Inspection on 28/03/08 for Piper Court

This inspection was carried out on 28th March 2008.

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

The inspector 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

Piper Court 12/01/10

Piper Court 19/03/09

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Piper Court Sycamore Way Stockton-on-Tees TS19 8FR Lead Inspector Key Unannounced Inspection 28th March 2008 09:15 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 Piper Court DS0000070978.V360593.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. Piper Court DS0000070978.V360593.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Piper Court Address Sycamore Way Stockton-on-Tees TS19 8FR 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) 01642 606512 01642 605503 Southern Cross BC OpCo Ltd Care Home 60 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Old age, not falling within any of places other category (60) Piper Court DS0000070978.V360593.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 60 Mental Disorder excluding learning disability or dementia, Code MD, maximum number of places 10 The maximum number of service users who can be accommodated is: 60 2. Date of last inspection Brief Description of the Service: Piper Court is a modern, purpose built facility that is registered to provide personal and nursing care to sixty older people. The home is divided into three units. On the ground floor of the home there is a twenty-eight bedded unit that accommodates people requiring personal care. On the first floor of the home there is a twenty-two bedded unit that accommodates people requiring nursing and personal care and also a ten bedded mental health unit. Each unit has separate lounge areas, a dining room, toilets and bathing facilities. Bedrooms are single in nature and meet the required amount of space, all have ensuite facilities, which comprise of a toilet and hand wash facilities. The home is situated close to North Tees Hospital and other local amenities. The cost of care at the time of the inspection visit ranged from £370 to £559.50 per week. Piper Court DS0000070978.V360593.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means that people who use this service experience adequate quality outcomes. This unannounced key inspection was carried out on 28 March 2008 by two inspectors. The inspection started at 09:15 and finished at 17:45. The home does not currently have a registered manager, however, the home’s deputy manager was present. Also present were a project manager and operations manager for the company. The project manager is supporting staff and working at the home until a new manager is appointed. The reason for the inspection was to see how good a job the home does in meeting the National Minimum Standards set by the government for Care Homes. Numerous records including care plans, complaints and staff recruitment and training records were examined. The inspector spoke at length to three people that use the service and in general to others, a discussion also took place with a relative. The Inspector also spoke to two care staff, the deputy manager of the home, a project manager and the operations manager. The inspector walked around the home with the deputy manager. Before the inspection twenty surveys for people who use the service and twenty surveys for relatives were sent to the home for the manager to distribute accordingly. Surveys requested feedback on the service and staff provided. We received nine surveys from people who use the service and ten surveys from relatives. Comments received can be read within the report. A manager completed and returned an Annual Quality Assurance Assessment, (AQAA). The AQAA is the services self-assessment of how they think they are meeting national minimum standards. This information was received before the inspection and was used as part of the inspection process. The details of any issues identified at this inspection requiring action are to be found at the back of this report. Following this inspection the Commission for Social Care Inspection has received from the Provider a development action plan for the mental health unit and care home in general. Piper Court DS0000070978.V360593.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: There are a number of improvements that need to be made as a result of this inspection. Assessments of people on the mental health unit (new and existing) need to be more detailed and care plans need to include the impact that the mental health problem has on life and how it can be managed. Activities and outings have been limited, however a new activity co-ordinator has been appointed and as such they need to speak with people that use the service and relatives to find out interests. Mixed comments were made in relation to the food provided, some people that use the service said that they thought food provided by the home could improve. Newly appointed staff need to receive induction and adult protection training and some mandatory training for staff is overdue. Staff who work on the mental health unit need to receive training specific to the people that they care for. Water temperatures of baths, and showers should be taken on a weekly basis as recommended by the Health and Safety Executive. Piper Court DS0000070978.V360593.R01.S.doc Version 5.2 Page 7 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. Piper Court DS0000070978.V360593.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 Piper Court DS0000070978.V360593.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): Standards assessed 3 and 6 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 this service. Assessments of people who are to use the service are carried out, however, some are insufficiently detailed and as such do not help to ensure that the needs of people using the service can be met. EVIDENCE: The deputy manager said that, before going into the home, people who are to use the service are first assessed by a social worker or health care professional to determine if they need nursing or personal care. Staff at the home then carry out their own pre-admission assessment either visiting the person in their own home or at hospital to ensure that the needs can be met at Piper Court. Piper Court DS0000070978.V360593.R01.S.doc Version 5.2 Page 10 The deputy manager said that she is a nurse and that she carries out assessments of people who require personal or nursing care. For those people who are to move into the mental health unit, the unit co-ordinator who works on the mental health unit carries out assessments. Four plans of care were looked at during the visit, one from the residential unit, one from the nursing unit and two from the mental health unit. Some assessments looked at during the visited included a detailed history of the person receiving care. Staff had taken time to find out about working years, family, places lived and interests/hobbies. Assessments were available on files looked at during the visit. Assessments for the residential and nursing unit were satisfactory, however, assessments looked at for the mental health unit were not. An example being the homes assessment for one person included medical problems, however did not refer to the persons aggression and behaviour that had been highlighted by social services as needing intervention. A long discussion took place with management of the home regarding the mental health training that the person who is carrying out such assessments has received. Management of the home acknowledged that assessments of people residing on the mental health unit were insufficiently detailed. Following this inspection the Provider forwarded an action plan to the Commission for Social Care Inspection of training to be provided in April and May 2008. The home does not provide intermediate care and as such standard 6 does not apply. Piper Court DS0000070978.V360593.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): Standards assessed 7, 8, 9 and 10 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 this service. People who use the service are protected by the home’s policies and procedures for dealing with medicines. Some improvements are needed in respect of care planning this will help to ensure that needs are met. EVIDENCE: Four plans of care were looked at during the visit. The home is in the process of changing over to new care plan documentation and as such there was a mixture of old care plan documentation and new on file. The operations manager said that all information for people that use the service is to be transferred onto the new documentation within the next couple of months. Piper Court DS0000070978.V360593.R01.S.doc Version 5.2 Page 12 The content of care plans was inconsistent, some were better than others. One plan of care described in detail how to help the person with washing and dressing and how they prefer a shower and need someone to stay with them. This same plan of care also described in detail how to manage pain. Another plan of care looked was not individual to the person and did not include evidence of personal choice. An example being for help needed with washing and dressing it stated offer regular baths and check skin daily. Plans of care for those people residing on the mental health unit did not include the impact/effect that the persons mental health problems have on life and how this can be managed. One person highlighted as having problems with aggression had a plan of care on file, however this was insufficiently detailed. The plan of care did not highlight what triggered the aggression, how to manage the situation or how successful the plan of care was in de-escalating the aggression. A long discussion took place with management of the home and the need for care plans to improve particularly those of people on the mental health unit. It was pointed out that this has been identified at previous inspections of the service before the change in ownership. The operations manager for the company said that she would take action to address the matter. In general, care plans were updated on a monthly basis or more often if required. Files of people who use the service included healthcare visits and appointments. The records showed the regularity of visits for treatment from: doctors and district nurses, opticians, dentists and other healthcare specialists. People who use the service, the relative spoken to during the inspection by the inspector, and surveys received said: “They care for my mothers needs and health very well. The staff are friendly and helpful” “I think that they do a marvellous job” “Sometimes it’s good sometimes it’s not so good” “As one who visits daily I have ample opportunity to be impressed by the care and patience with which the sometimes difficult patients are treated” “The care at Piper Court has gone downhill” “Very happy at this home, staff are very good” Piper Court DS0000070978.V360593.R01.S.doc Version 5.2 Page 13 “All members of staff have treated me in a gentle and caring manner and always greet me with a smile”. Two surveys received highlighted that at times people who use the service have to wait too long for staff to take them to the toilet. Both surveys commented on how dignity was compromised in having to wait 15 to 30 minutes for staff to take to the toilet. The deputy manager said that she would look into the situation as a matter of urgency. Nurses are responsible for giving out medication to people on the nursing unit and senior care staff give out medication to those people on the residential and mental health unit. The deputy manager said that all care staff have received appropriate training and have received supervised practice. Each unit have their own medication storage room. During the inspection arrangements for receiving, storing, administering, recording and disposing of medication on the residential unit were observed and examined. The ordering and returning of unused medication was good and records were well written. A medication audit of one person who uses the service was carried out. Medication administration charts had been completed correctly and the stock balance of medication belonging to the person was correct, matching up with medication ordered, received, administered and remaining in the home. Medicines were stored appropriately. Appropriate records and storage are in place for controlled drugs. Records were available to confirm that daily temperature checks of the medication storage room and medication fridge are taken to ensure that medication is stored at the correct temperature. Piper Court DS0000070978.V360593.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): Standards assessed 12, 13, 14 and 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 this service. Visitors are encouraged and made to feel welcome at anytime, however, lack of activities and outings over recent months has resulted in some of the people that use the service feeling unfulfilled. Food provided is not always enjoyed by people living at the home. EVIDENCE: The home has just appointed an activity co-ordinator to work thirty five hours a week over five days to plan, arrange and take part in activities for people who use the service. The deputy manager said that the home has been without an activity coordinator for a number of months and as such has relied on care staff to organise activities when time permitted. Piper Court DS0000070978.V360593.R01.S.doc Version 5.2 Page 15 People that use the service and surveys received commented on the lack of stimulation at the home, Comments made included, “People need something to do during the day, ie bingo, activities and outings. In general there needs to be a big improvement” “It’s boring” “We did make flower arrangements for the tables that was good” “Piper Court residents need social activities, in the past social activities were good ie Easter bonnet competitions, bingo, singers and bus trips” “I am fine, I have got a video and DVD player. I like to watch television and spend time in my room” The deputy manager said that activities and outings are set to change now a new activities co-ordinator has been appointed. The deputy manager spoke of recent entertainment/activities provided at the home. A singer entertained people that use the service in February and is to come back in April. The home have also hosted a cheese and wine afternoon and had a clothes party. The deputy said that the home has received some grant money, which has been allocated to spend on equipment for people that use the service. Some of the equipment ordered consists of nostalgia cards and exercise equipment. The deputy manager said that there are only a few people that use the service who have expressed a wish to practice their religion. One person visits the temple on a Saturday and a couple of other people have individual visits from church representatives. The deputy manager advised that she thought that she needed to speak to people living at the home to see if there had been any changes to what they wanted and maybe arrange some short church services. Visits from relatives and friends are welcome at any time. One relative spoken to during the visit said, “I am always made to feel welcome. All the staff are friendly and you can help yourself to a coffee”. The lunchtime of people that use the service of the nursing unit was observed. The lunchtime menu of the day was cod in batter or spam fritters with chips and peas. Some people were having poached fish and mashed potato. Lunchtime was relaxed and people appeared to be enjoying the food that was provided. One person was heard saying, “That’s lovely just what I wanted”. Tables were nicely set and large print menus were displayed on tables. Piper Court DS0000070978.V360593.R01.S.doc Version 5.2 Page 16 The home last had a food safety visit from the Council in May 2007 in which it was identified that chopping boards needed to be replaced and that staff that handle food need to be trained. The deputy manager said that all kitchen staff have received the appropriate training, however a number of care staff still need food handling training. Mixed comments were received from people that use the service and surveys in respect of the food provided. Comments made included, “Today’s dinner was lovely but we always enjoy the fish and chips. Food is up and down” “The food is very poor at the minute at one time it was pretty good” “There have been a few complaints from staff and residents about the quality of food served. I am told now that some of the issues have improved” “The food could improve” “He/she continually complains about the food. I have observed so many meals returned to the kitchen uneaten” Some surveys received said that people that use the service liked the food that was provided, however did not make any additional comments. Comments received in respect of the food provided were discussed with the management of the home. Piper Court DS0000070978.V360593.R01.S.doc Version 5.2 Page 17 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): Standards assessed 16 and 18 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 this service. People who use the service were confident their complaints would be listened to, taken seriously and acted upon. Adult protection procedures are in place, which helps to protect residents from abuse. EVIDENCE: The home has a complaint procedure, which informs people who use the service and relatives of their right to complain, timescales for action and who to contact. The home keeps a record of complaints. There have been thirteen complaints made in the last twelve months, five of which have been since November 2007 when there was a change in ownership. The home has an adult protection policy that details action that staff should take if abuse is suspected. The deputy manager said that staff receive adult protection training on induction and on a regular basis thereafter. The deputy manager said that some of the staff that have been employed within the last six months still need to do the training. Adult protection referrals made within the last twelve months, have been dealt with appropriately by the home. Piper Court DS0000070978.V360593.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): Standards assessed 19 and 26 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 this service. The standard of the environment within this home is good providing the people who live there with and attractive, homely and comfortable place to live. EVIDENCE: The home is a modern, purpose built facility the home is divided into three units. On the ground floor of the home there is a twenty eight bedded unit that accommodates people requiring personal care. On the first floor of the home there is a twenty two bedded unit that accommodates people requiring nursing and personal care and also a ten bedded mental health unit. Piper Court DS0000070978.V360593.R01.S.doc Version 5.2 Page 19 Each unit has separate lounge areas, a dining room, toilets and bathing facilities. Bedrooms are single in nature and all have ensuite facilities, which comprise of a toilet and hand wash facilities. There is a lounge on the ground floor of the home, which is designated for those people that wish to smoke. The Inspector walked around the home with the deputy manager. The home is well maintained and furniture provided is of a good standard. Lounges are bright and nicely decorated. Bedrooms looked at during the visit were personalised with many of the people that use the service bringing familiar and favourite items of furniture from home. The deputy manager said that windows on the first floor of the home are restricted to ensure the safety of people that use the service. The home has a policy in respect of control of infection. Staff spoken to during the inspection said that there was always a plentiful supply of protective clothing. On the day of the inspection the home was clean and odour free. Appropriate laundry facilities are in place. Of the surveys received two people said that they thought that the laundry service could improve. Two surveys stated that underwear and slippers often went missing. The deputy manager said that the laundry staff try their best, however when they are dealing with so much laundry for so many people it is possible for personal items to be misplaced. She said that if laundry items do go missing, then the person that uses the service or their relative should approach senior staff who will then take action to address the situation. Piper Court DS0000070978.V360593.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): Standards assessed 27, 28, 29 and 30 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 this service. The home’s recruitment procedure is robust which helps to ensure that people are protected. Insufficient staffing, lack of induction training and out of date mandatory training for staff could impact on safety and the care given to people that use the service. EVIDENCE: At the time of the inspection there were forty-seven people living at the home, twenty on the nursing unit, nine on the mental health unit and eighteen on the personal care unit. The homes duty rota for the nursing unit showed that there are three or four care assistants on duty between the hours of 7:30 am and 12:30 pm, three care assistants 12:30 pm until 8:30 pm and one care assistant on night duty. In addition there is one trained nurse on duty during the day and night. The home’s duty rota for the mental health unit showed that there are two care staff on duty between the hours of 7:30 pm and 8:30 pm, one of which is a senior care assistant and one care assistant on night duty. Piper Court DS0000070978.V360593.R01.S.doc Version 5.2 Page 21 The homes duty rota for the personal care unit showed that there are three care staff on duty between the hours of 7:30 pm and 8:30 pm, one of which is a senior care assistant and two care assistants on night duty. People who use the service and staff that were spoken to during the visit did not feel that there was enough staff on duty. Seven surveys received also stated that they did not think that there was enough staff on duty to meet the needs of people living at the home. Comments made included, I don’t think that there are enough staff on duty. On an evening staff are really busy, they work hard and are pleasant. When I visit I often can’t find anyone, they are always seeing to people in their rooms, which of course they have to, but others are left on their own for too long” Two other surveys received advised that people who spend time in their rooms are also left for long periods of time. As highlighted earlier two surveys received stated that they were having to wait too long to be taken to the toilet. During the inspection care staff were spoken to. Staff also felt that there was insufficient staff on duty, in particular on the mental health unit where staff felt vulnerable. The mental health unit has two care staff on duty during the day and evening. At times staffing can reduce to one care staff member an example being at break times or if a person who uses the service needs to go and see a GP or go on a hospital visit. Staffing can also be reduced when a person that uses the service goes to the lounge designated for those people that wish to smoke and needs to be accompanied by a staff member. Staff spoken to during the inspection advised of an incident on the unit, which they felt could have been managed better if there had been more staff on duty and they had received appropriate training. This was discussed with the Operations Manager at the time of the visit who advised that immediate action would be taken to address staffing levels on the mental health unit. She advised that she would work the weekend on the unit to support staff, which would also give her the opportunity to review staffing, assess the people that use the service and determine if more staff were needed. It was also pointed out that consideration must be given to other units in the home. The operations manager was asked to review dependency of all people living at the home and ensure that there was sufficient staff on duty. The AQAA detailed that 53 of care staff working at the home have achieved a minimum qualification of NVQ level 2 in care. Piper Court DS0000070978.V360593.R01.S.doc Version 5.2 Page 22 The homes recruitment procedure is robust. The files of three newly appointed staff contained evidence to confirm that an appropriate Criminal Record Bureau checks are carried out before staff start working at the home. Files examined contained all of the required information including, proof of identity and two references. Files examined did not contain evidence to confirm that new staff had commenced or completed an induction. The project manager advised that she is aware of this as she has carried out an audit of all staff files to look and see what training staff have received and what training they need to do. Records also highlighted that mandatory training for a number of staff was also out of date. Previous inspections prior to the change of ownership have highlighted the need for staff working on the mental health unit to have specific training about the client group they care for. Staff spoken to during the visit said that they have not received any training. Concerns regarding the lack of training staff have received particularly those working on the mental health unit was discussed with an operations manager during the visit. The operations manager advised that she would address the situation as a matter of urgency. Since the Inspection the Commission for Social Care Inspection has been provided with a development action plan for the mental health unit and care home in general. A number of training sessions in relation to mental illness have been planned, some of which have already taken place. An action plan has also been provided in respect of staff undertaking induction and other training relevant to the job that they do. Piper Court DS0000070978.V360593.R01.S.doc Version 5.2 Page 23 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): Standards assessed 31, 33, 35 and 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 this service. Quality assurance monitoring systems are in place to ensure that the home is run in the best interest of people who use the service. At present the home does not have a registered manager. The appointment of a suitably qualified and experienced manager will help to ensure leadership and effective management of the service. EVIDENCE: At the time of the inspection the home did not have a registered manager in post. The position had been advertised, applications had been received with interviews to be planned. In the interim the home’s deputy manager with the Piper Court DS0000070978.V360593.R01.S.doc Version 5.2 Page 24 support of a project manager and operations manager has been managing the home on a day-to-day basis. The operations manager said that the home have quality assurance systems in place. Surveys are sent out to people that use the service and relatives on a yearly basis to see if they are happy with the home. The deputy manager said that meetings with people that use the service and relatives are held on a monthly basis. The home looks after small amounts of money belonging to some people who use the service. Appropriate records of transactions are kept. A sample of health and safety records were examined and were found to be in order. Records were examined to confirm that fire alarms and fire extinguishers had been serviced within the last year. On average there are weekly tests of the fire alarm system some of which involve staff to help to ensure that they would know what to do if there was a fire at the home. Records were available to confirm that water temperatures are taken on average monthly. A discussion took place with the manager in respect of the Health and Safety Guidance to monitor water temperatures weekly. As highlighted previously mandatory training for some staff was overdue. Piper Court DS0000070978.V360593.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Piper Court DS0000070978.V360593.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement Timescale for action 30/04/08 2 OP7 15 3 OP12 16 The registered person must ensure that assessments of people who reside on the mental health unit or people who are to be admitted to the unit in the future are sufficiently detailed to help to ensure that all needs are met. • The registered person 30/06/08 must ensure that care plans for those people residing on the mental health unit detail the impact that the mental health problem has on life and how it can be managed. • Care plans for those people residing on the mental health unit must include what triggers a problem, intervention required and how successful the plan of care is at de-escalating or managing the problem. The registered person must 30/05/08 consult with the people that use the service and plan suitable activities and outings DS0000070978.V360593.R01.S.doc Version 5.2 Piper Court Page 27 4 OP15 13 5 OP15 16 6 OP18 13 7 OP27 13, 18 8 OP30 18 9 OP30 18 10 OP30 OP38 13, 18 The registered person must ensure that they address the areas requiring action following the last food safety inspection on 16 May 2007 to ensure safe practice The registered person must consult with people living at the home regarding the menus and food provided to ensure that food is enjoyed and that a wholesome pleasing balanced diet is provided. The registered person must ensure that all staff receive adult protection training to help to ensure safety of the people that use the service. The registered person must carry out and assessment of people that use the service on each units to determine if there are sufficient staff on duty. Consideration must be given to times when staffing numbers can be reduced e.g. break times, hospital and GP visits, social outings or any other reason where a staff member is taken away from the unit to which they are allocated. There must be sufficient staff on duty to meet the needs and help to ensure the safety of people that use the service. All new staff who are not qualified to NVQ Level 2 must complete the Skills for Care Induction programme. The registered person must ensure that staff are suitably qualified/experienced and receive training to meet the mental health needs of people that use the service The registered person must ensure that all staff receive mandatory training on a regular DS0000070978.V360593.R01.S.doc 28/03/08 30/04/08 30/06/08 28/03/08 30/06/08 28/03/08 30/05/08 Piper Court Version 5.2 Page 28 11 OP31 8 basis to help to ensure safe practice. The registered provider must appoint a manager. The application to register the manager must be forwarded to the Commission for Social Care Inspection. 30/06/08 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 OP38 Good Practice Recommendations The registered person should give consideration to the Health and Safety Executive Guidelines to monitor bath and shower water temperatures weekly. Piper Court DS0000070978.V360593.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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