Inspection on 20/07/06 for Regency Care Centre

This inspection was carried out on 20th July 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

Regency Care Centre 10/07/07

Regency Care Centre 12/01/06

Regency Care Centre 07/06/05

Regency Care Centre 11/11/04

Regency Care Centre 14/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Regency Care Centre 140 Lilyhill Street Whitefield Manchester M45 7SG Lead Inspector Grace Tarney Unannounced Inspection 10:00 20th & 21st July 2006 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 Regency Care Centre DS0000017328.V297998.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. Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Regency Care Centre Address 140 Lilyhill Street Whitefield Manchester M45 7SG 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) 0161 796 1811 0161 796 1819 Ashbourne Homes Limited Care Home 63 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (10), Old age, of places not falling within any other category (53), Physical disability (6), Terminally ill (2) Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 63 service users, to include up to 53 OP, up to 10 MD(E), up to 6 PD including 4 post cardiac (40 years and over) and up to 2 (TI). The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 12th January 2006 2. Date of last inspection Brief Description of the Service: The Regency Care Centre is a purpose built Home with accommodation on the ground and first floors. The home is situated in Whitefield close to a main bus route and not too far from the motorway network. There is level access to the front of the home to allow access for wheelchair users and people who have problems climbing steps. There is plenty of parking to the front of the home and it is surrounded by very pleasant gardens. The bedrooms on the ground and first floor are for the nursing and residential residents and are reached either by stairs or a passenger lift. In the near future the nursing residents will be on the first floor and the residential residents on the ground floor. The 10 bed Dementia unit is a separately contained unit with its’ own lounge and dining areas and is situated on the first floor. There are several lounges and a dining room on the ground floor. All the bedrooms are single and have an en-suite facility of a toilet, some also having a bath or shower. The toilets and bathrooms have aids to assist any resident with a disability or mobility problem. The home is registered to care for the following categories: Mental Disorder, excluding learning disability or dementia - over 65 years of age. Old age, not falling within any other category , Physical disability , and terminal illness. Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was not told that this inspection was to take place although the home was aware that an inspection was due. This was because several weeks before the inspection questionnaires were sent out to the residents, their relatives and to the home itself. These questionnaires asked what people thought of the quality of the service and the facilities provided. 8 questionnaires were returned. 4 were from relatives and 4 were from residents. The inspector visited the home over two days and spent a total of 13 hours inspecting. During this time the Inspector looked at care and medicine records to ensure that the health and care needs of the residents were being met. She also looked at how many staff were provided on each shift to make sure the residents needs were being met, and also looked at how management recruit and train their staff. To make sure that the home and the equipment in it was safe, the Inspector looked at the maintenance and service records of the equipment within the home. The Inspector then looked around the building at the bedrooms, bathrooms toilets and sitting areas to check if they were clean and well decorated. She then visited residents in their own bedrooms and lounge areas. This was to check out the care that was being provided for them. The Inspector also looked at what the residents had for their lunch and evening meal. In order to get further information about the home the Inspector also spent time speaking to 8 residents, 4 relatives, 2 qualified nurses, 6 care assistants, the maintenance man and the manager. A copy of the last inspection report is kept in the administrators’ office and the managers’ office. The Service User Guide informs that residents/relatives can request a copy from the manager The provider informed the inspector that the fees within the home ranged from £530.00 to £642 per week. This information was received on the 21st July 2006. What the service does well: Before residents went into the home one of the senior members of staff visited them in their own homes or in hospital to make sure that the care they needed could be provided by the home. The nurses and senior care staff make sure that they continually look at the residents care plan and anything that may be a risk to the residents. They Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 6 then make sure that they write down in the residents care plan when they have done this, and what action they have taken to reduce the risk. Meals and mealtimes were considered to be an important part of the residents’ day. The dining room was a very pleasant place to sit, eat and meet with other residents. The residents live in a very clean, safe and pleasant environment Residents spoke very positively of the kindness and consideration of the staff. Comments such as “Yes they are all very nice”, “I have no complaints” “Everyone is so helpful” were made to the Inspector. o What has improved since the last inspection? 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. Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 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 Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 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&6 Quality in this outcome area is good. The system for ensuring that all prospective residents had a detailed assessment undertaken before their admission to the home, gave an assurance both to residents, relatives and staff, that a resident was only admitted if the home could meet their needs. This judgment has been made using available evidence including a visit to this service. EVIDENCE: Inspection of three resident care files showed that assessments had been undertaken prior to admission. Before any resident was admitted to the home a senior member of the staff from the home undertook an assessment of their needs. Assessments undertaken by other professionals requesting a residents’ admission i.e. care manager/social worker were also in place. The home also admits people from the Rapid Response Team. Rapid Response is a system whereby people who require urgent nursing care but not admission to hospital, can be cared for on a 24 hour basis by qualified nurses for a short period of time, normally no longer than 2 weeks. When a person was admitted Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 9 under this scheme they had an assessment undertaken by the qualified nurses from the rapid response team. The home also admits people who have undergone heart surgery, who whilst being medically fit for discharge from hospital, need nursing support. Their assessments are undertaken by the hospital and this assessment accompanies the patient when they are admitted to the home. Standard 6 does not apply. The home does not provide Intermediate Care. Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 10 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 good. Overall the care plans reflected the support needs of the residents. Care practices ensured that the residents health care needs were met, although their privacy and dignity were, at times compromised. The system for handling medicines was not as safe as it should have been. This could put the residents at risk of not receiving their medicines correctly and safely. This judgment has been made using available evidence including a visit to this service. EVIDENCE: Each unit throughout the home was in the process of changing the care plan documents to those of the new company. Each care plan had a photograph of the resident attached. The care plans gave a lot of good information and clear instruction and guidance on how the care needs of the residents were to be met when problems had been identified. The admission assessments also gave detailed information about what a resident was able to do and also how they liked to dress, spend their day, their social history and their likes and dislikes. Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 11 The staff also looked at whether or not there was any risk in relation to the residents developing pressure sores and also if they were at risk due to problems with their diet and fluid intake. These are called risk assessments. They also assessed if it was safe to use bed rails and looked at any other general safety risks. Risk assessments were in place for whether a resident was at risk of falling. There were lots of very detailed care documents available for the staff to use when needed. These included accident observation, positional changes, diabetes care, wound care, challenging behaviour, nutritional intake and returning from hospital assessment forms. Ground floor. The care plans of 3 residents were looked at. The care plans were detailed and contained a lot of important information about how to care for the residents. One of the residents had a pressure sore. There was a good plan of care in relation to the prevention of pressure sores and a good plan of care on how to treat the wound. The care plan also gave a clear indication of the condition of the pressure sore. One resident had recently sustained an injury that needed stitches and a good plan of care was in place for care of the wound. This resident however was of residential status but was receiving treatment for the wound by the nurse on the unit. District nurses have the responsibility to care for residential residents who have nursing needs. First Floor. The care plans of 4 residents were looked at. 3 of them were detailed and contained a lot of important information about how to care for the resident, each of whom had intensive nursing needs. The care plan of a resident who was recovering from heart surgery was not adequate. There was no information about how to care for the residents’ wounds, nothing about how and when to get the resident walking around and nothing about the necessity of assessing the ability of the resident being able to look after and take his own medicines. Dementia Unit. The care plans of 9 of the residents were looked at. They were detailed and contained a lot of important information about how to care for the residents. From the care plans inspected it was evident the residents were weighed at least on a monthly basis and any weight loss identified and acted upon. A discussion with the residents and relatives identified that the residents had access to other health care services including hearing, sight tests and a visiting chiropodist. Evidence of these visits was kept in the residents’ individual files. Equipment necessary for the prevention and treatment of pressure sores was available on all the units. The medication systems on the all the 3 units were inspected during this visit. The qualified nursing staff administer the medications on the ground and first floor units and only suitably trained and designated care staff administer the medications on the Dementia Unit. Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 12 The following areas of concern were identified: Ground floor. The medication trolley was left on the corridor and was not secured to the wall. The Inspector was told that it was difficult to fit the medicine trolley in the small medicine room situated off the nurses’ station. Following a discussion with the maintenance man and the manager it was agreed that the trolley had to be kept within the medicine room until a secure place could be found for it. The medicine room was without any ventilation, felt extremely warm and there was no room thermometer in place. To ensure that medications are stored at the required temperature a thermometer must be in place. Stock medications were not segregated and internal and external medications were mixed together. This could result in inadequate stock rotation and even drug errors. Handwritten instructions for medicines (Transcriptions) were not signed, checked and countersigned. Signing and checking transcriptions reduces the risk of drug errors. When a prescription stated that one or two tablets were to be given, staff were not documenting just how many tablets had been administered. The medication administration sheets (MAR sheets) were not always being filled in when the medication had been given. The medication of 1 resident had been changed by an unsigned handwritten instruction on the MAR sheet from twice a day to 3 times a day. The medication of another resident had been changed from 1 twice a day to 2 at night. No explanation was given as to why there had been a change. Staff must not change a prescription. They must refer the issue back to the prescribing GP. Some medications were not stored in the container that they were dispensed in. The temperature of the medicine fridge was not always being recorded. To ensure that medicines are stored at the correct temperature the temperature must be checked and recorded at least on a daily basis. First Floor. Handwritten instructions for medicines (Transcriptions) were not signed, checked and countersigned. Signing and checking transcriptions reduces the risk of drug errors Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 13 When a prescription stated that one or two tablets were to be given, staff were not documenting just how many tablets had been administered. Stock medications were not segregated and internal and external medications were mixed together. This could result in inadequate stock rotation and even drug errors. One resident was being shown how to look after his own medicines. Despite there being a lockable space in this residents’ room he was not told that he needed to safely store his medicines in it. Dementia Unit. No issues of concern were identified. The Controlled Drug Cupboard is kept in the medicine room on the first floor and is used by all 3 units. Controlled drugs were stored and recorded correctly. The residents said that the staff treat them with kindness and respect. During the inspection staff members spoke with residents in a kindly and respectful way. Staff spoken to gave examples of how privacy and dignity were promoted. Comments such as “Yes they are so very nice”, “Couldn’t be treated better”, “They are very respectful, very kind” were made to the Inspector. During the inspection of the environment it was identified however that both the shower rooms on the ground and first floors were without a door lock. This compromises the dignity and privacy of the residents. On the first floor care needs were displayed on a whiteboard at the nurses’ station. Staff were asked to remove this on the day of inspection which they did. Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected 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 good. The home enabled residents to exercise as much personal freedom and choice as possible and find some enjoyment with the range of activities available. Great importance is attached to ensuring that the meals are varied and nutritious and that mealtimes are considered to be an important part of the residents’ day. This judgment has been made using available evidence including a visit to this service EVIDENCE: The residents spoken to said that they were satisfied with the way they were allowed to spend their day, more or less as they pleased. Several residents told the inspector that the staff let them stay in their rooms if they do not want to eat in the dining room. The Inspector saw several residents dining in their rooms at lunchtime. The residents’ routines of daily living and their social interests were recorded in detail in their care plans. An activities co-ordinator is employed by the home on a full-time basis. A programme of activities, events, and outings was prominently displayed. Two of the residents told the Inspector that they joined in with some of the activities but they would like more trips out especially to one of the local garden centres. They both said that the home are bringing in more singers these days and they liked that. Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 15 Two residents wrote in the questionnaires that the activities were not always suitable for them. Another resident wrote that they could do with something more mentally stimulating than snakes and ladders and bingo. Residents are encouraged to bring personal possessions into the home. Many of their bedrooms were highly personalised with small pieces of their own furniture, pictures, photographs and ornaments etc. Residents told the Inspector that they are able to have visitors at any reasonable time and they can see their visitors in private. Relatives confirmed this. On the inspection days, some residents were sitting outside, some with their visitors, enjoying the lovely gardens and the sunshine. The inspector did not dine with the residents but observed lunch being served. The dining room is large and is used by the majority of the residents, although some residents preferred to eat in their own room. The tables were nicely set with tablecloths, napkins, cruets and individual teapots, cream jugs and sugar bowls. A waitress service is provided. The residents were asked the day before for their choice of menu. Staff informed the Inspector that if the residents changed their minds or did not like what was being served to them then there was no problem in giving them an alternative. Those residents who chose to dine in their rooms were served their meals on trays that were set with tray clothes, napkins, condiments and individual teapots cream jugs and sugar bowls. Menus were not available. The Inspector was told that they were in the process of being amended. This was following a consultation with the residents about what they wanted on the menus. Two of the residents commented on their questionnaires that the home used poor quality ingredients for the menus. These 2 residents plus another 3, told the Inspector on the day that there had been a definite improvement in the quantity and quality of the food served, since the beginning of July. Another resident commented that the home catered well for their diabetic diet. One resident said that the home now used a well-known brand of bread, that the tinned fruit is of a better quality and is much softer and the marmalade is now served up “ just like at the airport”(meaning in little sachets) Several of the residents in the home were of the Jewish faith but did not stick to a strict Kosher diet. What they could and would eat was written in their care plans. Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 16 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 good. The complaint system in place enabled residents to feel that their views were listened to and acted upon. Staff had a good knowledge and understanding of what abuse was, thereby reducing the possible risk of harm or abuse to residents. This judgment has been made using available evidence including a visit to this service EVIDENCE: A detailed complaints procedure was in place and was displayed in the reception area. It did not however, give the contact details for the Commission for Social Care Inspection. The Service User Guide that is given out to all residents/families also explained the complaints procedure and this did give the contact details for the Commission for Social Care Inspection. A discussion with residents and relatives indicated that there was a general awareness of how to make a complaint. Replies from the questionnaires showed that the residents knew how to make a complaint if they had to. Staff also knew what to do if someone complained. No complaints have been made to the CSCI in the last 12 months. A policy and procedure was in place in relation to the detection of abuse and neglect (including whistle-blowing) and how to respond to suspected abuse. The home had a copy of the Local Authorities procedure for protection of vulnerable adults. A discussion with the manager and several care staff showed that they were very aware of the different forms of abuse and the procedure to follow in the event of any allegation of abuse. Staff continue to receive training in abuse awareness. Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 17 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 24 25 & 26 Quality in this outcome area is good. The residents were living in a clean, safe and very pleasant environment but the issue of a lack of locks on the shower room doors needs to be addressed to protect the residents’ privacy and dignity. This judgment has been made using available evidence including a visit to the service EVIDENCE: There is level access to the front of the home to allow access for wheelchair users and people who have problems climbing steps. There is plenty of parking to the front of the home. The Inspector visited each unit, walked around most of the building and looked at several bedrooms, the lounges, the dining room, bathrooms and toilets. The lounges and dining room are on the ground floor. There is a large reception area that is used by visitors and residents. This reception area leads onto the patio and very pleasant gardens. Next to the reception area there is a further lounge that is well decorated and furnished. Next to this is a further lounge and leading off from this is the spacious dining room. Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 18 The dementia unit has its own dining room and lounge on the first floor. There remained no ramped access to the enclosed patio area leading off from the lounge. It was evident that there was an ongoing programme of redecoration and refurbishment. Assisted bathing facilities were on either floor. The shower rooms on the first and second floors however had no door locks. To ensure the privacy and dignity of the residents is upheld, locks must be fitted to the shower room doors. These shower rooms and the bathroom on the dementia unit also had inadequate ventilation. The bedrooms on all the units were clean, suitably furnished and most were very personalised. The rooms were individually and naturally ventilated, they were all centrally heated and radiators were covered. The bedroom doors were fitted with over-riding safety door locks and each bedroom had a lockable space for the residents’ use. Each bedroom had either an en-suite bathroom or shower with toilet, or an ensuite toilet and washbasin only. Staff hand washing facilities were in place in bedrooms bathrooms and toilets and the home was very clean and free from any unpleasant smells.. Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 19 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 good. . Apart from the concerns raised about the staffing situation on the Dementia Unit, the residents elsewhere in the home were cared for by sufficient numbers of nurses and care staff. The residents were cared for by staff that were safely recruited, who were suitably experienced and trained, and therefore had the knowledge and skills to meet the residents’ needs. This judgment has been made using available evidence including a visit to the service EVIDENCE: Ground and First Floor Examination of the duty rotas and a discussion with staff, residents and relatives identified that there was usually sufficient nursing and care staff on duty to meet the needs of the residents. Resident and relative questionnaires showed that overall they were satisfied with the numbers of staff on duty. Two residents stated “ there are always staff available”. One resident stated “at times I have to wait for over 30 minutes for somebody to answer the call bell”. Another resident stated “usually there is staff available”. Dementia Unit There were 9 residents on the unit on the 20th of July 2006 and 10 residents on the unit on the 21st of July 2006. An inspection of the duty rota and a discussion with staff identified that the unit operated on 2 care assistants (this includes the unit manager) between Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 20 the hours of 8 a.m. to 8 p.m. and 1 care assistant between the hours of 8 p.m. and 8 a.m. The staff on the unit informed the Inspector that 5 of the residents need 2 to 1 care for dressing and bathing. Delivering 2 to 1 care meant that at certain times during the day the residents were left unsupervised. The Inspector was also informed that following the residents’ evening meal the day staff get the residents ready for bed in their nightclothes and then sit them in the lounge area until the night care assistant puts them to bed. This practice compromises the dignity of the residents and is unacceptable. The residents are also left unsupervised whilst the 1 care assistant on the unit puts residents to bed. Leaving the residents unsupervised is unsafe practice and puts the residents at risk of harm Following a discussion with senior management during the inspection, an in depth assessment of the residents’ needs and care practices was undertaken by the homes’ manager and 2 managers from other Southern Cross Homes. This assessment was undertaken over a period of days. The Inspector was informed that once the assessments were completed the staffing and practices would be reviewed and the unit staffed accordingly. The duty roster on the dementia unit did not document the full name of the staff members. In addition, all the staff rotas documented how many hours staff worked in the morning and afternoon/evening but did not actually document the times of the shifts. To ensure that an accurate duty roster is in place these details must be added. Of the 21 care staff employed 3 have obtained their NVQ level 2 or above in care. This is a percentage of 14 and therefore the home has not yet met the Standard. The personnel files of 3 staff members were inspected. All were in order and these staff had been properly and safely employed. They had a completed application form, 2 professional references, an enhanced criminal records disclosure (CRB) check and a health status declaration. An induction-training programme was in place. . All members of staff receive induction training within six weeks of appointment to their post and further training within the first six months of appointment Training records were in place in the staff files inspected. These showed training had been undertaken in the following areas: Moving and Handling. Fire Safety. First Aid. Food Hygiene. Infection Control. Health & Safety Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 21 Protection of Vulnerable Adults Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 22 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 33 & 38 Quality in this outcome area is good Although the manager is fairly new in post, her experience and qualifications should ensure that there is effective leadership and guidance to the staff thereby ensuring that the residents receive consistent quality care. The home was safe and very well maintained thereby promoting and safeguarding the health, safety and welfare of the people using the service. This judgment has been made using available evidence including a visit to the service EVIDENCE: The manager is not yet registered with the CSCI. She has been working at the home since March 2006. She is a Registered General Nurse and Registered Mental Nurse who has a diploma in nursing plus certificates in care training. She has experience working in the NHS and extensive experience in the private care home sector. She has not yet enrolled for the Registered Managers Award. Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 23 The company has developed a quality assurance system. Questionnaires have been developed and given out to residents and relatives. Management need to ensure that the results of the responses are collated and published in the Service User Guide. Management make sure that checks are undertaken on all areas of the home in relation to health and safety and fire issues. Regular checks are also undertaken of care plans, the kitchen, accidents, incidents, medications and anything else that affects the safety and well-being of the residents and staff. The home had a detailed Health & Safety Policy. Regular weekly checking and testing of fire detection system, fire exits and emergency lights was undertaken and documented. Any accidents that happen are properly recorded and monitored. The equipment and services within the home were serviced on a regular basis in accordance with the individual requirements Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 24 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 2 x x 3 2 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x x x x 3 Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 Requirement Residents admitted for post operative cardiac care must have a care plan that defines the action the staff need to take to assist in their recovery and rehabilitation. Except in an emergency the registered nurses within the home must not deliver nursing care to the residential residents. District nurses have the responsibility to care for residential residents who have nursing needs The medicine trolley must be securely stored. To ensure that medications are stored at the correct temperature a room thermometer must be in place in the medication storage area. Stock medications must be segregated into a form of order. Medications must be signed for once they have been given Staff must document the actual amount/number of tablets being given Medications must be kept in the DS0000017328.V297998.R01.S.doc Timescale for action 21/07/06 2 OP8 13 20/07/06 3 4 OP9 OP9 13 13 20/07/06 31/08/06 5 6 7 8 OP9 OP9 OP9 OP9 13 13 13 13 31/08/06 20/07/06 20/07/06 20/07/06 Page 26 Regency Care Centre Version 5.2 9 OP9 13 10 OP9 13 11 OP9 13 12 OP19 13 & 23 13 14 OP21 OP25 12 & 23 23 15 16 OP27 OP27 17 & Schedule 7. 18 17 OP28 18 container they were dispensed in Staff must not change a prescription. They must refer the issue back to the prescribing GP. To ensure that medications are stored at the correct temperature the drugs fridge temperature must be checked and recorded at least daily. When a resident has been assessed as able to self medicate, they must be advised, in the interest of safety, to keep their medication in the lockable space provided. Ramped access must be provided to the patio area on the Dementia unit (Previous requirement of 28/02/06 not complied with) Overriding door locks must be fitted to the shower rooms on the 1st and 2nd floors. Adequate ventilation must be in place in the shower rooms on the 1st and 2nd floor and on the dementia unit. The duty rotas must contain the full name and designation of the staff members The staffing levels must be kept under constant review. Staffing must be provided according to the needs and dependency of the residents, not in accordance with the numbers Training to at least NVQ level 2 for care staff must continue. A record of progress to be forwarded to CSCI by the stated date. 20/07/06 20/07/06 20/07/06 30/09/06 31/07/06 30/09/06 31/07/06 20/07/06 30/09/06 Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 27 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 Refer to Standard OP9 OP16 Good Practice Recommendations To ensure the accuracy of a transcription, handwritten transcriptions should be checked with another member of staff, signed and countersigned The contact details of the CSCI should be added to the complaints procedure on display Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Regency Care Centre DS0000017328.V297998.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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