Inspection on 29/11/06 for Randolph House Care Centre

This inspection was carried out on 29th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Randolph House Care Centre 05/11/07

Randolph House Care Centre 12/12/05

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Randolph House Care Centre Ferry Road West Scunthorpe North Lincolnshire DN15 8EA Lead Inspector Mrs Kate Emmerson Key Unannounced Inspection 29th November 2006 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 Randolph House Care Centre DS0000066375.V322996.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. Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Randolph House Care Centre Address Ferry Road West Scunthorpe North Lincolnshire DN15 8EA 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) 01724 272500 01724 272505 www.fshc.co.uk Four Seasons (DFK) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Shirley Hannan Care Home 70 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (51), of places Physical disability (41), Physical disability over 65 years of age (41) Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is able to accept two named service users with Learning Disability and should revert to the original registration as they leave the home. 12th December 2005 Date of last inspection Brief Description of the Service: Randolph House is a dual registered home for residential, and nursing care for older people, there is also one bed registered for terminal care. The home was pleasantly decorated and furnished, and provided a homely atmosphere. The accommodation is provided over two floors, and has a unit on the first floor, which provides specific care for those with Dementia. The first floor is accessible by a lift, and stairs There are good parking facilities to the front of the building, and there are enclosed gardens to the rear and sides of the home. These were well maintained. The home is close to local amenities, including a post office, and general shops. It also has close links to the M180 motorway. The range of fees at the time of inspection was £312 - £535 per week. Additional charges were Hairdressing £4.75 - £15.25, Chiropody £10 and Top up fees £33 per week. Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over two days in November 2006. To find out how the home was run and if the people who lived there were pleased with the care they got the inspector spoke to the manager and staff working in the home at the time of the inspection. Surveys were sent to fiftythree staff, twenty-five service users, ten relatives and nine social and health care professionals. Of those four service user surveys were received back to the Commission, two staff surveys were received and three health and social care professionals surveys were received. During the inspection the inspector spoke to people who lived in the home and a visitor. Records kept in the home were also seen, this was to make sure that the checks to make sure staff are safe to work in the home were done before they started and that they had been trained to their job safely. Records were looked at to make sure that the home and the things used in it were safe and were checked often. A partial tour of the home was completed to check standards of cleanliness and maintenance. There were some improvements in the home and the way it was managed and the many of requirements from the last inspection had been met. The standards of care were being affected by staffing levels in the home and this must be addressed as soon as possible. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Care plans had generally improved and these were more detailed and had been kept up to date. Medication practises and records had been improved and were being constantly checked by the manager. They had made sure that medication was checked properly when it arrives at the home to make it is correct and they made sure that records show if someone has been given their medication or not. The manager now checked accident records to make sure that all risks are identified and then reduced to prevent accidents happening again where possible. The management of health and safety in the home had improved with staff training and regular equipment checks now being completed. Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 7 What they could do better: 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 Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 8 be made available in other formats on request. Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 9 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 Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 10 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): 1, 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A wide range of information about the service was provided which was sufficient for service users to make an informed choice about the home. However the documents available to service users must be kept up to date to ensure access to the correct information. All the service users were assessed prior to moving into the home. Records were generally detailed and well maintained. The assessments would benefit from consistent application of documentation. EVIDENCE: Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 11 The home provided information about the service in the form of a statement of purpose, service users guide, colour brochure and information leaflets. These were displayed in the reception area of the home. The statement of purpose had some minor omissions, which were addressed by the manager by the time of writing the report. The service users guide was informative and user friendly but to meet the standard the document also needed to include service users views of the home, further information in relation to the manager and her experience and the responsible individuals name, qualifications and experience. The manager provided this information after the inspection but all documents must be kept up to date and all the information must be made available to service users. Of the four service users who responded to questionnaires all stated that they had received sufficient information to make n informed choice about the home and all but one stated that they had received a contract/statement of terms and conditions. The three service users spoken with in the home stated that they had received a contract/statement of terms and conditions and had received information about the home and the service provided prior to admission. The manager stated that she completes all the assessments prior to admission to the home where possible. Social Service assessments and multi disciplinary assessments were obtained where applicable. Random samples of assessments were examined. The five assessments seen were detailed and care plans had been developed from the assessments. A wide range of documents was available to record information and to identify risk on assessment but there was some evidence that these were not completed consistently. The assessment process included a very detailed social assessment, which recorded the service user preferences in daily routines, diet, and activities; this had been completed in three of the five assessments seen. Risk assessments for use of bedrails had been well documented on the appropriate assessment format in one case but not in another. Another assessment indicated the use of a handling belt from assistance with transfers but the care plan stated the use of a hoist. The home accepted emergency admissions and had an on call management arrangement to assist this process. The policy and procedure provided adequate information for staff regarding the process of accepting an emergency admission to the home. Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 12 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): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there was some improvement in the care planning processes there were variations in quality and content of care plans across the home and service users health needs were not monitored consistently. However the manager was proactive in this area and continued improvement is expected. There were significant improvements in the records relating medication and storage of medication. Oxygen cylinders were not secured safely when used in bedrooms and may put service users health and safety at risk. Service user felt they were treated with respect and had their privacy protected. Policies and procedures and staff training supported this. EVIDENCE: Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 13 Case tracking of 5 service users was completed. This included examination of care records, discussion with service users where they were able and staff and observation of care practises. There was continued improvement in the care plans however the care plans varied in quality and detail across the three units. There were very good examples of care planning on the Dementia unit where care was planned in a holistic manner outlining care all aspects of the service users life and focusing on maintaining independence where possible. Whereas on the other units care plans were more clinically based and focused on care/nursing tasks. Where service users were at risk of pressure sores care plans did not always adequately state the care to be provided. Staff when questioned were vague about how often a service user should be moved and could not in one instance identify when a service user had last been moved. Another service user who required all assistance to move stated early afternoon they had not been assisted to change position since early in the morning. There was little evidence that monitoring charts were consistently used to ensure that service users had pressure relief at appropriate intervals. Nutritional screening was completed as standard but monitoring of service users weight was inconsistent across the three units. Records of wound management and evaluation was inconsistent, one unit provided very comprehensive information about a wound and progress towards healing although this had only been completed up to August 2006 and another had provided no information or wound analysis for a service user with a pressure sore. Care plans relating to wound care and records of dressing changes were inconsistent and lacked detail. Records of access to health services such chiropody; dentists and opticians were inconsistently recorded. There was some improvement in daily diary recordings in terms of reporting the care provided and health and wellbeing of the service users but entries did not sufficiently describe events that had occurred in some cases. There was evidence that service users were invited to see and agree their care plans, only one seen had not been signed but the service user had only been admitted the day prior to the inspection. Evaluations of the care plans had been completed monthly and key worker records had improved and were now more consistent and detailed. There were no service users self-medicating at the time of the inspection due to the dependency of the service users accommodated. However there were policies and procedures and risk assessments in place to support this. Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 14 Nursing staff were responsible for all aspects of medication in the home. There were records of observed medication rounds with the manager where the nurse’s competency was assessed. The manager completed weekly audits of medication. These identified shortfalls and actions to be taken. Medication records and storage were examined on all three units. Overall there was a significant improvement in medication records on all the units. Only one issue identified on Poppy unit where medication had been provided in a box and in the monitored dosage system and both had been used, the manager was requested to review this to prevent confusion and possible risk of incorrect administration. Poppy unit and Primrose unit – oxygen cylinders were not secured when in use in bedrooms. Daily checks of medication fridge temperatures to ensure that the medication was being stored safely had now been recorded. Service users who were able to express themselves stated that generally they were treated with respect and privacy was upheld. The manager stated that all the service users were accommodated in single rooms at the time of the inspection due to their personal choices but if rooms were shared a privacy screen would be provided. Service users had access to use of a telephone in private or they could have a telephone in their own room. Service users clothing was labelled and each had a laundry basket to ensure service users wore their own clothes at all times. Preferred terms of address were recorded at the assessment. Staff were provided with training in protecting privacy and dignity during induction. Randolph House Care Centre DS0000066375.V322996.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users were able to maintain contact with their family and friends and the local community. Service users were able to exercise choice in some aspects of their life but low staffing levels impacted on the individualised care that could be provided in the home. Service users were generally offered an adequate diet except those who required special diets the standard of the meals was poor. Some service users received inadequate standards of care at meal times due to staffing shortages. EVIDENCE: Service users visitors were made to feel welcome by the staff and information regarding visiting arrangements was provided in the service users guide and Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 16 statement of purpose. Information with regard to regular visitors and contact details were recorded in the social assessments. Service users choices and preferred daily routines and dietary preferences were recorded at assessment. However low staffing levels impacted on how service users needs were met leading to task orientated care rather than individualised care. Staff stated that service users couldn’t always be offered baths or showers due to lack of staff. Service users stated that they had to wait for care and one said they had to ‘ask for their position to be changed’ and another said ‘it can take an awful long time to be seen too’. Two activities coordinators were employed and service users interests were recorded on social assessments. The coordinators had received training in the role. Records were maintained of the activities the home arranged and the involvement of service users. Evidence from records, coordinators, staff and service users showed that although there was no formal activities plan, activities were provided on an ad hoc basis and time was spent giving one to one activities. Three of the four service users who responded to surveys stated that there were always activities for them to part in and one stated that there were usually activities for them. The home had been decorated for the Christmas season and the service users had been encouraged to join in this activity and had made many of the decorations and a large wall hanging. The coordinators hours spent in this area were reduced by the need for them to cover care shifts. Although most of the service users who completed questionnaires and were spoken to said they usually enjoyed their meals there was evidence that the quality of the food and the choices available had deteriorated since the last inspection. Service users stated ‘the choice and quality have gone down hill’ and that the food provided was ‘average’, they said ‘it seems to be the same everyday’, ‘I can’t complain about the breakfast that is okay but the other choices leave a lot to be desired’. The menus developed by the company would offer the service users variation and good choices at each meal but the cook was not adhering to these and choices at lunchtime were not offered each day. Food provided for those who required a soft diet lacked variety and on the second day of the inspection the previous lunch menu was served again and staff stated that service users had had the same thing for tea the previous night. There was little effort to meet special needs and one service user who required a vegetarian diet was provided with frozen ready prepared meals rather than freshly prepared meals. The lunch meal was observed; the spacious dining rooms were well presented with a copy of the menu, condiments and napkins on each table. Service users had the choice of where to take their meals and could be served in their room Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 17 if they preferred. The service users were offered choice where there was an alternative available. The staffing rotas had changed since the last inspection and the overlap of staff which been arranged to ensure there were sufficient staff on duty to assist with the meal at lunchtime had been discontinued. There were seven service users who required feeding in the main dining room with only two staff to assist them. In the dementia unit there were three staff to assist seven service users who required feeding and the other six service users required supervision and prompting. Whilst the staff should be commended for the individual attention they gave service users whilst assisting with their meal the process took an hour and a half to complete and other service users had to wait to be served or to made comfortable after lunch. A relative stated that although they were ‘satisfied with the care there were not enough staff at lunchtime’. Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 18 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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were aware of the complaints procedure and could identify whom they would speak to in the event of a complaint. The home had systems in place to protect vulnerable adults but need to improve recruitment practise to ensure adequate protection. EVIDENCE: The service users surveyed and spoken with spoken with stated that they knew how to make a complaint. Information regarding the complaints procedure was provided on admission to the home to the service users guide and was displayed in the foyer. A visitor stated that the manager ‘sorts things out if you complain’. Records in the home showed that the home had received seven complaints since the last inspection three of which were partially substantiated and one was undergoing investigation. The complaints were varied and included lack of falls management in the home, cleanliness, staffing levels and inadequate care. Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 19 Staff group had received training in the protection of vulnerable adults and all spoken with displayed knowledge in the recognition of abuse. They all gave acceptable responses to the action that they would take in the event of suspicion of abuse. The home had a variety policies and procedures to protect vulnerable adults. A copy of the Local Authority protection of vulnerable adult procedures was available in the home. The manager had attended managers training with the Local Authority. Deficiencies in recruitment practise did not offer adequate protection to service users. Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 20 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): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The cleanliness and odour control in the home had been maintained and the standard of décor had now improved. The kitchen required a thorough clean and replacement of some equipment. The environment in the Primrose unit had been improved with signage to meet the specific needs of service users with dementia. Service users health and safety was being put at risk due to fire doors being wedged open, linen cupboard doors not locked and oxygen cylinders not being adequately secured. EVIDENCE: Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 21 The home provided comfortable homely accommodation with a variety of communal space for the service users to enjoy. The gardens were well maintained and accessible. The home was generally clean tidy and odour free. The service users stated that the home was always clean and fresh. There was evidence of an ongoing maintenance and redecoration in the home. Some of the dining tables had very loose legs and were very badly marked. The manager stated that she ordered some new furniture. A replacement dishwasher had been purchased and was being fitted on the day of the inspection; staff stated that they had been waiting a month for this piece of equipment to arrive. On checking with the manager there was a complicated system for ordering new equipment and this should be reviewed in the case of essential pieces of equipment to ensure a timely response. Service users safety was being compromised due to fire doors being wedged open, linen cupboard doors not being locked and oxygen cylinders not being safely secured in bedrooms. Signage had been provided in the dementia unit to assist service users in maintaining independence and orientation in their environment. The kitchen was tidy and a cleaning schedule was maintained but the kitchen would benefit from a deep clean including floors under units and walls. The flooring in the kitchen had come away from some of the edges and required repair or replacement to enable adequate cleaning. The two Bain Marie’s were in a poor state of repair the doors were broken and fixed with tape on one and the temperature could not be controlled on another. The staff on the dementia unit stated that the window at the end of the corridor had been fixed so that it could not be opened but ventilation was required in this area. Randolph House Care Centre DS0000066375.V322996.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staffing levels were not consistently and adequately maintained. It is advised that admissions policy is in line with available staff numbers. The staff received training appropriate to their role. There was evidence that not all the checks to ensure staff are safe to work with service users had been obtained prior to employment. This does not afford adequate protection for service users living in the home. EVIDENCE: The home was divided into 3 areas for arranging the staff group. Each area should have had 1 nurse and at least 3 carers on duty during the day except where occupancy levels were reduced and following discussion with the commission. Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 23 There was evidence from records and discussions with staff that these staffing levels were still not consistently maintained in the home and each unit was regularly short staffed. There was evidence during the inspection that there was insufficient supervision and assistance for the service users when they were sat in the communal areas and during meal times. The manager confirmed that the company provided sufficient budgets for staffing to be maintained but that there were insufficient staff employed to cover the rota and staff sickness had also impacted on the staffing levels. The low staffing levels were impacting on all areas of the care provided in the home and although service users needs were being met the care was provided in a task-orientated manner and lacked individuality. The service users reported that they had to wait for care and one service user stated that they sometimes waited ten to fifteen minutes for assistance. This is not appropriate and must be addressed. The management team and the Responsible Individual were advised that they should review their admissions policy until they can provide consistent and adequate staff numbers on duty at all times. The manager had identified the staff training needs and had implemented a training plan to meet mandatory training requirements for 2006. Records of staff training had not been kept up to date but information was provided prior to writing the report which showed that care staff had received training including moving and handling training, fire safety training, food hygiene and protection of vulnerable adults training in the last year. Training was provided for nurses specific to their role and they had completed training in catheterisation, pressure ulcer prevention, diabetes, medication, supervision and infection control. A training plan for 2007 had not been developed at the time of the inspection. There was evidence that the activities coordinators had had training in this area. There was evidence that new staff completed an in-depth induction to the home and their role. An assessment of the nurse’s competency in the safe handling of medication was also completed as part of induction. There were deficiencies in the recruitment process. Files for four staff who had been employed since the last inspection were examined. In four cases Criminal Record (CRB) checks had not been received before employment although in three of these cases a POVA first check had been obtained and in another where a nurse had been employed form abroad a police check had been received from their own country. There was no evidence that the staff member had been supervised at all times until receipt of the full CRB and staff stated that new staff were on the rota and counted in the staff numbers on their first day in the home. There was evidence that two staff had commenced work before two written references had been received and there was no evidence that the references provided by the nurse employed from abroad had been authenticated. Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 24 There was evidence that nurse Personal Identification Numbers (PIN) where now checked both prior to and after employment. Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 25 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): 31, 32, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An experienced manager runs the home. Service users money was safe guarded but current systems breach regulations. The home is committed to a providing a quality service but will need to improve staffing levels to meet requirements and develop further. Staff supervision was provided regularly. Management of health and safety had improved but there were some deficiencies to be addressed. Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 26 EVIDENCE: The manager Shirley Hannon has been in post since December 2005 prior to this she was the deputy manager at the home. Ms Hannon is a Registered Nurse and has many years experience in the care industry. Since the last inspection Ms Hannon has successfully completed the process with the Commission to become the registered manager at the home. The administrator maintains clear records where service users money is held by the home and receipts were held and there was evidence that the records were regularly audited. Service users money was paid into a single bank account and a small single cash float was held at the home, which service users could access. The bank account paid a low interest rate on the money held but there was no evidence available to state where this went. The administrator stated that the systems were company procedures. The procedure of pooling service users money into a single bank account is in breach of Regulation 20, which states that ‘the home shall not pay money into an account unless the account is in the name of the service user or, any of the service users, to whom the money belongs’. There had been general improvement in most of the working practises in the home and the manager completed regular in-depth audits in most areas. The home provided an audit report completed May 2006 and they had been awarded the North Lincolnshire gold award in the Quality Development scheme just prior to the inspection. Although there was a commitment to a quality service in the home and staff were committed to providing a high standard of care staffing levels will need to be improved if requirements arising from this inspection are to be met. There was evidence from staff and records that staff received regular supervision. There were improvements in the management of health and safety in the home. The manager had previously identified that not all the staff had received mandatory training and had implemented a training programme to address this over the last year. There were significantly improved fire safety processes and records showed regular fire equipment checks and alarm and emergency light testing. Regular checks of escape routes and fire doors were completed and weekly fire drills were recorded. However there were fire doors wedged open in both bluebell and poppy units and oxygen cylinders were unsecured in bedrooms in poppy and primrose unit and the linen cupboard door was not locked on the poppy Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 27 unit. A basic fire risk assessment had been completed and the manager stated a detailed assessment was to be completed in January 2007. Logs of maintenance plans and tasks completed were held. There was evidence that equipment used in the home had been regularly serviced and staff confirmed that all equipment was working and that sufficient equipment was now provided. There was improved monitoring of accidents/falls in the home and there was evidence that service users had been referred to the falls prevention team as necessary. Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 28 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 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 1 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 3 X 2 Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 and 5 Requirement The registered person must ensure that the information provided to service users is regularly reviewed and kept up to date The registered person must ensure that assessments are consistently completed and all needs are identified are recorded. The registered person must ensure that the care plans are consistently completed. The registered person must ensure that service users health is monitored and risks to health reduced. Records relating to assistance with pressure relief, monitoring of service users weight and wound care and progress towards healing must be consistently recorded. Access to health professionals must be consistently recorded. The registered person must ensure that oxygen cylinders are secured in bedrooms. The registered person must ensure that the care in the home DS0000066375.V322996.R01.S.doc Timescale for action 01/04/07 2 OP3 14 01/03/07 3 4 OP7 OP8 15 15 01/03/07 01/03/07 5 6 OP9 OP12 13(2) 12(3) 14/01/07 01/02/07 Randolph House Care Centre Version 5.2 Page 30 7 OP15 16(2)(i) 8 OP19 23(2) 9 OP19 23(4) 10 OP19 23(2)(p) 8 OP27 18 9. OP29 19 10 OP35 20 meets individual needs and preferences. The registered person must ensure that a nutritious diet is provided and the quality and variety of meals for specific diets such as soft diets and vegetarian diets are improved. The registered person must ensure that the kitchen is thoroughly cleaned and equipment is in good order. The Bain Marie’s require replacement and the floor covering repairing to edges. The registered person must ensure that fire doors are not wedged open and linen cupboard doors are kept locked. The registered person must ensure that there is adequate ventilation in Primrose unit corridor. The registered person must ensure that the staffing levels in the home are sufficient to meet the needs of the service users and are consistently maintained. They must ensure that there are sufficient staff on duty to meet the demands of the busiest times of day such meal times. Copies of staff rotas must be provided to the Commission until further notice. The registered person must ensure all checks as listed in Regulation 19 are obtained prior to employment of staff. (Previous timescale - 12/12/05 was not met) Where staff are employed prior to a full CRB being obtained a POVA 1st must be obtained and the staff member must be supervised at all times. The registered person must ensure that service users money DS0000066375.V322996.R01.S.doc 14/01/07 01/02/07 29/11/06 14/01/07 14/01/07 29/11/06 01/02/07 Page 31 Randolph House Care Centre Version 5.2 is only paid into a bank account, which is in the service users own name. (Previous timescale of 01/02/06 not met) 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 OP1 Good Practice Recommendations The registered person should ensure that the service users guided includes service users views of the home, further information in relation to the manager and her experience and the responsible individuals name, qualifications and experience. The registered person should review processes for ordering essential pieces of equipment to ensure timely response. The registered person should review the homes admission policy should be reviewed in line with available staff numbers. 2 3 OP19 OP27 Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Randolph House Care Centre DS0000066375.V322996.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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