Inspection on 21/11/05 for Pinebeach

This inspection was carried out on 21st November 2005.

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

Pinebeach 30/07/07

Pinebeach 07/11/06

Pinebeach 08/05/06

Pinebeach 14/04/05

Pinebeach 02/12/04

Pinebeach 02/07/04

Pinebeach 03/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Pinebeach 53 Southcliffe Road Friars Cliff Christchurch Dorset BH23 4EW Lead Inspector Jo Palmer Unannounced Inspection 21 November 2005 10:30 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 DS0000020485.V252012.R01.S.doc Version 5.0 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. DS0000020485.V252012.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pinebeach Address 53 Southcliffe Road Friars Cliff Christchurch Dorset BH23 4EW 01425 273122 01425 277876 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) Lifecaring Holdings Limited Mrs Mary Ann Price Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places DS0000020485.V252012.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th April 2005 Brief Description of the Service: Pinebeach is located opposite the sea and beach at Friars Cliff near Mudeford. The lounge and some of the rooms have sea views. Resident accommodation is on ground and first floor levels. The building has a lower ground floor where the laundry, kitchen, boiler room, responsible individual’s office and staff facilities are located. Resident bedrooms, bathrooms and toilets are located on the ground and first floor levels and communal lounge and dining room areas are on the ground floor. There is level access throughout the home and access by stairs and passenger lift to all floors. Gardens around the home provide seating and overlook the sea, there is off road parking for staff and visitors. DS0000020485.V252012.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection on 21st November 2005 lasted for four hours and forty-five minutes. Mary Price the registered manager was taking a day off and a trained nurse was in charge of the home, although Ms Price arrived during the morning to take part in the inspection process. Mr Dedman, responsible individual for Lifecaring Holdings Ltd was available and also assisted with part of the inspection. The purpose of this inspection visit was to monitor progress in addressing requirements and recommendations of previous inspections and to review practices in relation to some of the National Minimum Standards. This inspection concentrated on the outcomes of care and services for residents, measuring against some of the standards. The inspector spoke with ten residents, one care assistant, a trained nurse, Mary Price and Mr Dedman, took a tour of the home and examined relevant records. What the service does well: What has improved since the last inspection? Some refurbishment and redecoration has taken place. DS0000020485.V252012.R01.S.doc Version 5.0 Page 6 What they could do better: This inspection has resulted in many areas of concern which the registered persons are required to address with urgency. Resident’s needs are not fully assessed prior to them moving to the home and ongoing assessments, care planning systems and reviews are poor resulting in residents having little assurances that their needs can be met at Pinebeach. Although care plans are written from some assessment information, there is little evidence that these are implemented effectively or that staff are equipped with the skills to deliver care appropriately and review changing needs. Although care plans have been signed by residents in order to indicate their agreement with care outcomes, there is little evidence to support that their choices and preferences with care routines are upheld and maintained. Social care choices are limited. Policies are in place referring to procedures to be followed should any form of abuse or neglect be suspected and some staff have received training. However, as care assessments, care planning, staff recruitment, training and supervision are not based on good practice methods, current systems of care delivery at the home can result in staff and management overlooking and have limited knowledge of incidents of poor practice. Whilst residents have risk assessments carried out in the home relating to risks posed by hot surfaces, these are not based on current guidelines issued by the Health and Safety Executive to ensure comprehensive assessment and control measures are in place. An emergency alarm call system is in place although where residents are unable to operate this system to summon assistance, there are no care strategies in place to offer continued support and monitoring for residents in their rooms. Staffing numbers are acceptable although the ratio of trained staff to untrained staff requires review if Mary Price, registered manager is to provide adequate management and administrative time to the home. Staff training records were not inspected, requirements from previous reports have been repeated with regard to induction and foundation training and that numbers of staff trained to NVQ level 2 meets the standards. It has also been required that a record of evidence is maintained demonstrating that staff have the skills to provide the services the home offers Staff recruitment practices are poor, staff are employed to work at the home before suitable vetting procedures have been undertaken to ensure their suitability and ‘fitness’ to work with older people. DS0000020485.V252012.R01.S.doc Version 5.0 Page 7 Management arrangements in the home require considerable review to ensure that all requirements of this inspection are addressed. In order to effectively manage the home, the registered persons must develop systems to ensure continuous review of care practices and audits of the home’s performance against the National Minimum Standards and in order to achieve this, staff must be recruited safely, trained and supervised. A system of self-review and consultation must be established which includes seeking the views of residents, staff, relatives and other interested persons to ascertain where improvements can be made. All records must be available for inspection and for the effective running of the home. 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. DS0000020485.V252012.R01.S.doc Version 5.0 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 DS0000020485.V252012.R01.S.doc Version 5.0 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): 3, 4 & 5 Standard 6 is not applicable. The admissions process does not always allow for the home to establish the extent of a persons needs prior to admission although prospective residents are invited to the home where possible before agreeing to move in to enable staff to establish whether the home would be a suitable place for them to move to. Staff are not equipped with the skills necessary to meet assessed need. EVIDENCE: The last inspection made the requirement that accommodation must not be provided to persons at the care home until their needs have been assessed. The care records of one recently admitted resident, did not evidence any form of pre-admission assessment. However, Mary Price, registered manager stated that this person was a frequent visitor to the home prior to moving in and had minimal care needs although some personal care was being provided. However, it remains a requirement that an assessment is undertaken and recorded to ensure the home has details of a persons immediate needs. It was evident that this person was invited to the home frequently prior to making the decision to move and in speaking with this resident, it was confirmed that they felt, given the pre-admission visits that Pinebeach would be a suitable place to live. DS0000020485.V252012.R01.S.doc Version 5.0 Page 10 Assessments and care plans are not available in a style that provides residents assurance that the home is suitable to meet their needs (see standards 7, 8 and 28). DS0000020485.V252012.R01.S.doc Version 5.0 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 & 10 Care plans provide staff with basic care instructions regarding most, but not all, health and welfare needs although this is not sufficiently referenced to other material available to fully inform staff how to meet residents needs. Residents spoken with confirmed that they are treated with respect and kindness. EVIDENCE: Care records examined evidenced that the home gives consideration to the health and welfare needs of residents although information is insufficient to inform the caregiver. Pinebeach uses set proforma for assessing resident’s needs, these include assessments for moving and handling, skin assessment, and nutrition. Care plans are written based on assessment findings and other information available regarding the resident’s personal care needs and social care. There was no evidence that assessments followed clinical guidance issued by the Department of Health with regard to pressure area care, continence or mobility. Care plans for pressure relief referred the use of specialist mattress but not to action necessary by staff in day-to-day management of pressure areas, personal care needs care plans referred to washing and personal hygiene of persons with DS0000020485.V252012.R01.S.doc Version 5.0 Page 12 continence care needs although did not refer to pressure relief. Similarly, assessments for moving and handling referred to equipment necessary although care plans where moving and handling were necessary such as getting in and out of the bath, personal care routines and continence care did not refer to the moving and handling need identified in assessment. Nutritional assessment did not include the person’s weight and were not linked to other aspects of health such as pressure area care. There was no care plan for one service user for pressure area care and wound management. This same service user was receiving treatment for a specific condition, there was no plan of care detailing when and how this treatment was to be delivered. Some care plans showed evidence of resident consultation, although where this was done, there was little evidence of the resident’s agreement with care outcomes or reviews. For example, one assessment identified the resident’s preferred personal care and bathing routine; the care plan, written from this assessment gave instruction to the caregiver to provide a different routine, records of care provided to this resident, written daily by staff indicated that neither the resident’s preferred routine or the scheduled care routine identified in the care plan had been delivered. Of ten residents spoken with, five were able to offer comment on the home and confirmed that staff work hard and treat them with respect and kindness. Five residents seen were unable to engage in meaningful dialogue due to various levels of confusion. DS0000020485.V252012.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 14 There is little or no evidence in service users’ records that the individual needs and preferences of specific social, cultural or religious groups are understood and catered for. The manner in which the home supports and enables residents to exercise choice in other areas of their daily lives was not evident. EVIDENCE: Resident care records examined detailed limited social care assessments and care plans gave no clear instructions for staff regarding specific intervention required to meet resident’s social, leisure and recreational needs. Of the ten service users spoken with, five were able to speak coherently about their lives in the home; they confirmed that they had sufficient stimulation by means of books, newspapers, television and receiving visitors. Residents were not aware of any organised activities that took place in the home. Of the five other residents seen, two were in the lounge, one was seated in their rooms with their televisions on; two were lying in bed, one being very agitated. Residents spoken with confirmed that they were able to receive visitors, one visitor spoken with confirmed that she was able to visit freely and that there were no restrictions. Daily records examined noted when residents received visitors. DS0000020485.V252012.R01.S.doc Version 5.0 Page 14 There was no recorded evidence that residents are able to maintain choice and control over their lives. Some care documentation held the residents signature and detailed their choices with regard to some care activities but daily records did not evidence how these choices and decisions were upheld by the home. As mentioned in the previous section of this report, one example where the resident had, at assessment, specified a preference for a particular care routine, the care plan did not inform staff of this and records did not evidence that this resident had those preferences met. DS0000020485.V252012.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 A written complaints procedure details how concerns will be addressed, and assures residents that their complaints will be listened to or taken seriously. Whilst policies are in place relating to protection of vulnerable adults and managing suspected abuse, practices do not protect residents from neglect. EVIDENCE: The last inspection reported that information was available to residents in the form of the Service User Guide and Statement of Purpose. This information contains the home’s complaints procedure, this was not examined during this inspection although residents spoken with that were able to comment, confirmed that if they had any concerns, they would know who to speak to. Policies are in place in accordance with Department of Health guidelines giving procedural guidance for staff to follow should any incidents of abuse or neglect be reported. Training records were not examined although a matrix seen indicated that of the five trained staff employed, three received training in elder abuse and of sixteen care assistants, nine have received training. As records were not available, there was no evidence indicating whether a competent person had provided this training, which was given in 2004. Two incidents have been reported resulting in adult protection investigations, one was unsubstantiated and one is on-going following allegations that a resident suffered a degree of neglect in the home due to poor care practice; this will result in ongoing monitoring of the care practices employed at the home, monitoring of staff training and knowledge of best practice. Requirements regarding poor care and management are under other sections of this report. DS0000020485.V252012.R01.S.doc Version 5.0 Page 16 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): 20, 21, 23, 24, 25 & 26 Pinebeach provides a comfortable environment for those living there and visiting. The home is generally clean and well maintained. Sufficient space is provided for residents and toilet and bathing facilities are accessible and aids and adaptations are in place to meet resident’s mobility needs. Rooms are appropriately furnished and recent upgrading of the premises has improved its appearance. Residents are not always safeguarded from risks posed by hot surfaces and strategies are not in place to enable less able residents summons assistance. Some hygiene and infection control processes need further consideration. EVIDENCE: The interior décor of rooms’ hallways and corridors are decorated, furnished and carpeted to a good standard. Residents are able, if they wish, to bring in items of their own furnishings subject to suitability. There are eighteen single rooms, eight with en-suite and nine shared rooms of which five have en-suites. Registered for thirty six residents, Pinebeach uses just five of it’s shared rooms for double occupancy, the remainder are used as single rooms reducing the DS0000020485.V252012.R01.S.doc Version 5.0 Page 17 overall number of residents accommodated to twenty-eight. Bathrooms, showers and toilets are sited around the home conveniently for residents. The home was a reasonable temperature, well lit and ventilated at the time of inspection. Most radiators have been guarded since the last inspection to prevent accidental scalding, where radiators are not covered, risk assessments are in place although these are not based on guidance from the Health and Safety Executive and do not provide measurable criteria on which to base judgements about levels of risk. Water temperatures were not measured during this visit although Mr Dedman has confirmed at previous inspections that regulators have been fitted to hot water outlets where full body submersion occurs to ensure against accidental scalding. Alarm call points are in place throughout the home for residents to summons assistance when needed. One resident in a bedroom was agitated and ringing the alarm bell which was not being answered. Staff attended when a bell from a nearby bathroom was activated. The call bell the resident had been using had been deactivated, having been pulled from the wall. The laundry is situated on the ground floor of the home and provides two washing machines and two dryers. Washing machines have programmes enabling temperatures of 95°C and sluicing programmes. The laundry room is clean and well organised, residents spoken with confirmed that laundry is washed and returned appropriately and in good condition. The laundry floor is an impermeable surface, necessary for infection control purposes although porous surface, wooden steps provide access to the tumble dryers. The home was generally clean and free from odours although one bedroom had a very strong, offensive odour. DS0000020485.V252012.R01.S.doc Version 5.0 Page 18 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. Records for standard 30 were not provided. The deployment and number of available staff is considered sufficient by residents although the registered person must ensure the ratio of trained staff to care assistants is sufficient to meet resident’s needs. Limited progress has been made in ensuring that staff are equipped with the skills necessary to meet assessed needs and protect residents Staff vetting and recruitment practices are poor, potentially putting residents at risk. EVIDENCE: The staffing arrangements do not meet the previous regulators total of eight staff for each day shift and five staff at night although these figures were based on occupancy of thirty-six. As Pinebeach currently keeps occupancy at a maximum of twenty-eight residents, the previous regulators guidance states that for twenty-eight residents there should be six staff for each day shift and four staff at night. At Pinebeach, during the morning shift, there are two trained nurses and four care assistants (6 staff), in the afternoon there is one trained nurse and five care assistants (6 staff) and at night there is one trained nurse and three care assistants (4 staff). This meets the previous regulators requirement for the current number of residents accommodated although Ms Price, registered manager is on the staff roster for three morning shifts and four afternoon shifts. As one of the numbers of trained staff available to meet resident’s DS0000020485.V252012.R01.S.doc Version 5.0 Page 19 needs, Ms Price therefore has limited time for management and administrative duties (see standard 31) Ancillary staff are employed to run the home’s catering and domestic services. An objective of this inspection was to examine staff training records however, records were not available for examination. Mr Dedman did provide a copy of the home’s training matrix indicating which staff had undertaken which training and when, this does not constitute evidence that training has been received by a competent trainer. The matrix showed that three staff have attained NVQ level 2 and Mr Dedman confirmed that a further five care assistants are undertaking this award. There are six trained staff employed (including the registered manager) and fifteen care staff. The matrix indicates which staff have attended the following statutory training courses: • • • • • • • • • Moving and Handling – five trained staff and fourteen care staff between May 2004 and March 2005. Basic food hygiene – two trained staff and nine care staff*between April 2001 and October 2005. Emergency Aid – four trained staff and thirteen care staff between September 2003 and April 2005. Health and Safety – four trained staff and four care staff between November 2000 and May 2005. Infection control – four trained staff and fourteen care staff between May 2001 and June 2005. Elder Abuse – four trained staff and nine care staff between February 2004 and August 2004 Care of the dying – one trained staff in 2002 Handling aggression – one trained and one care assistant in 2004 Continence care – one trained staff in 2003. *both the cooks employed have received this training most recently in October 2005. Induction and foundation training records were not provided for inspection. Findings from this inspection with regard to assessment, care planning and care reviews have demonstrated that staff at Pinebeach are not familiar with current best practice and whilst records of evidence were not examined, trained staff are required to keep a record of evidence for the Nursing and Midwifery Council and for the Commission to demonstrate they keep up to date with developments in practice and can assure residents that their needs can be met. Three staff files were examined to check recruitment practices. Mr Dedman confirmed that a recruitment policy remains unchanged since it was written in 2002. One file indicated that the staff member had been employed using a DS0000020485.V252012.R01.S.doc Version 5.0 Page 20 CRB* and POVA* certificate obtained by a previous employer, two files demonstrated that CRB and POVA checks had been made after the person had taken up post. Two of the staff files examined did not hold references from their last employers, on one file the registered persons had accepted a reference from a person not named as a referee on the employment application form. One employee did not have a full employment history and gaps in employment had not been explained or explored at interview. *CRB – Criminal Records Bureau POVA - Protection of Vulnerable Adults – a list of persons held by the Secretary of State who are deemed unsuitable to work with vulnerable adults DS0000020485.V252012.R01.S.doc Version 5.0 Page 21 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, 32, 33, 36 & 37 Management arrangements have failed to promote the health and welfare of residents and do not support good staff practices. The home does not hold regular reviews of its performance using a programme of self-review and consultations, including seeking the views of residents, staff and relatives. Records required by regulation for the protection of residents and for the effective and efficient running of the home are not always up to date or accurate. EVIDENCE: Mary Price, registered manager works seven shifts each week as one of the required registered nurses, this does not enable sufficient time for her to discharge her management responsibilities. DS0000020485.V252012.R01.S.doc Version 5.0 Page 22 This inspection has identified areas of the home’s performance where it is evident that management practices are failing, particularly with regard to some assessments, care practices and reviews, risk management strategies, staff recruitment, training and supervision. The responsible individual for the registered provider company does not arrange for performance reviews and does not report on the conduct of the home. Mary Price, registered manager confirmed that staff supervision is carried out for care staff; trained nursing staff do not receive regular supervision. Records relating to staff supervision of care staff were not available for inspection as Ms Price stated that these records were confidential. Ms Price is reminded that Regulation 17 (3)(b), Care Homes Regulations 2001, states that records shall be available for inspection in the care home by any person authorised by the Commission to enter and inspect the care home and Regulation 17(2), Schedule 4, 6 (f) identifies records that are to be kept in the care home including correspondence, reports, records of disciplinary action and any other records in relation to (his) employment. Requirement has been made following the last six inspections that effective quality assurance and quality monitoring systems are in place having sought the views of residents, whilst questionnaires are in place as part of the Service User Guide, Mr Dedman confirmed that few of these have been returned and that he has not compiled a development plan or audit from the outcomes. As part of Lifecaring Holdings Ltd overall quality monitoring and management responsibility, the responsible individual for the company must report monthly on the conduct of the home, this has not been done and requirement is repeated. DS0000020485.V252012.R01.S.doc Version 5.0 Page 23 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 x x 1 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 1 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 X 3 3 X 3 2 1 2 STAFFING Standard No Score 27 1 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 1 X X 1 1 X DS0000020485.V252012.R01.S.doc Version 5.0 Page 24 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. Standard Regulation Requirement Accommodation must not be provided to persons at the care home until their needs have been assessed; assessments must be comprehensive and provide sufficient detail to enable staff at the home to understand the needs that are to be met. Previous time-scale (30.06.05) not met All service users must have an individual plan of care, based on assessed need that must be followed in order that care needs can be met and risks reduced or eliminated. Service users must be consulted with regard to decision making processes of assessment and care planning. Previous time-scale (30.06.05) not met Care plans must be implemented and evaluated and clarify all service users actual and potential needs providing information to clearly direct and inform the caregiver. All service users must have appropriate evidence based risk DS0000020485.V252012.R01.S.doc Timescale for action 1 OP3 14 31/01/06 2 OP7 15 31/01/06 3 OP7 15 31/01/06 4 OP7 13 31/01/06 Version 5.0 Page 25 5 OP8 15 6 OP14 12 7 OP24 13 assessments regarding their physical health which link in to the care planning process and are evaluated appropriately. Wound care must be provided following thorough assessment and using a documented wound chart with information relating to the aetiology and size of the wound, a description of the wound and surrounding skin and a rationale for the wound dressing which should then be reviewed and evaluated at each dressing change. Appropriate intervention from specialist health services i.e. Tissue viability, continence specialists, physiotherapist must be demonstrated and recorded and qualified staffs knowledge base for tissue viability must be reviewed and developed based on current best evidenced based practice. As part of their responsibility under the Nursing and Midwifery Council Code of Conduct, trained nurses must adhere to the Code, Section 2.1 of which states, ‘You must respect the role of patients and clients as partners in their care and the contribution they can make to it’. The registered persons must ensure that service users are enabled to make decisions regarding the care they are to receive and their health and welfare and that they are consulted and their views are sought and acted upon. Service users must have access to their alarm call bells at all times, where they are unable to successfully operate these, alternative means of monitoring their health and comfort must be maintained. DS0000020485.V252012.R01.S.doc 31/01/06 31/01/06 31/01/06 Version 5.0 Page 26 8 OP26 16 9 OP25 13 10 OP27 18 11 OP4 18 The registered persons must have strategies in place for managing cleaning schedules and refurbishment to ensure the home remains free from offensive odours. All service users must have an assessment in relation to the risks of accidental scalding posed by unguarded pipe-work and radiators. In the absence of risk assessments, all pipe-work and radiators must be guarded or have guaranteed low surface temperatures. This requirement was first made at the inspections dated 20.05.03 and repeated on 03.03.04. Inspections dated 02.07.04 and 02.12.04 assessed this as being met although it had lapsed again at inspection dated 14.04.05 and is repeated again from this inspection. The inspector has recommended to the Commission that Statutory Notices are served for breach of regulation and noncompliance. Staffing levels set by the former Health authority should be adhered to or a clear, robust and written case must be made in order for a lower ratio of qualified nursing staff to health care assistants to be used. Such a case must have been made following discussion and agreement with the Primary Care Trust responsible for funding free nursing care. The registered persons must ensure that a record of evidence is maintained demonstrating that staff have the skills to provide the services the home offers. 31/01/06 31/01/06 28/02/06 28/02/06 DS0000020485.V252012.R01.S.doc Version 5.0 Page 27 12 OP28 18 A minimum of 50 of care staff must be trained to NVQ level 2 with evidence of core and optional National Occupational Standards being attained. This requirement was first made at inspection dated 14.04.05 and is repeated for the second time. Written evidence must be provided indicating how and when this requirement will be addressed New staff must only be confirmed in post following completion of a satisfactory check by the Criminal Records Bureau, and must be supernumerary until such time as this confirmation is received. Information held on staff must include their ID (birth certificate and passport), a recent photograph and a Criminal Records Bureau certificate This requirement was first made at the inspection dated 20/05/03, was repeated at the inspection dated 03/03/04 as records were unavailable, and was repeated as not met at the inspections dated 02/07/04 and 02/12/04. The last inspection dated 14/04/05 confirmed that from a sample of two files, the requirement had been addressed but recruitment procedures have again lapsed. The inspector has recommended to the Commission that Statutory Notices are served for breach of regulation and noncompliance. 28/02/06 13 OP29 19 31/01/06 DS0000020485.V252012.R01.S.doc Version 5.0 Page 28 The regulations regarding employment of staff in care homes were amended in September 2005 and the following is now also required: The registered persons must not employ any staff to work at the home until such time as check against the POVA register has been made. A new member of staff must not work unsupervised in the home until such time as a satisfactory CRB certificate has been obtained, the supervisor must be a named member of staff. The registered persons must obtain a full employment history, together with a satisfactory written explanation of any gaps in employment. Two written references, one of which must relate to the person’s last period of employment must be obtained. The registered person must ensure and be able to evidence that the training provided for all staff meets NTO specification. All members of staff must receive induction training to NTO specification within six weeks of appointment to their posts, and Foundation training within the first six months of appointment, which equips them to meet the assessed needs of service users accommodated as defined in their individual plan of care. This requirement has been made at inspections dated 07.10.02, 20.05.03, 03.03.04, 02.07.04, 02.12.04, 14.04.05 and is repeated here for the seventh time. The inspector has recommended to the DS0000020485.V252012.R01.S.doc 14 OP29 19 31/01/06 15 OP30 18 31/01/06 Version 5.0 Page 29 16 OP31 10 17 OP32 10 18 OP33 26 19 OP33 24 Commission that Statutory Notices are served for breach of regulation and noncompliance. The registered manager must have a minimum of 30 hours per week supernumerary to the staffing rota in order to effectively manage the home. Management arrangements must be reviewed to ensure the registered persons develop better management strategies for addressing areas where the home is failing, ensuring efficient management of care practices, staff recruitment, training, staff supervision and improvement strategies. The responsible individual for Lifecaring holdings Ltd, Mr Dedman, must visit the home each month specifically for the purpose of reporting on the conduct of the home, a copy of the report of this visit must be made available to other of the directors, the registered manager and to the Commission. In the absence of the responsible individual, management accountability must rest with the registered manager who must have access to all records required by regulation in order to effectively manage the home. This requirement was first made at inspections dated 02.12.04 and 14.04.05 and is repeated here for the third time. The inspector has recommended to the Commission that Statutory Notices are served for breach of regulation and noncompliance. Effective quality assurance and quality monitoring systems, DS0000020485.V252012.R01.S.doc 31/01/06 31/01/06 31/01/06 31/01/06 Page 30 Version 5.0 20 OP36 18 based on seeking the views of service users, must be in place to measure the success in meeting the aims, objectives and Statement of Purpose of the home. This requirement has been made at inspections dated 07.10.02, 20.05.03, 03.03.04, 02.07.04, 02.12.04, 14.04.05 and is repeated here for the seventh time. The inspector has recommended to the Commission that Statutory Notices are served for breach of regulation and noncompliance. Care staff should receive formal supervision at least 6 times a year. Supervision covers: - all aspects of practice; - philosophy of care in the home; - career development needs. This requirement was made at inspections dated 07.10.02, 20.05.03, 03.03.04, 02.07.04, was addressed in part at the inspection dated 02.12.04 and was not assessed at inspection dated 14.04.05. The inspector has recommended to the Commission that Statutory Notices are served for breach of regulation and noncompliance. 31/01/06 DS0000020485.V252012.R01.S.doc Version 5.0 Page 31 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard OP12 Good Practice Recommendations As part of the requirements to meet the standards regarding assessment and care planning, the home should consider individual preferences and abilities with regard to social, recreational and cultural activities and plan activities around individual and group need. It is recommended that the registered persons take advice from the Environmental Health department regarding provision of wooden steps in the laundry room. The home’s recruitment procedure must be revised to ensure it refers to the amended regulations. 1 2 3 OP26 OP29 DS0000020485.V252012.R01.S.doc Version 5.0 Page 32 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000020485.V252012.R01.S.doc Version 5.0 Page 33 - 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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