Inspection on 15/09/05 for Radcliffe

This inspection was carried out on 15th September 2005.

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

Radcliffe 11/01/07

Radcliffe 24/01/06

Radcliffe 11/03/05

Radcliffe 24/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Radcliffe 444 Huddersfield Road Mirfield West Yorkshire WF14 0EE Lead Inspector Bronwynn Bennett Unannounced Inspection 15th September 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Radcliffe Address 444 Huddersfield Road Mirfield West Yorkshire WF14 0EE 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) 01924 493395 01924 493225 Mr Kevin Martin Janet March Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th March 2005 Brief Description of the Service: The Radcliffe is a care home registered to provide personal care and accommodation for up to thirty four older people. There is an extension to the original building with all the bedrooms in this extension being en-suite, and five bedrooms in the original building with en-suite facilities. All the bedrooms are for single occupancy. There is an outdoor seating area for the residents and car parking is available. Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over a six and a half hour period. The residents and the staff working in the home were spoken with throughout the day and written records were looked at. What the service does well: What has improved since the last inspection? What they could do better: The care records of the residents should clearly identify the care needed to meet their health care needs. Care needs to be taken with the handling, safekeeping, safe administration, storage and disposal of medication. The homes recruitment practices must improve to ensure that they are robust and offer protection to the residents. Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 6 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. Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 7 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 Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The resident’s needs are assessed prior to admission to the home. EVIDENCE: There was information in the individual care records that the resident’s individual health and welfare needs are assessed through the homes preadmission assessment. Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 9 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. The staff are working hard to ensure the residents needs are met. The home’s policy and procedure for medication must be followed. EVIDENCE: The residents spoken to said that the staff are kind and supportive. The care records for three residents were examined. The standard of these records is good and gives a clear and well laid out plan of care. There was general information relating to the oral hygiene needs of the individual. However, this needs to be specific to each resident. Assessments for tissue viability did not have a separate care plan for those residents who are at risk, and this was discussed with the manager. The daily records were detailed and showed that the staff have a good understanding of individual needs of the residents. Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 10 There was no indication within the care records that the residents had been involved in their care plan. The residents should be involved in the development of their care plan and this was discussed with the manager. The residents are registered with local GP’s. The manager said that advice and support is available form health care professionals such as the district nurses and the community psychiatric nurses. Tissue viability assessments and nutritional assessments are carried out for all the residents. The medication records were looked at for three residents. The pain relief medication did not correspond with the records kept. A discussion with a member of staff identified that staff do not dispose of medication in the appropriate way. This was discussed with the manager. The staff must follow the policy and procedure for the safe administration and disposal of medication. During this inspection the staff were observed respecting the privacy and dignity of the residents. The residents spoken with said that they are supported to maintain social contact with friends, relatives and the local community. Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 11 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. The residents are supported to experience their preferred lifestyle and are supported to maintain contact with their friends and family. EVIDENCE: The home offers a variety of activities. Trips out, aromatherapy, hairdressing and exercise sessions take place on a regular basis. A church service is held on a monthly basis and some residents go out to church. The home has an open visiting policy and the residents spoken with said that they are able to see their friends and relatives when they wish. The residents are supported to maintain contact with the local community. Some residents attend the Age Concern day-care service. Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 12 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 The residents feel able to raise concerns or make a complaint. All staff should receive adult protection training in order to protect the residents from abuse. EVIDENCE: The home has an up to date complaints procedure. The residents spoken with said that they would feel comfortable in raising any concerns or making a complaint. Staff spoken with had a good understanding of adult protection issues and the necessary action that should be taken should there be any allegation of abuse. The home has an elder abuse policy and whistle blowing policy in place. Some staff require adult protection training and this was discussed with the manager. Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20,26. The residents live in a comfortable environment that is generally clean and tidy. EVIDENCE: There is communal space in both the original and in the extension of the home. There is a smoking lounge, a non-smoking lounge and a dining room in the original building. There is a non-smoking lounge and a dining area to the homes extension. The furnishings in these areas are of a satisfactory standard. The dining area in the original building was dark, the lighting in this area is not satisfactory and should be addressed. On the day of this inspection the home was clean and free from offensive odour. Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 14 The laundry facilities were clean and well organised. The manager said that the homes washing machines have the ability to meet the required disinfection standards. Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 15 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): 27,29,30. The home’s recruitment procedures are not adequate to support and protect the resident’s. Not all staff have received the training appropriate to their work. This poses a potential risk to the health and welfare of the residents and the staff. EVIDENCE: The home has a record of all the staff that works in the home. In addition to care assistants and domestic staff there is the homes manager, a deputy and ancillary staff. Three staff records were checked as part of this inspection. Two of these records were not satisfactory. Any gaps, in a member of staff’s employment history, needs to be explored. Where the outcome of CRB checks requires further discussion with the applicant, the manager should conduct this and the records should be kept. Staff should not commence working at the home until satisfactory police checks and satisfactory checks for the protection of vulnerable adults have been carried out. The deputy manager continues working towards a management course. All new staff undergo induction training. Some staff are awaiting adult protection training and a number of staff are awaiting training for movement and handling. The training outstanding for adult protection and movement and handling should be addressed as part of the homes ongoing training programme. Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 16 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): 37,38. There are satisfactory records maintained. There is a potential risk to the health, safety and welfare of the residents when the hot water temperatures are not monitored and recorded. EVIDENCE: Satisfactory records of the duty rotas are now being maintained. A sample of maintenance records and certificates checked were satisfactory and up to date. The manager said that many of the staff have completed fire safety training and the home has conducted fire drills. The fire safety officer last visited the home June 2005 and some fire safety works are outstanding Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 17 There are risk assessments that are completed by the manager. A record of hot water temperatures are carried out in the bathrooms in the original building, but there were no records evident for other areas in the home. The inspector noted that the hot water was above the recommended 43 degrees centigrade. Water temperatures should be carried out throughout the whole of the building to ensure the health and safety of the residents and the staff. Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 18 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 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 x 2 x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x 3 1 Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 19 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 OP9 Regulation 13.2 Requirement The homes policy and procedure for the recording, handling, safekeeping, safe administration and disposal of medication must be followed. The employment history of staff must be checked. All references and disclosures must be checked. All staff should complete training for the protection of vulnerable adults. The hot water temperatures must be checked and recorded. Timescale for action 30/09/05 2 OP29 19 30/09/05 3 4 OP30 OP38 13.6 13.4 30/12/05 30/09/05 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 OP7 Good Practice Recommendations Care plans should include individual oral hygiene needs. Where an assessment for tissue viability indicates that a resident is at high risk, then a plan of care should be Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 20 2 3 OP20 OP30 completed. The lighting in the dining area of the original building should be renewed in order to provide the residents with adequate light. Staff should complete movement and handling training annually. Radcliffe DS0000026287.V251002.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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. 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