approaches to residents were friendly and informal. Throughout the day we saw that staff and residents got on well together and that residents individuality and choices were generally respected. The staff do work hard to support people in following their own interests inside and outside the home and even in their own time. There are robust recruitment procedures for staff and the thoroughness of pre employment checks helps to safeguard the welfare of people living in the home. Staff are well supported by the registered manager to undertake training and gain qualifications for the work they do and to support people living there. Petteril House DS0000036543.V346150.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: It is recommended that the manager reviews the service’s admission processes to see if they can find ways to personalise admissions for people and make them less process led. All people using the service must have a care plan that reflects their existing and changing healthcare and personal needs. This will ensure that their needs are monitored and they receive care, treatment and advice promptly to meet their needs. It is recommended that individual’s mental health be more consistently monitored and thorough nutritional and pressure area screening done to consistently monitor healthcare for all residents. For good practice a more individualised approach to a person’s care would be to include the person’s own perspective, where possible, on how they want to be supported, cared for and their independence promoted. We found that medicines handling needed improving to safeguard residents. We found not all medicines received into the home have the quantity checked for accuracy and recorded on the Medicine Administration Record (MAR) or elsewhere. Therefore there was not always a complete audit trail of medication to follow to account for the medicines in the home. Medications should always be signed for when they are given and on one unit this had not happened. The MAR charts are working documents and should always be signed at the time a medicine is administered. To promote safe practice and reduce the risk of errors the staff should check and sign any hand written charts or alterations to charts done by hand. The manager should consider using protocols to inform staff on the use of ‘as required ‘drugs. This would help staff make sure that they are given only when residents need them and allow easier monitoring. The manager should consider logging all concerns raised by relatives and residents and feedback all actions and outcomes to the persons concerned. This will encourage people to have confidence that their concerns will be treated seriously and they’re acted upon. Similarly the manager should consider the ways they feedback any actions they take as a result of views expressed through surveys and meetings so people can see what effect their views have had on the service. There are manual sluice facilities on the EMI unit and within the laundry area where commode pots are cleaned. It is not good infection control practice to Petteril House DS0000036543.V346150.R01.S.doc Version 5.2 Page 7 have manual sluicing facilities sited in a laundry or where laundry is kept and is contrary to published professional guidance. To promote good infection control for residents the manager should remove any clean laundry from the sluice room on the EMI unit. They should also carry out a risk assessment on the use of the sluicing facilities and the cleaning of commode pots close to the laundry area and find ways to minimise any cross infection risks. The manager must look at staffing provision on day duty and their deployment on the elderly frail units in terms of delivering outcomes for people rather than rigid staff requirements and deploy staff in such numbers as appropriate to meet residents’ assessed individual needs safely. 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. Petteril House DS0000036543.V346150.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 Petteril House DS0000036543.V346150.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): NMS 1 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is an assessment procedure for people coming to live in the home and information is available for people. EVIDENCE: Information about this home and the services it provides is available in the Statement of Purpose/service user guide that is on display in the foyer of the home. This is in a standard written format. A copy of the latest inspection report is also available. We asked people if they had a copy of the information and they did not. A relative spoken with felt that when their relative was admitted there were very few other places available to them. An individual care needs assessment is carried out under care management arrangements by someone qualified to do this for each prospective resident. This is done by social services before people are placed in the home and the manager obtains a copy of the assessment. We discussed with the manager Petteril House DS0000036543.V346150.R01.S.doc Version 5.2 Page 10 the admission assessments and process and how the service supports the individual during admission. The manager does not does not always go out to meet and assess prospective residents individual needs before they come to the home. The manager may rely on the care management plan in deciding to accept a placement and use this as a basis from which to decide if the service can meet an individual needs and then develop the initial care plan. It is recommended that the manager reviews the service’s admission processes to see if they can find ways to personalise admissions for people and make them less process led. It is good practice to place residents at the centre of the admission process and recognise the need for support and reassurance at a difficult time. Residents are provided with terms and conditions of residency so they are aware of their rights and responsibilities. The home does not provide intermediate care. Petteril House DS0000036543.V346150.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): NMS 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of residents are generally being assessed within individual care plans but inconsistent medication records and assessment can affect people’s health care. EVIDENCE: Each resident has a plan of care that has been drawn up from the initial assessment of needs and capabilities provided to the home. During the visit we looked at a sample of four and found that they set out assessed health and personal care needs and these were generally being regularly reviewed. We examined, one plan that had only basic nutritional information, no detailed evidence of psychological/emotional monitoring and no evidence of pressure area assessments. It is recommended that individual’s mental health be consistently monitored and thorough nutritional and pressure area screening done to consistently monitor healthcare for all residents. Petteril House DS0000036543.V346150.R01.S.doc Version 5.2 Page 12 We found some gaps in the information recorded but during discussions with the staff on duty it was evident that they knew the residents well and were able to identify and meet their needs in a personal and caring manner. However, we found that one person was not having their health care needs attended to promptly in regard to pain relief. Daily records show they had been complaining of pain and discomfort in the same place for several weeks. Care staff had noted this in the daily report and that the person had asked to see the doctor, they also noted “bad moods” with the person at the same time. Medication records show the person was prescribed painkillers as needed and was taking the maximum dose allowed each day for pain. Despite a monthly review having been done to identify changing health and personal care needs this problem was not identified or acted upon as problem for that person. Their experience of pain needs to be monitored and action taken quickly to relieve it. As a result this person continued to experience pain, had “bad moods” and did not see a doctor, as they asked, to review their condition and pain relief. For good practice a more individualised approach to a person’s care would be to include the person’s own perspective, where possible, on how they want to be supported, cared for and their independence promoted. This was discussed with the manager who appreciates the need for more person centred planning. Cumbria Care is currently making changes to their care plan format that should address this when implemented. We looked at the medication handling and records and found that not all medicines received into the home have the quantity checked and recorded on the Medicine Administration Record (MAR) or elsewhere. Therefore there was not always a complete audit trail of medication to follow. Staff told us they do check the quantities coming in but do not record the quantity in the monitored dose system on the MAR just check visually. Medicines received, from whatever source, must have the quantity recorded so all a person’s medicines can be accounted for and any errors dealt with quickly. Several people have medicines prescribed to be take ‘as required’ especially for pain and it would be good practice if the service had protocols in place for their use. This would help staff make sure that such medicines are given only when residents need them and allow easier monitoring for medical review when maximum doses are reached. We found that medicines for all the residents on the elderly frail unit had not been not been signed as given at morning administration on the day of the visit by the person giving them out. Although the medication was not in the MDS and had apparently been given out. The MAR charts are working documents and should always be signed at the time a medicine is administered. To promote safe practice and reduce the risk of errors the staff should check and sign any hand written charts or alterations to MAR charts. We also checked the procedure for recording any controlled drugs that may be prescribed and found these to be correctly and safely maintained. Petteril House DS0000036543.V346150.R01.S.doc Version 5.2 Page 13 Petteril House DS0000036543.V346150.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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are being supported to make choices about daily life and activities and are able to maintain contact with family and friends. EVIDENCE: The home encourages relatives and friends to visit and residents say there are no restrictions on when people can visit them. We spoke to some visitors who said they liked the “informal and homely atmosphere in the home” and the way they can go and make themselves and their relative a drink when visiting. Care plans have information about people’s preferred social and religious activities and some useful personal profiles and preferences. This is useful information that could be used more in promoting a person’s own perspective on recreation particularly for those who have difficulty communicating their thoughts and feelings at present. The manager is aware of the need to provide recreational opportunities tailored to an individuals preference and capabilities as well as group activities. The manager and staff are trying to develop their Petteril House DS0000036543.V346150.R01.S.doc Version 5.2 Page 15 activities programme within the resources they have to be more person centred. There was no formal programme of activities on display or a designated activities organiser. Staff do however support people living there to take part in activities in groups and individually and to make choices in their daily lives. The service has an amenities fund that is used for social events for people living there. One person told us about how this fund paid for them and others living there to go out for lunch, which they had enjoyed. Staff members arrange activities in the different units such as dominoes, cards and bingo and a ‘PAT’ dog comes in to visit which some residents enjoy. Some people choose to go out into the community using public transport and one person told us they took the bus to Carlisle regularly. Staff do support people to pursue their own interests where they can, for example a member of staff who was annual leave had come in to take a resident out shopping which the person enjoyed. Provision is made for people to follow their individual religious preferences. We looked at the menus in use and the meals seemed varied. There were new menus prepared after a recent resident’ meeting and these will be started soon. There are some diabetics but no vegetarians to prepare food for at present. The kitchen was very clean, the fridges and freezers were well stocked, as was the dry goods store. All food is delivered weekly. We spent lunchtime with residents on one unit and it was a relaxed occasion with staff giving appropriate support and assistance and providing aids to suit people’s capabilities. There were some residents not feeling well and just wanted chicken soup, which the staff prepared for them. Petteril House DS0000036543.V346150.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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is an accessible complaints procedure although not all people living in the home have confidence in the system. There are adult protection procedures in place to help protect resident’s welfare. EVIDENCE: Since the last inspection the home has referred two adult protection incidents to social services. These have been investigated and addressed by the home manager with relevant social services agencies. Adult protection procedures are in place and local multi agency guidance available to staff and information on whistle blowing. There are procedures regarding the Protection of Vulnerable Adults (POVA) in place. The home’s supervisors have all had training on adult protection and preventing abuse and feed this back to staff. Some staff have attended POVA training and the manager is addressing the need to get training in this for all staff. The home has a complaints procedure and a system for logging complaints for investigation. The complaints procedure is displayed and appears in the Statement of Purpose. The manager has not recorded any complaints since the last inspection. However we (CSCI) have received letters and comments prior to the inspection from people coming into contact with the services who wanted to make their experiences and concerns known. Views were expressed to us that indicated Petteril House DS0000036543.V346150.R01.S.doc Version 5.2 Page 17 that some people lacked confidence in senior staff to investigate sensitively and take action about concerns when they are raised. We discussed this view with the manager and what they recorded as ‘a complaint’. It was recommended as part of monitoring quality that all concerns, however small, raised by residents or relatives should be logged and all actions and outcomes fed back to the persons concerned. People must have confidence that their concerns will be treated seriously and acted upon and always be kept informed what has been done as a result of their concerns. Survey responses and comments from people in the home indicate that they are aware of how to make a complaint Surveys from local GPs indicate the home has always responded to any concerns they have raised. The home did not deal with any resident’s personal finances only small amounts of spending money for safekeeping and practices and procedures are in place to protect resident’s financial interests. Petteril House DS0000036543.V346150.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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 19, 20, 21, 22, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises are kept to a satisfactory standard of cleanliness but the use of manual sluicing facilities close to clean laundry areas poses a potential cross infection risk to people in the home. EVIDENCE: There is an annual programme of maintenance and improvement agreed for the home. Five bedrooms are due for redecoration as part of this programme. We made a tour of the premises and the areas used by people living there. The home is looking run down in places with worn carpets, torn wallpaper, chipped paint on the skirting boards and doorframes, small areas of cracked plaster and hole in the ceiling area of a ground floor bathroom behind which were pipes. On the EMI suite the top of a radiator grill fell of when we touched it. These areas of general maintenance should be attended to promptly as they Petteril House DS0000036543.V346150.R01.S.doc Version 5.2 Page 19 detract from the homely atmosphere and appearance of the home. One relative commented that the home needed to be “brought up to date”. We spoke with staff who had been trying to attend to minor decoration issues themselves to keep the home looking more homely. The home was generally clean and tidy and has its own small laundry area on site with suitable washing machines and driers. There are manual sluice facilities on the EMI unit and within the laundry area where commode pots are cleaned. It is not good infection control practice to have manual sluicing facilities sited in a laundry or where laundry is kept and is contrary to published professional guidance. On the EMI unit people’s clean clothes returned from the laundry were being kept in the sluice room. We discussed this with the manager as a matter of concern as the risk of cross infection from this practice could have adverse effects upon resident’s health. To promote good infection control the manager should remove any clean laundry from the sluice room on the EMI unit. They should also carry out a risk assessment on the use of the sluicing facilities and the cleaning of commode pots close to the laundry area and find ways to minimise any cross infection risks. This should be part of their overall infection control procedures for the home The home has a range of adaptations and equipment, including bathing aids to assist individuals to maintain their independence and to meet their assessed needs. There are sufficient communal areas on the units for people living there and these are comfortable and warm. We spoke to some people in their rooms and they had been able to personalise them and bring in some of their own possessions to do this. Petteril House DS0000036543.V346150.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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are good staff recruitment processes in place and the manager is aware of the need for staff training and development but the present staffing structure during the day is not consistently based around delivering outcomes for people that can affect their quality of life. EVIDENCE: We looked at the staff files and recruitment process for 3 new members of staff. These contained all the necessary checks including Criminal Records Bureau (CRB) checks and references. Staff training is on going and NVQ training well established and supported and staff have a five day induction period to do their work. The induction includes instruction on infection control, health and safety and fire awareness and adult protection. There are three moving and handling key workers on staff to train and support staff in this. Staff have their own professional development files recording individual training and development. We spoke to care staff on duty who were knowledgeable about the needs of the residents living in the home and did strive to provide good care for people. Staff we spoke to told us they enjoyed their work and had good access to training and support. Petteril House DS0000036543.V346150.R01.S.doc Version 5.2 Page 21 We looked at staff rotas, care plans and spoke with staff working on the units and discussed staff levels with the manager. There are 3 members of staff on night duty recognising the need for additional supervision and support to meet individual needs at night, especially on the EMI unit. On day duty there are always two staff on the EMI unit and one support worker on the other elderly frail units. We found there is more often than not only 1 member of staff working and supporting residents on the Lakeland unit. Care plans indicated and staff told us this can be is a “heavy” unit in terms of resident’s high physical dependency with at least 2 residents who currently need two staff members to hoist them safely. Staff told us and we saw that they often have to rely on staff leaving other units to come to help with care activities assessed as needing two people to carry out, leaving that other unit unattended. It is also difficult for one person to supervise and support people as this unit is split between the ground and first floor with 2 of the bedrooms being on the ground floor. Survey responses indicated that there are not always enough staff around to attend to people promptly “especially at weekends” and that they “sometimes had to wait a long time before the buzzer was answered” leading to “accidents” that can cause people distress. Although relatives and residents did also feel the staff worked hard and people were well cared for and were “ always clean and well fed”. We observed that staff were attending to people’s needs and supporting them in a conscientious manner as their resources allowed. Such staffing provision does lack flexibility to meet changing needs and does not reflect the assessed needs of some of the people using the service in an individualised or person centred way. The manager must look at staffing provision and deployment in terms of delivering outcomes for people rather than rigid staff requirements. Petteril House DS0000036543.V346150.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): NMS 31, 32, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager supports staff and runs the home to promote the best interests of people living there with the resources available to them. EVIDENCE: The home’s manager is experienced and has achieved the Registered Manager’s Award. She has an open and approachable management style and comments from the staff evidenced that she is very supportive to the staff team in the workplace and in training. The manager is clear about her role and the ways in which the service can continue to develop and improve for people living there given the budgets she works within. There are clear lines of Petteril House DS0000036543.V346150.R01.S.doc Version 5.2 Page 23 accountability between the manager and staff, with the manager working closely with the supervisory team to provide support and guidance for them. The home completes an annual “customer satisfaction survey” with residents, relatives and advocates to get feedback on the service. The manager completes a report for her senior management, which is part of a quality monitoring system that relates to the organisations business plan and enables the manager to measure the home’s progress against Cumbria Care’s key targets. Opinions are sought from people using and coming into contact with the services. The manager should consider the ways they feedback any actions they take as a result of views expressed from any surveys and meetings so people can see what effect their views have had on the service. Policies and procedures are reviewed corporately and updated in the home when needed. The home is responsible for small amounts of residents’ monies used to pay for personal items. Records are kept with all receipts held on file and expenditure signed out by two members of staff as a safeguard for the residents. There were examples of general risk assessments and specific risk assessments to promote resident’s safety. An internal health and safety audit is also completed on an annual basis by the organisation. We examined records of fire and other mandatory training, fire drills, equipment, electrical testing and gas service testing and the servicing of equipment and appliances under service agreements and these were in good order. Petteril House DS0000036543.V346150.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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 17 3 18 3 2 3 3 3 X 3 X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 X X 3 Petteril House DS0000036543.V346150.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 13 (1) Requirement All people using the service must have a care plan that reflects their changing healthcare and personal needs. This will ensure that their needs are monitored and they receive care, treatment and advice promptly to meet changing needs. A complete record must be kept of all medicines received into the home for people so there is a complete audit trail and all medicines received can be accounted for. The manager must look at staffing provision and deployment on the elderly frail units in terms of delivering outcomes for people rather than rigid staff requirements and deploy staff in such numbers as appropriate to meet residents’ assessed individual needs safely. Timescale for action 31/12/07 2. OP9 13 (2) 31/12/07 3. OP27 18 (1) 31/12/07 Petteril House DS0000036543.V346150.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations It is recommended that the manager reviews the service’s admission processes to see if they can find ways to personalise the admission process and support people through it. It is recommended that individual’s mental health be consistently monitored and thorough nutritional and pressure area screening done consistently to monitor health care for all residents. To promote safe practice and reduce the risk of errors the staff should check and sign any hand written charts or alterations to charts done by hand. Medication should always be signed as given at the time it is administered to people to reduce the risk of administration errors. The manager should consider using protocols to inform staff on the use of ‘as required ‘drugs. This would help staff make sure that they are given only when residents need them and allow easier monitoring when maximum doses are reached. The manager should consider logging all concerns raised by relatives and residents and feedback all actions and outcomes to the persons concerned. This will encourage people to have confidence that their concerns will be treated seriously and their concerns acted upon. To promote good infection control and reduce risks from cross infection the manager should remove any clean laundry from the sluice room on the EMI unit The manager should carry out a risk assessment on the use of the sluicing facilities adjacent to the laundry and when cleaning commode pots close to the laundry and find ways to minimise any cross infection risks. The manager should consider the ways they feedback any actions they take as a result of views expressed through surveys and meetings so people can see what effect their views have had on the service. 2. OP8 3. 4. 5. OP9 OP9 OP9 6. OP16 7. 8. OP26 OP26 9. OP33 Petteril House DS0000036543.V346150.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 Petteril House DS0000036543.V346150.R01.S.doc Version 5.2 Page 28 - 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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