Inspection on 31/05/06 for Priestley Rose

This inspection was carried out on 31st May 2006.

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

Priestley Rose 12/12/07

Priestley Rose 27/06/07

Priestley Rose 19/12/06

Similar services:

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Maple Lodge

Heathlands

Aston Court Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Priestley Rose 114 Bromford Lane Erdington Birmingham West Midlands B24 8BY Lead Inspector Ann Farrell Unannounced Inspection 31st May 2006 08:15 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 Priestley Rose DS0000067126.V297307.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. Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Priestley Rose Address 114 Bromford Lane Erdington Birmingham West Midlands B24 8BY 0121 377 6707 0121 240 6181 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) MACC Care Limited Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to accommodate 42 older people. Registration category 42 OP N/A Date of last inspection Brief Description of the Service: Priestley Rose formally Raymond Priestley House was taken over by Concept care approximately two months ago. The home was built in the 1940s and has been extended and converted and currently provides accommodation for 42 residents who require nursing care. The home is a detached property and provides off street car parking for a small number of cars. There is a small garden to the rear and side of the home, which is enclosed and accessible to wheelchair users. The home offers a choice of single or double rooms over the two floors that are equipped with call bell and wash hand basin. There are 3 lounges and one dining room and a well equipped snoozelem. A passenger lift enables access to all areas of the home. The home is situated on a main route into Birmingham City centre and there is easy access to bus routes. Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection for Priestley Rose, which was only taken over by the current proprietors approximately two months ago. The inspection was undertaken on an unannounced basis over two days commencing at 8.15am on 30th May 2006. Currently the home is being managed by the manager from the organisations other home and she was present for the duration of the inspection. The inspection process included a tour of the home, inspection of records and documents relating the management of the home and staff. Case tracking of resident’s records was undertaken to determine care from the time of admission. The manager, three members of staff, approximately five residents and two relatives were spoken to. A number of residents were unable to communicate verbally. What the service does well: What has improved since the last inspection? The process of re-decoration and refurbishment has commenced with new carpets throughout the home, some decorating of the first floor and some new furnishings. Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 6 The recruitment process has improved since the new organisation took over and provides a robust system to protect residents. Staff meetings have commenced with the new management team and it is hoped to commence meetings with residents and relatives. A programme of staff training has commenced and one member of staff stated she is to start NVQ level 3 training with the new organisation. The manager has introduced a key worker and named nurse system to provide closer liaison with residents and ensure their needs are identified and met. The new manager has been in contact with health professionals e.g. the dentist, optician and chiropodist who are reviewing all residents. The activities co-ordinator has returned to work and is to implement a programme of activities. What they could do better: The nursing assessment and care planning process needs to be enhanced to ensure resident’s needs are identified and appropriate plans of action put in place to meet them. There needs to be a more pro-active approach to care with the early identification of concerns and referral to appropriate health professionals. More attention to detail is required in respect of aspects of basic care. Where unexplained bruising is found or residents are having recurrent falls they must be investigated, re-assessed and a referral made to appropriate agencies if required. The medication system needs to be reviewed and improved to ensure a robust system is in place and residents receive the medication they are prescribed. Improvements in infection control procedures and cleaning are required to ensure a more hygienic environment. A quality assurance system needs to be developed to include feedback from stakeholders and drawing up an annual development plan. The manger will need to review the approach to complaints with staff to ensure it becomes an environment that learns from any complaints or concerns raised. Some areas in respect of maintenance and servicing of equipment need to be addressed to ensure a safe environment for residents. Continued re-decoration and refurbishment is required to enhance the surroundings and provide a homely environment for residents. Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 7 Menus need to be reviewed to provide more variety and cultural options. 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. Priestley Rose DS0000067126.V297307.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 Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 6 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The home has information about the services and facilities available for prospective residents, but they will require further development to reflect the services available. The pre admission documents are satisfactory, but further development of the nursing assessment is required to guarantee that resident’s needs are identified. EVIDENCE: The home provides mainly long-term care for residents who are over 65 years of age requiring nursing care. In addition, they provide respite care for residents where possible. The current proprietors only acquired the home approximately two months ago and they are in the process of developing systems and upgrading the home. Information has been provided for prospective residents and their families and draft copies were provided at the time of inspection. Some of the areas were rather brief in the statement of purpose and more detail is required. It was stated that the contract of residence is currently Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 10 being developed. These documents will need to be developed further to ensure they meet the Regulations and provide comprehensive information to residents and their representatives. The staff liaise with social workers who may provide a written care plan for residents entering the home. The manger undertakes a pre-admission assessment of all residents before admission to determine if the home is able to meet their needs. Upon admission a nursing assessment is undertaken which includes risk assessments. On inspection it was noted that pre admission assessments had been undertaken and there was evidence that the home writes to confirm that they are able to meet the assessed needs. The nursing assessment was not always completed and they were of varying standards. Risk assessments had been completed for tissue viability, nutrition and manual handling, but there was no evidence of assessments in respect of bed safety rails, continence or falls. Assessments will need to be more comprehensive to ensure resident’s needs are identified and a comprehensive care plan drawn up to meet residents needs. Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. Care planning and a more pro-active approach to care with early identification of problems and attention to detail are required to ensure resident’s needs are met. The medication system needs to be developed in order to ensure there are robust systems in place and all residents receive the medication prescribed by the G.P. EVIDENCE: Following the nursing assessment nurses develop care plans for all residents, which outlines how staff should meet resident’s needs. On inspection of a sample of records it was noted that they were rather generalised, lacked detail, gave vague instructions, were based only on physical care and there was no care plan for nights. They had been reviewed every month along with the risk assessments. However, some of the evaluations lacked detail, where changes had been noted there was no evidence of follow up. In some cases there had been changes in residents conditions and it had not been reflected in the risk assessments. Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 12 There was no indication that residents or their relatives had been involved in drawing up the care plans initially although in some cases it appeared that they had been consulted at the time of some of the evaluations. Nurses and carers write reports in respect of the care of the residents. In one instance it was noted that a carer had reported a residents dietary intake was poor. When the nurse’s record was checked it had not been documented and there was no evidence that any action had been taken. Also it was noted that some of the carer’s reports for residents only related to night duty. The manger will need to review the recording systems and ensure a consistent method of recording is implemented. There were other instances where issues had been raised and there was no evidence of follow up. The home uses charts to record when residents are turned and it was noted that residents were turned regularly at night, but were usually left sitting in one place during the day. Also there were large gaps on the recording sheets as they were changed each day. It is recommended that this practice be reviewed. Nutritional assessments are undertaken on admission to the home and reviewed on a regular basis and residents are weighed. In one case the records indicated that the residents BMI was over 20, but there was no evidence that they had been weighed, in other cases residents were of low body weight on admission and another was noted to have lost weight, but there was no record of action taken. A review should be undertaken and where any ones BMI is below 20 action must be taken and a referral made to an appropriate health professional where appropriate All residents are registered with local G.P’s and records indicated visits by the G.P. However, there was no evidence of health checks for chronic diseases such as diabetes, asthma, hypertension etc. On reviewing the records of other health professionals visits it was noted that regular visits by the dentist and chiropodist had not occurred. The manger stated that all residents had been referred to a dentist, chiropodist and optician and visits where currently being undertaken. On reviewing one resident’s records it was noted that an external health professional had visited and had advised the nurse to refer the resident to the G.P. It was concerning that this referral had only occurred as the result of this visit. There will need to be a more pro-active approach to care with monitoring by nurses, early identification of any concerns and referral to appropriate health professionals in order to reduce the risk of complications and ensure early intervention. Whilst touring the home it was noted that a number of residents did not have socks/stockings or slippers on properly, call bells were not always accessible to those in their bedrooms or some had been partially removed so that the residents could not summon assistance. Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 13 Bibs used at meal times to protect residents clothing were still on residents when breakfast dishes had been removed. Drinks were not accessible, a residents walking frame was found in the toilet, wheelchairs were not in the correct residents rooms and therefore were not available for the residents use. Some residents had not had their oral care attended to upon getting up and others who had spectacles were not wearing them. Systems need to be implemented to ensure there is more attention to detail when providing care to residents The home had a supply of glycerine and lemon swabs for moth care, which is no longer considered to be appropriate and the nurses were advised to undertake research as to the current good practice in respect of mouth care. A number of nutritional drinks were found in one of the lounges, but these are tolerated better when served cooled. Some of the pressure relieving cushions and mattresses were noted to have “bottomed out” and are therefore not suitable for adequate pressure relief. A full audit of cushions and mattresses should be undertaken and replaced where necessary. On reviewing records it was noted that there were a number of incidents in respect of challenging behaviour and staff will need training in this area. The accident book indicated incidents of unexplained incidents of bruising on residents, but there was no evidence that any investigation had been undertaken to determine the causes. There was one resident who had a number of falls over the past few months and there was no evidence that they had been re-assessed in respect of this aspect. It is recommended that the resident be re-assessed and appropriate action taken. The home uses a monitored dosage medication system and on inspection it was found that a number of areas needed to be addressed. Areas requiring attention include: • An accurate system for recording all medication that is disposed of and a suitable system for disposal is required. • Medication had been signed as administered and not given. The manager was advised that she would need to undertaken audits. • Codes had been used for the non-administration of medication and not explained. • Some medication could not be audited. • Creams were in use that were not prescribed, where they were prescribed they had not been signed as administered. Also creams had not been dated when opened and it appeared that some had been in use for over 28 days and there is an increased risk of bacterial contamination. • On discussion with the nurse she stated that on some occasions they do not receive the prescriptions and they are forwarded directly to the Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 14 • • • • • • • • chemist. The home has a responsibility to ensure they check all prescriptions, photocopy them and check medication against the prescription when it enters the home. Variable doses of medication had not been recorded consistently and the medication could not be audited. It was noted that one medication requiring refrigeration had not been stored appropriately. Medication was available for homely remedy use. The nurse stated there was no policy. However, on inspection of the procedure folder a policy was located, but there was no evidence that it had been agreed with the G.P’s. All nurses should acquaint themselves with the policies and procedures of the home. Jewellery was found in the controlled drugs cupboard. Such items should be stored in a more appropriate place. One record in respect of some controlled drugs indicated it was in the home. On discussion with the nurse she stated it had been returned to the pharmacist some time ago, but there was no record to verify this. Sharps bin had been assembled and closed, but there were no details of the person and date that this was undertaken as required. Medicine pots had been washed and left to dry on the drainer upside down. These should be washed and dried after use. In some cases there was no record of medication carried forward from previous months to enable auditing. On touring the home it was noted that bedroom doors did not have locks and there were no lockable facilities in bedrooms for residents to store medication or valuables. There is a telephone in the reception area, but it does not provide privacy. The manger stated that one of the offices could be used if privacy was required. Net curtains are provided to windows to enhance resident’s privacy. On discussion with residents comments were favourable about staff and it was stated they were pleasant. On discussion with some relatives they stated that the resident they were visiting had improved since moving into the home. The inspector found the majority of staff to be pleasant and helpful, but there were a minority that did not display these qualities. This are will need to be addressed and training given where necessary. Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The meals offered are of an adequate standard, but menus need to be reviewed to include more variety, cultural options and some fresh vegetables. The activities co-ordinator has just returned, which will be much appreciated by residents as some stated they were bored. The programme of activities needs to be developed to meet the needs of existing residents and those who have recently moved into the home. EVIDENCE: Residents are free to come and go as they wish and visiting is flexible. On discussion with relatives they confirmed that they could visit at any time and found the staff welcoming. Residents are able to bring personal items of furnishings etc into the home and it was stated they may get up, go to bed and spend time as they wish. On discussion with some residents they stated they got up and went to bed when they wished. The homes activities co-ordinator has only recently returned from sick leave after a considerable period of time, therefore the activities programme has not been implemented yet. Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 16 On discussion it was stated that they currently celebrated birthdays with a cake, sherry and a singsong. Over the past couple of months entertainment has been brought into the home twice. The activities co-ordinator stated that she was hoping to start some bingo, exercise and gardening sessions. Her return will be greatly appreciated by residents as some of them stated they were bored. The hairdresser visits the home on a regular basis and ministers of various religions visit at residents request. The home employs separate catering staff who cover all three meals. However, there is some sickness at the moment and a member of staff who had worked in the laundry was helping during the afternoon. It is not appropriate for staff who have been working in care or laundry to go to work in the kitchen afterwards due to risk of cross infection. On the second day of inspection it was also noted that the majority of the care staff were congregated in the kitchen. Ideally care staff should not be entering the kitchen and should only do so if kitchen staff are not present to address any requirements. There are three main meals, which includes the option of a cooked breakfast, lunch and evening meal. On inspection of menus it was noted that there was a four-week rotating menu, there was a choice of meals but there was some repetition, there were no cultural options and the menus had been in use for some time. The manager stated that they had plans to review the menu in the near future. It appears that residents make their choices of meals a full week in advance. It is recommended that this practice be reviewed, as it is difficult to know what you would like to eat for a whole week in advance. Residents have the choice where to have their meals. There is a dining room on the ground floor adjacent to the kitchen. If residents wish to remain in their room’s food is transported to the first floor where it is stored in heated trolleys. However, at the time of inspection it was noted that staff was not using the heated trolleys. The inspector had lunch with residents in the dining room. Tables were pleasantly arranged to accommodate four residents, but there were no condiments on the tables. Staff were observed to be helpful, polite and provided assistance appropriately. The meal was hot, there were adequate portions and it was well presented. However, all vegetables were frozen. Consideration must be given to using fresh ingredients to ensure that the food served is wholesome, balanced and nutritious to meet resident’s needs and preferences. All residents will not like frozen or tinned vegetables and will prefer fresh as this has a different taste, texture and appearance. The inspector did not view records of food and this will be undertaken at the next inspection. Priestley Rose DS0000067126.V297307.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The home has systems in place to deal with complaints and allegations to ensure residents are protected. A system for informal complaints needs to be developed to ensure the home learns from any concerns EVIDENCE: A copy of the complaints procedure was available in the service users guide provided to the inspector. However, it stated that residents or their relatives could contact the Commission if they were not satisfied with the home investigation. This needs to be amended as they have the right to contact the Commission at any stage in the process. When this is completed a copy should be made available to residents and their representatives, as on discussion with some relatives they were not aware of the procedures. On inspection of complaint records it was noted that seven complaints had been made and the home had dealt with them in every case. Some of the records lacked detail regarding the date and outcome/resolution of the complaint. Records should indicate the date, nature of the complaint, investigation, outcome and resolution. A record for one complaint was not in the folder and the manager located in another area. It was recommended that the home should have a matrix indicating the compliant and where the records can be located for easy reference. Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 18 During a tour of the home one of the residents informed the inspector of a complaint she had in respect of the food and staff attitude. The manager, who was present, is dealing with this and is required to inform the Commission of the outcome and action taken. On discussion with nurse it appears that they would take action to address informal complaints, but there was no process for monitoring these issues to enable to home to learn from issues raised and implement systems to ensure there are no further re-occurrences. It is recommended that this be reviewed with staff. On discussion with the majority of staff they were aware of the action to take in the event of an allegation of abuse. However, there was some hesitancy with some. This are should be reviewed with staff to ensure they are all aware of the procedure to follow including the whistle blowing policy. The home has a copy of the latest vulnerable adult guidelines, but the whistle blowing policy will need updating and all staff made aware of the contents of the procedure. Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25, 26 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. The new proprietors have started to re-decorate and re-furbish the home in order to enhance the homeliness, but considerable work is required. Aspects in respect of infection need to be addressed in order to reduce the risk of cross infection. EVIDENCE: The current proprietors took over the home approximately two months when it was generally in a poor state of décor and maintenance needing total refurbishment. Since then new carpets have been fitted in all areas. They have also purchased some new furniture for bedrooms including drawers, bedside cupboards, chairs, counterpanes, curtains and there is a gradual replacement programme taking place. The first floor corridor has been painted and many of the other areas require re-decoration. Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 20 There are 30 single rooms and six double bedrooms with wash hand basin and call bell, but the doors do not have locks. There was an area that accommodated five residents, which is currently closed and the proprietors are hoping to re-arrange this in order to provide some further single/double bedrooms. A sample of rooms were inspected and it was noted that the lighting requires attention as some rooms do not have over bed lighting that is operation and in some cases there are two ceiling lights one of which does not work. It was also noted that some commodes were rusting; radiators were not covered and may pose a risk due to scalding. Some rooms had been personalised according to resident’s preferences. All bedrooms have two double sockets and television ariel. There are five communal bathing facilities, one of which is currently used for storage, but will need to be operational when the home is fully occupied. There is a choice of bath or shower on each floor. It was noted that the ground floor shower did not have a wash hand basin or toilet in the bathroom and the call bell was not accessible to the shower. There are a number of toilets situated around the home. However, some of them require partitioning from ground to ceiling to ensure residents privacy and some of the toilets do not have a call bell accessible. It was also noted that water was continuously dripping from a number of taps. All areas are individually and naturally ventilated and windows are provided with restrainers, but it was noted that some of the windows need replacement, as they are the old metal frames. Water from hot water outlets is regulated and temperatures were generally satisfactory to protect residents from scalding. On touring the home it was noted that some of the doors were not closing properly into the rebates properly. An audit should be undertaken and appropriate action taken. The stairs have a handrail along it, which provides partial enclosure, but it may pose a risk to some residents and this will need to be reviewed and appropriate action taken. Laundry facilities are situated on the ground floor. On inspection there were two washing machines and dryers, but only one of each was working. On discussion with the member of staff she stated red bags were used for soiled items, but they did not always dissolve in the washing machine and some were found in the household rubbish. This area will need to be reviewed to ensure they are being used appropriately. There was no lock on the laundry door and this may poise a risk if residents are wandering around the home. There was no information regarding the chemicals in use and the member of staff did not have any knowledge about them. It is recommended that COSHH risk assessments are placed in appropriate locations e.g. laundry, kitchen, domestic’s cupboard for staff and they are made aware of them. Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 21 There is a small garden to the rear of the premises with wheelchair access and some benches for residents to sit when the weather permits. It was noticed that some clinical and domestic waste bags had been left outside the laundry and the clinical waste bins were not locked. These areas will need to be addressed in order to make the area safe for residents to use. There are separate sluice facilities on each floor, but there was no sluicing disinfectors, there was shelving instead of racking for the storage of commode pots, urinals etc. Also in some of the areas tiles were damaged or missing and the areas needed decorating. This area will need to be addressed in order to improve infection control procedures At the beginning of the inspection the manger stated they had been working on the cleanliness of the home and she had already employed a member of staff and was hoping to employ some more ancillary staff. Although some efforts had been made further work is required in this area to ensure the home is cleaned to an acceptable standard. It was noted that staff had individual bottles of hand gel for use in order to reduce the risk of cross infection. However some other areas need attention to ensure adequate infection control procedures: • • • • • • • There were no paper towels and liquid soap in resident’s rooms for staff to wash their hands after dealing with residents. Washbowls were found on floor in resident’s rooms. In double rooms toiletries were not labelled. Colour coded mops and buckets were in use, but they were not always being used appropriately and some of the mops were in dirty water or appeared not to have been cleaned properly after use. A full clinical waste bag was found on the floor in a sluice. On occasions staff were seen walking around the home with gloves on. These should be removed after use and hands washed. The arrangements in place for barrier nursing need to be developed further. It was recommended that the manger contact the Health Protection Unit in order to provide advice and undertake an audit. In the kitchen it was noted that the chopping boards needed replacement, some of the crockery was chipped, sugar was stored on the floor and it required more thorough cleaning. Fridge, freezer and hot food temperatures were recorded. Whilst touring the home it was noted that some of the cleaning chemicals had not been stored properly. All chemicals must be stored in a locked cupboard when not in use. Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Staffing levels are satisfactory and the recruitment of staff has improved since the new proprietors took over. Staff training needs to be reviewed and developed further. EVIDENCE: Currently there are twenty-seven residents in the home. The manager works on a full time basis and is supernummary. Staff rotas indicated there is one nurse on duty 24 hours per day plus five carers during the day and three carers at night. The manger is on call at all times and it is recommended that this be reviewed. In addition, to nursing and care staff there is separate domestic, laundry, catering, maintenance and administration staff. A small number of staff files were inspected in respect of staff who have been employed by the new proprietors and they were found to be of a satisfactory standard with application form, health questionnaire, two written references and POVA check. There is a good cultural mix of staff to reflect the current resident group All the current care staff have been in the home for a considerable period and the manger has not employed any new care staff to undertake induction training. She stated she is aware of the new induction training standards and it would be implemented with new care staff. Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 23 Currently over 50 of care staff are trained to NVQ level 2 or above. Since the manger has been at the home there has been training in respect of dementia awareness, infection control, fire prevention and training has also been organised for moving and handling. On discussion with staff they stated they had undertaken a range of training, but it was difficult to evidence this due to the record keeping from the previous providers. The manger will need to develop a training file with copies of certificates to determine where there are any gaps in staff training and then develop individual training profiles for staff to ensure they have the appropriate knowledge and skills. Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 24 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, 35, 36, 38 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. Currently a manger from the organisations other home is taking control and staff stated they respected her and found her fair. Arrangements will need to be made for a permanent manger to run the home. Systems in respect of quality assurance and staff supervision will need to be developed. Outstanding servicing of equipment will enhance resident’s health safety and well-being. EVIDENCE: The home is currently managed by a manager from the organisations other home. She is a registered nurse with many years experience and is registered with the Commission in her capacity as manger at the other home. She is currently undertaking the Registered Mangers Award and demonstrates a commitment to improving standards of care. On discussion with staff they stated they respected her and found that she was very fair. Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 25 Since she took up the post she has had two staff meetings and a large number of the staff attended. Meetings with residents and their representatives have not commenced yet, but it is hoped that they will commence in the future. A quality assurance process and staff supervision is yet to be developed. The home does not hold personal money on behalf of residents and it was stated that families would be invoiced for nay extra costs such as chiropody, hairdressing etc. Samples of records were inspected in relation to maintenance/servicing of equipment and were found to be up to date with the exception of the following: • There was no evidence of Legionalla testing. • There was no evidence that the call bell system had been serviced. • Some pressure relieving mattresses and profiling beds had been serviced. An audit will have to be undertaken to determine if any still require servicing. • There was no evidence that wheelchairs had been serviced. • Risk assessments were not comprehensive or had not been reviewed in respect of chemicals, fire and the environment. • In house testing of emergency lighting had not been undertaken. • There was no evidence of a clinical waste contract. • There was no up to date gas safety certificate • There was no evidence that the scales had been serviced and calibrated. Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 26 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 2 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 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 2 17 X 18 2 1 1 1 X 3 1 1 1 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 1 X 3 1 X 2 Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A 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 2 3 Standard OP1 OP1 OP2 Regulation 4 5 5(1)(b) Requirement The registered person will need to enhance and develop the statement of purpose further. The registered person will need to develop and enhance the service users guide further. The registered person must develop the contract of residence, provide a copy to all residents or their representatives and retain a copy on their file. The registered person must ensure all nursing assessments are comprehensive and fully completed to include assessment for bed safety rails, falls and continence where appropriate. The registered person must ensure staff undertake training in respect of continence management where necessary and ensure appropriate continent management programmes are implemented. The Registered Person must: • Ensure that a robust system of care planning is in operation, which is holistic and provides detail DS0000067126.V297307.R01.S.doc Timescale for action 30/11/06 30/11/06 30/08/06 4 OP3 14 30/07/06 5. OP3 18(1) 12(1) 30/08/06 6. OP7 15(1)(2) 30/08/06 Priestley Rose Version 5.2 Page 28 7 OP8 12(1) 8 OP8 12(1) 23(2)(c) 9 OP8 12(1) 12(4) 18(1) 10 OP8 12(1) 23(2(n) 11 OP8 37 12(1) as to how resident’s needs are met. • The care plan should also include a night plan of care. • When drawing up care plans the resident or relative’s involvement must be sought. • Care plans must be regularly reviewed in a meaningful manner and updated to reflect the residents’ changing needs. The registered person must: • Ensure there is a proactive approach to care. • Ensure there are systems in place for early identification of concerns with appropriate follow and referral to health professionals as required in order to prevent complications. • Liaise with the G.P. regarding monitoring of chronic diseases. The registered person must ensure a full audit is undertaken of pressure relieving cushions and mattresses and replace any that have “bottomed out” The registered person must ensure that all staff are aware of how to approach and interact with residents and how to deal with challenging behaviour providing training in these areas where required. The registered person must ensure a call bell is accessible to all residents when they are in their room and they are fully operational. The registered person must ensure that where any bruises are noted on residents a full DS0000067126.V297307.R01.S.doc 15/06/06 30/06/06 30/06/06 10/06/06 10/06/06 Priestley Rose Version 5.2 Page 29 12 OP8 12(1) 13(4) 13 OP8 12(1) 13(1) 14 OP9 13(2) investigation is undertaken and appropriate action taken to ensure there are no reoccurrences and the Commission informed. The registered person must undertake a review of the resident identified as having had a number of falls at the time of the inspection. The registered person must: • Ensure that all residents are weighed on admission to the home and at regular intervals afterwards. • Where any unexplained loss of weight is noted referral must be made to the appropriate health professionals. • Undertake a review of all current residents in the home and where there BMI is under 20 a referral is made to an appropriate health professional The registered person must ensure there is a fully auditable and robust medication system to include: • The correct administration and recording of all medication. • All codes must be explained. • There must be an accurate record of all medication that is destroyed. • The home must have a robust system for checking that medication entering the home is what has been prescribed. • Review the current arrangements in respect of creams to ensure they are prescribed, the administration is recorded, DS0000067126.V297307.R01.S.doc 30/06/06 30/06/06 10/06/06 Priestley Rose Version 5.2 Page 30 15. OP10 12(1) 12(4) 16 OP12 16(2)(m) (n) they are dated when opened and discarded after one month. • The correct storage of all medication. • Record the amount of mediation carried over from previous months to enable auditing. • Ensure the dose of variable dose medication is recorded consistently. • Consult G.P.’s regarding homely remedies used. • Ensure only controlled drugs are stored in the controlled drug cupboard. • The correct recording of controlled drugs. • Where controlled drugs are destroyed it must be done in the presence of the pharmacist and a record retained in the home to verify this. • Medicine pots must be washed and dried thoroughly after use. • Sharps boxes must be clearly labelled with the date and name of the person who made them up and closed them. • Regular staff audits should be undertaken. The registered person must 25/06/06 ensure systems are in place to maintain residents dignity with attention to detail to include: • The use of socks, stockings, slippers/shoes. • Oral care. • The use of spectacles. • Accessible drinks. • Hair combed and neatly arranged etc. The Registered Person must 30/07/06 ensure all residents have access DS0000067126.V297307.R01.S.doc Version 5.2 Page 31 Priestley Rose 17 OP15 16(2)(i) 18 OP15 16(2)(j) 20 OP16 22 21 OP18 13(6) to a range of recreational activities to meet their needs, preferences; past lifestyles and cultural backgrounds and records are retained in the home to demonstrate this. The registered person must: • Ensure menus are reviewed with residents and cultural options included. • Review the current arrangements of ordering of meals. • Include a range of fresh vegetables. • Ensure meals are hot when served. • Ensue condiments are available for residents use. The registered person must: • Ensure that staff from other areas do not go into the kitchen or work in the kitchen unnecessarily. The registered person must: • Ensure the complaints procedure is reviewed and is inline with guidance. • Ensure all residents and their representatives are informed of the procedure. • Ensure a comprehensive record of complaints to include the date, nature of the complaint, the investigation, outcome and resolution. • Develop a system to enabling learning from complaints. • Provide feedback about the complaint received at the time of the inspection. The Registered Person must ensure: DS0000067126.V297307.R01.S.doc 30/06/06 22/06/06 20/06/06 30/06/06 Priestley Rose Version 5.2 Page 32 22 OP19 16(2)(j) 23 OP19 23(2)(b) 24 OP19 23(4) 13(4) 25 OP21 23(2)(b,j, n) 12(4) 26 OP24 16(2)(c) 12(1) 23(2)(c) All staff have training in relation to adult protection procedures and clearly understand their role. • The whistle blowing policy is updated. The registered person must ensure: • The chopping boards are replaced. • Chipped crockery is replaced. • Food items are not stored on the floor The Registered Person must draw up a plan of re-decoration and refurbishment and forward it to the Commission The registered person must ensure: • All doors close properly into the rebates. • A review is undertaken in respect to of the safety of the stairs and appropriate action taken. The registered person must ensure: • All toilets are fully partitioned from ceiling to floor. • A call bell is accessible to all toilet and bathing facilities. • A toilet and wash hand basin is fitted in the ground floor shower. • Attention is paid to all dripping taps. The registered person must ensure: • Locks are provided to bedroom doors. • Lockable facilities are provided for all residents in their bedrooms. • Damaged commodes are replaced. DS0000067126.V297307.R01.S.doc • 30/06/06 30/06/06 30/07/06 30/09/06 30/08/06 Priestley Rose Version 5.2 Page 33 27 OP25 23(2)(p) 28 OP26 13(3)(4) 29 OP26 13(3) 30 OP26 13(3) Damaged furniture is replaced. Forward an action plan to the Commission. The registered person must ensure: • All lighting is satisfactory to meet resident’s needs and a light can be accessed from the bed. • An audit of windows is undertaken and replaced where necessary. • Covers are provided to radiators. Forward a plan of action to the Commission The registered person must; • Ensure all equipment in the laundry is working at all times. • Provide a lock to the laundry door. • Review the use of alginate bags. The registered person must: • Provide a sluicing disinfector in sluices on each floor. • Provide suitable racking in sluices. Forward a plan of action to the Commission. The registered person must ensure suitable hygiene conditions in the home to prevent the risk of cross infection to include: • Staff hand washing facilities in resident’s rooms. • Washbowls must be stored appropriately after use. • Ensure the correct use of colour coded mops and they are cleaned after use. • Review the arrangements for barrier nursing. DS0000067126.V297307.R01.S.doc • 30/08/06 20/06/06 30/06/06 20/06/06 Priestley Rose Version 5.2 Page 34 31. OP26 23(2)(k) 32 OP26 13(4) 33 OP26 13(3) 13(4) 34. OP30 18(1) 35. 36 OP31 OP33 8 25 37 38. OP35 OP36 17(2) Sch 4 18(2) 39. OP38 13 (4)(a) The Registered Person must ensure that all areas are cleaned effectively and kept clean at all times. The registered person must ensure all chemicals are stored in locked cupboards when not in use. The registered person must ensure: • The garden is kept safe ensuring all bags of waste are removed and put in the appropriate containers. • Ensure the clinical waste bins are kept locked. The registered person must undertake an audit of staff training and develop a training file to provide evidence of the training completed by staff to determine where there are any gaps in staff training. Then develop individual training profiles for staff and ensure all staff have up to date core training. The Responsible Provider must ensure the appointment of a Registered Manager. The registered person must ensure a quality assurance system is implemented including feedback from all stakeholders and an annual development plan drawn up. The registered person must ensure all valuables held in the secure facility are recorded. The registered person must ensure that care staff receive formal supervision at least six times a year and records are retained in the home. The registered person must ensure: • All emergency lighting is tested monthly and a DS0000067126.V297307.R01.S.doc 20/06/06 10/06/06 30/07/06 30/07/06 30/09/06 30/11/06 20/06/06 30/08/06 14/07/06 Priestley Rose Version 5.2 Page 35 • • • • 40 41 OP38 OP38 13(3) 12(1) 13(4) record is retained in the home. The nurse call system is serviced regularly and records are retained in the home. There is an up to date gas safety certificate Testing for legionella is undertaken regularly. The weighing scales are serviced and calibrated 42 OP38 12(1) 23(2)(c) The registered person must 30/06/06 provide evidence of a clinical waste contract. The registered person must: 20/07/06 • Undertake an audit of all wheelchairs and ensure they are serviced on a regular basis. • Ensure all residents who use wheelchairs on a regular basis are referred for an assessment. The registered person must 20/07/06 undertake an audit of all profiling beds and pressure relieving mattresses and ensure they are all serviced on a regular basis and records are retained in the home. Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 36 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP7 OP7 OP26 OP26 Good Practice Recommendations It is recommended that the home take signage into consideration when undertaking the re-decoration programme It is recommended that the use of turn charts and carers recording system is reviewed to ensure consistency. The recommended that relevant COSHH risk assessments are kept in areas and staff working in those areas are aware of them. The Registered Person should contact the Health Protection Unit at Bartholomew House, Hagley Road, Birmingham for advice and to carry out an environmental audit. Tel 0121 224 4722. It is recommended that the on call system be reviewed. 5 OP27 Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Priestley Rose DS0000067126.V297307.R01.S.doc Version 5.2 Page 38 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!