CARE HOMES FOR OLDER PEOPLE
The Hollies & Bloomfield 2 Dudley Road Sedgley Dudley West Midlands DY3 1SX Lead Inspector
Mrs Jean Edwards Unannounced Inspection 23rd November 2005 07:50 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 The Hollies & Bloomfield DS0000024970.V267826.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. The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service The Hollies & Bloomfield Address 2 Dudley Road Sedgley Dudley West Midlands DY3 1SX 01902 883130 01902 665680 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) Midland Property Investment Fund Ltd Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Voluntary removal of cateogories of PD(E) and DE for a period of time to be agreed with CSCI. 27/07/05 Date of last inspection Brief Description of the Service: The Hollies & Bloomfield is a Care Home in two adapted properties, which have been linked via a connecting extension. The home provides 24-hour personal care for up to 39 older people, with general frailty (over the age of 65 years not falling into any other category). Previous registration categories for DE (Dementia) and PD/E (Physical Disabilities over 65 years) were removed following the announced inspection 12 & 13 July 2004. Thirty-six of the beds are provided within the two main buildings with a further three beds located in a flat accessed through a separate ramped entrance at the rear of the building. The stated intention of the management is to work towards running the two interconnected buildings as separate units under the direction of one registered manager. The flat is a semi-independent unit, with any residents accommodated accessing the home in the daytime and having access to staff at night via a call system. The Home is owned and managed by a Property Management Company and has a staff team of 35 people, including 22 care staff and 12 ancillary staff. There is currently no Registered Manager. A Director of the Property Company has been approved as the Responsible Individual with support from a Care Management Consultancy. The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection visit has been undertaken by two Inspectors from the Commission for Social Care Inspection. The purpose of this inspection is to assess the homes progress to improve a number of areas identified at previous inspection visits and assess its overall progress towards meeting the National Minimum Standards for Care Homes for Older People. A range of inspection methods has been used to obtain evidence and make judgements, which include the following: action plans submitted by the home, reports from the nominated representatives for the organisation relating to the conduct of the home, notifications of events and records held at the home. The visit started at 07:50am and lasted until mid afternoon. During the visit the Inspectors spoke to the majority of the 27 residents who are currently living at the home, with longer discussions taking place with the residents, whose care was looked at in depth. The manager, two team leaders, the Responsible Individual and Management Consultant took an active part in the inspection process. The Inspectors toured the building, looking in particular at the kitchen, laundry, bathing facilities, communal areas of the home and a sample of residents’ bedrooms, with their permission. What the service does well:
The organisation continues to have additional managerial support in place from a Care Management Consultancy. The organisation has responded to the unannounced inspection visit in July 2005 with a comprehensive action plan, giving dates for the required improvements to be put into place. There are now considerable improvements in a large number of areas. One resident who had her care review on the afternoon of this visit, attended by her social worker and daughter states, very pleased with the home and the care provided - staff are very patient especially with me. The menus have been revised and the meals are nutritious, well prepared and appear appetising. Members of care staff ask residents what they prefer for each meal and they take time to offer sensitive help if people need it. The residents are complimentary about the food. Another resident who has been living at the home for 10 weeks comments, This is a nice place, I have a nice bedroom. The Physiotherapist comes to see The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 Page 6 me 1 - 2 times a week - this home has done more for me than the hospital ever did - my husband comes and has Sunday lunch with me. The Hollies & Bloomfield is a generally clean, pleasant and comfortable home for residents. The majority of chairs are new; as are the tablecloths and the dining tables have attractive flower decorations. The home looks inviting, with festive Christmas decorations, which the staff have taken a great deal of time and effort to put in place. Residents have commented on the cheerful atmosphere. There is a more stable staff group, who are caring, committed and flexible, often willing to work extra shifts. There is a genuine and warm rapport between the staff and residents. A number of people have been complimentary about the staff and the care provided, such as the staff and manager are very good, very patient, very polite. One person states, I prefer older staff. The organisation has put in place a National Vocational Qualification (NVQ) training programme for all care staff and has made very good progress with a ratio of 57 of care staff with an NVQ level 2 award and 46 with an NVQ 3 award and a further group of staff undertaking training to achieve NVQ qualifications. This inspection has been conducted with the full co-operation of the Director, who is the Responsible Person, the Management Consultants, Manager, Team Leaders, staff and residents. The atmosphere through out the inspection has been generally relaxed and friendly. The Inspectors would like to thank management, staff and residents for their hospitality during this inspection visit. What has improved since the last inspection?
This home has made significant improvements in a number of areas in a relatively short period of time, mainly due to the leadership and direction provided by the manager, supported by the Care Management Consultants and the responsible person. The organisation now provides up to date and easy to read information about the home, the staff and the way care is provided. There is also information available about how to see the homes recent inspection reports. The home is about to publish its first newsletter, which includes results from a recent survey of views of residents and their relatives and visitors. Each person or their representative now receives written confirmation that the home is able to meet all of their needs, with offers and decisions about introductory visits now fully recorded on residents individual case files. This demonstrates that people have good information and opportunities, on which to make decisions about where they will live.
The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 Page 7 The way the home plans each persons care is now improving. The written information is more detailed and specific and provides staff with clearer guidance. Health care assessments have improved, with more detailed records of the measures in place to minimise risks of falls, risks involved in moving and handling people, or risks of people leaving the building unaccompanied. Each persons preference as to whether they wish to have personal care provided by a male or female carer is recorded. The considerable efforts to improve the way medication is stored, administered and recorded have been continued with good results. There is now a much safer system for the management of residents medicines. A small number of additional areas needing improvement have been identified at this visit. Although the home has not appointed a new activities co-ordinator as yet, there are increased opportunities for activities and outings. Residents enjoyed playing bingo and a sing-a-long during this visit. Everyone enjoyed Caribbean entertainments in the summer and there are lots of family photographs of the recent bonfire party. Additionally plans are well advanced for Christmas celebrations. The manager has improved signage around the home, which helps residents with limited capabilities to find their way around, especially to toilet and bathing facilities and it is positive that the day and date is on display in both areas of the Hollies and Bloomfield units. The posters advertising the complaints procedure have now been produced in a form that is understandable to the people needing to use it. The staff also make sure verbal information is given to those residents who may not be able to read or understand the written information. The management of the home are now reporting any incidents of aggressive behaviour between residents to the appropriate agencies, making sure that adequate protection is provided for any vulnerable person, who may be at risk. Staff are supported and are in the process of being trained to be aware of and recognise the needs and rights of vulnerable people. Improvements have been made to the decor of the interior of the home, with an ongoing programme of replacement of fixtures, fittings and furniture. This is making a noticeable difference to the comfort and contentment of the residents. The manager has resolved the fuzzy TV pictures in The Hollies and Bloomfield lounges by purchasing new TV aerials. The systems for controlling any sources of infection and promoting good standards of hygiene have generally improved. The Acting Manager and Management consultancy have continued the process to recruit additional suitable new staff, with safe processes, such as making sure detailed checks and clearances are obtained before people start work at the home. The organisation has appointed an experienced and efficient
The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 Page 8 administration assistant, who makes sure that the administration processes of the home run calmly and smoothly, which benefits the residents. The organisation has sent an application to the CSCI office, Halesowen to register the current acting manager. This will greatly assist the home to stabilise and continue to achieve improvements. Previously the Hollies & Bloomfield had not had a Registered Manager to provide good leadership and acceptable standards since November 2003. 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 Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 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 The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,5 The organisation has produced an updated and expanded statement of purpose and service user guide and is making some progress to update residents contracts / terms and conditions of occupancy. This has the effect that residents and their advocates now have improved information regarding their rights and entitlements, any agreed restrictions and how care will be provided. The home now uses comprehensive assessment tools, which means that residents’ needs are thoroughly assessed to ensure that care needs will be met. The home actively encourages introductory visits and there is now documentary evidence to demonstrate that people have been given the opportunity and time to make decisions, which are right for them. EVIDENCE: The organisation, with support from the Care Management Consultancy, has revised and expanded the home statement of purpose and service user guide and copies of these documents are now provided to residents and families, and copies are available for prospective residents and other professionals. A draft newsletter containing the collated results of a recent survey of residents views is nearing completion and publication. The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 Page 11 From discussions and assessment of a sample of residents case files there is evidence that the home now ensures that there is detailed care management assessment information from referral agencies. In addition the home carries out its own comprehensive pre admission assessment. There is ample evidence that a proactive reassessments and reviews of residents needs are conducted on an ongoing basis. The exception to this relates to the review and reassessment of MA. The home has documentary evidence of repeated requests for support from Dudley Social Services, without success. This follows concerns raised at previous inspections about how this residents care needs and family relationships can be safely managed. The home must continue with efforts and if necessary copy correspondence to the senior management of Social Services and to the CSCI office, Halesowen. The organisation has not yet provided the CSCI with an up-to-date documented assessment of needs for the residents currently accommodated, outside of the homes category of registration, nor has a request been made for an appropriate variation to conditions of registration, in order that the homes Certificate of Registration is accurate. The residents files assessed have provided documentary evidence that written confirmation is given to each person and/or their relative or representative that the home can meet their assessed needs. The home is also recording offers and outcomes of introductory visits. The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 There is now improved care planning and monitoring in place, which provides staff with the information they need to more adequately meet residents needs. There is improved evidence of good multi disciplinary working taking place on a regular basis, which results in the health needs of residents being more satisfactorily met. The home has made very good progress with regard to the arrangements for administration of medication, which now provides good safeguards for residents. EVIDENCE: There are improvements to the care planning processes, though further developments are needed. The manager acknowledges that further work needs to be done and is continuing with developments. Some areas of the care plans are more detailed and specific and provide staff with clear guidance, such as diabetic care. Examples of care planning needing fuller detail are medication regimes and evaluation of goals. Each persons choice as to the gender of staff preferred to provide personal care are now recorded. However two residents, DN and LD (or their family or representative) have not signed their care plans. There are now improved risk assessments and health care screening assessment tools in place for each person. There is recorded evidence that
The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 Page 13 each persons weight is regularly monitored, with appropriate referrals to GPs and community dieticians for advice for people considered to be at risk or with weight loss. The home has obtained advice where there are regimes of giving fortified drinks and foods, to ensure that there are no contra-indications relating to increased fats and proteins. There is some evidence of satisfactory nutritional and fluid intake, though not all food charts are completed with tea and supper taken. Though there are risk assessments in place relating to aggressive or challenging behaviour. The risk management strategies must have additional detail and be specific to provide sufficient guidance for staff to respond appropriately. This is particularly important where unacceptable behaviours are directed towards other residents. There is a record in a residents daily notes on 15/11/05 D wants to go home because other residents are picking on her. Observations at this visit are that another resident B is being very vocal towards her. The staff confirm that this frequently occurs. The home has copies of comprehensive medication policies and procedures available. There is evidence that efforts are being continued to improve systems and records of administration of medication. Increased monitoring arrangements have made sure improvements are maintained. The Home now has risk assessments in place for all residents who choose to administer any part of their medication. The medication storage has been relocated, which has resolved the problem of the severe damp on the walls of the room where medication was previously stored. However there are some areas at this visit, requiring additional improvements. Examination of the sample of MAR sheets at this visit identified 12 gaps over a two-week period, where there was no signature or code for nonadministration. A small number of random audits of medication stocks identified two discrepancies. These are Paracetamol (DN) 4 tablets missing and Chlorpromazine (KW) 3 tablets too many. In addition discussions with staff identified that new senior staff, who have no current training and have not been assessed as competent by district nurses, are carrying out blood glucose monitoring procedures. Training was originally provided some time ago and no refresher training sessions have been arranged. At this visit there is generally an improved standard of care at a practical level and a number of residents and visitors made positive comments about the kindness and care given by staff. Residents look well groomed and cared for. The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 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, 14 There is evidence of some progress to make planned and spontaneous activities available on a regular basis, which give residents improved opportunities to take advantage of and develop socially stimulating activities. Residents are offered opportunities to exercise choice and control over their personal environment and lifestyle. EVIDENCE: Though the post of activity co-ordinator remains vacant there is evidence that the home is providing improved opportunities for residents to participate in organised activities. The manager and senior members of staff have currently taken responsibility for organising activity programs, though there is still a major consultation exercise to conduct with residents. Recent and forthcoming activities are advertised on a notice board in the main corridor. It is evident that staff are enthusiastic about giving support to residents to enable them to participate in organised entertainments and trips. The proprietor has taken photographs at recent events such as the bonfire party, which are on computer and are made available to families and are used with residents for reminiscence. Currently there is no information about advocacy services proactively displayed in the home, though it is stated that people are encouraged to use their own
The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 Page 15 solicitor, support from the local authority or independent advocacy services according to their preference or needs. From the sample of residents case files examined there is evidence that property inventories are in place, however two are incomplete and notably items such as hearing aids have not been recorded. This is particularly important as one persons hearing aid is missing. The following previous requirements relating to meals have been actioned with good results: the home has undertaken a documented audit of residents food preferences, and revised menus have been devised, and the new menus are prominently displayed in the home, in suitable formats to the residents capabilities. The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 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 Complaints are listened to and action is taken to look into them, and action to make sure all residents are aware of the complaints process has improved. There are improved policies, procedures, guidance and progress is being made to provide staff training in order to safeguard residents from abuse. Good progress is being made to improve arrangements for protecting residents. EVIDENCE: The home has a complaints procedure, which is more accessible in larger print and there is evidence that all residents / representatives have been given a copy of the homes complaints procedure and that staff help them to be aware of the process. The home has not received any complaints since the inspection visit in July 2005. There is documentary evidence that the home has taken action to refer all incidents of aggressive behaviour between residents to Social Services in accordance with the multi-agency policy Safeguard and Protection (Protection of Vulnerable Adults). The CSCI office, Halesowen has received Regulation 37 notifications of all events adversely affecting the being of residents. Good progress is being made to provide all staff with awareness and training relating to the following areas: the protection of vulnerable adults, and challenging behaviour met. However training relating to use of restraint or non-physical intervention has not yet been provided. Although the home has a copy of the multi-agency procedure for the protection of vulnerable adults, there is currently no documentary evidence to
The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 Page 17 demonstrate that staff have been made aware of the Safeguard & Protect procedure. Currently there are no separate violence at work forms as well as the accident records. Any incidents involving violence against staff should be separately documented and acted upon. It is recommended that staff signatures be obtained to demonstrate their awareness of the homes policy. The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24,26 There continues to be significant and positive changes to the décor and furnishings. The incremental improvements contribute to creating a pleasing and pleasant environment for residents to live in. EVIDENCE: The majority of the standards in this section have been assessed at the previous inspection in May 2005. The internal decor is generally bright and cheerful and improvements continue to be made to the communal areas and the residents bedrooms on a rolling programme. There is evidence that all staff now follow appropriate procedures in the reporting of any maintenance issues, which require attention. No action has been taken to meet the requirement to provide a call point in the Bloomfield lounge, therefore the registered person must devise a written risk assessment as an interim measure and means of monitoring need for call point in Bloomfield lounge.
The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 Page 19 During the visit a resident ED had been seated in a recliner chair tilted to its optimal angle and though there is currently no evidence of an accident, arrangements must be made for a reassessment of needs to be carried out by an appropriately qualified occupational therapist. The manager has improved the signage appropriate to residents needs and capabilities for better orientation and it is positive that the day and date is on display in the areas of the Hollies and Bloomfield. She has also resolved the fuzzy TV pictures in The Hollies and Bloomfield lounges with new TV aerials. However during the visit the volume of radio in one of the communal rooms is excessively loud and only one resident in the room wished to have the programme on. Some improvements required in order achieving satisfactory standards of infection control remain outstanding. At the start of this visit used linen and clothing had been deposited and left on the floor outside the ground floor sluice room. A brief inspection of the homes main kitchen has taken place. There is generally good compliance with food safety regulations. The kitchen is clean, tidy and very well organised. The cook dealt with the one bottle of red sauce, which had not been refrigerated. The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Staff morale is improving resulting in improved attendance, diligence and less reliance on staff working in excess of contracted hours or use of agency staff, which has increased the potential for residents to receive a consistent and satisfactory service. Improved recruitment and selection of suitable, competent staff provides good safeguards for vulnerable people living at this home. The home demonstrates a strong commitment to staff training and development. EVIDENCE: There is now a stable core group of established staff at The Hollies & Bloomfield and this is being complimented with careful recruitment of additional experienced and well-trained people. Staffing levels are generally maintained with the use of existing staff working extra shifts, and it is stated that though agency staff can be used, there has not been the need recently. However there is some evidence that occasional shifts have been short of one carer. The CSCI has yet to receive or agree staffing proposals from the organisation. The organisation must provide revised staffing proposals to demonstrate that there will be sufficient numbers of staff to meet the needs of the people currently living at the Hollies & Bloomfield and for prospective people who may be planning to choose the home, especially as there is evidence of occupancy increasing to fill the vacant beds.
The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 Page 21 The assessment of a sample of staff personnel files demonstrate that staff files are very well organised and contain the majority of information required for compliance with legislation. Interview questions and answers are retained on file, as is good practice. However the organisation must provide recent photographs of newly employed staff on their personnel files. The Organisation has not been able to forward to the CSCI satellite office, Halesowen copies of valid work permits for all overseas staff, which are specific to the Hollies & Bloomfield or documentary evidence that existing work permits have the approval of the Home Office. The responsible person has documents from the Home Office demonstrating ongoing communication, however the Home Office have not reached final decisions about the validity of their employment status at this home. The home is continuing progress to meet requirements issued at previous inspection visits relating to staff training together with progress to introduce a formal structured supervision process for all care staff and a key worker system. Though these initiatives are at an early stage. The manager has submitted documentary evidence of current training targets achieved to the CSCI office, Halesowen. The home has a ratio of 57 of care staff with an NVQ 2 award and 46 have also achieved an NVQ 3 care award. The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 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, 32, 35,37,38 The acting manager, supported by the Care Management Consultants and proprietor, is providing good leadership and direction. The communication and monitoring systems are effective and ensure that staff are clear about their roles and responsibilities. There is an improvement in the standards of record keeping and health and safety compliance at this home, which improves protection for residents from risks of harm. EVIDENCE: The manager, Dorothy Fagan, appointed in October 2004, is providing leadership and implementing improvements, supported by the Care Management Consultancy NRF and Matthew Hughes, a director and the Responsible Individual for the organisation. The CSCI has received an application to approve Dorothy Fagan as the registered manager. The process is due to be completed by February 2006. This has been a priority because the home has been without a registered manager since November 2003.
The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 Page 23 There is improved evidence to demonstrate that residents, their families or representatives are actively involved in processes affecting the way they are supported or cared for, such as assessments and care planning. There is evidence that residents meetings take place, and formal systems have recently commenced to regularly seek, collate and evaluate peoples views about the homes performance. NRF Management consultancy, in the role as the organisations nominated representative, are conducting regular monthly, unannounced visits to monitor the homes performance, providing reports for the organisation, the home and the CSCI office, Halesowen. The home holds monies in temporary safekeeping for a number of residents. The home operates sound financial systems to protect residents monies held in temporary safekeeping. A sample of balances and financial records examined are satisfactory. However at least one person has a large sum of money held in safekeeping, therefore the organisation needs to confirm with the homes insurers the maximum amounts of residents monies, which may be held in the homes safe. Residents / or their representatives need to be advised and encouraged to place any large amounts of money in appropriate bank accounts. There is evidence that efforts are continuing to improve the standard of record keeping at this home, with positive results. An analysis and evaluation of accidents involving residents and staff is conducted on a monthly basis. The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 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 3 X 3 2 3 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 X 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X 2 X X X 2 STAFFING Standard No Score 27 2 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 4 X X 3 2 2 2 The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 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 OP4 Regulation Care Stnd S24 14(1) Requirement The registered person / manager must carry out an assessment of all service users’ primary need where there is doubt as to whether they are within the homes categories of registration, and if appropriate apply for a variation to the certificate of registration. (Timescale of 17/09/04 and 31/08/05 Not Fully Met) Timescale for action 01/02/06 2 OP7 15(1) This must now be actioned as a priority To ensure that service user plans 01/02/06 are developed in consultation with each person and / or their representative, to include aspects such as: 1) Full details of all care provided to meet assessed identified needs (Timescale of 30/09/04 and 31/08/05 Not Fully Met) 2) Specific guidelines for staff regarding care to be provided (Timescale of 30/09/04 and 31/08/05 Not Fully Met) The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 Page 26 4) Agreed limitations on choice, freedom or decision-making (Timescale of 30/09/04 and 31/08/05 Not Fully Met) 5) To include hearing impairment, hearing aids and communication needs (Timescale of 31/08/05 Not Fully Met) To ensure that the service user plan is (consistently) signed by the service user and / or representative (Timescale of 31/10/04 and 31/08/05 Not Fully Met) Risk management strategies must be detailed and specific to provide sufficient guidance for staff to respond appropriately to aggressive (or challenging) behaviours (Timescale of 14/06/05, 31/08/05 Not Fully Met) Additional detail needed A format for the assessment of tissue viability must be developed, with these assessments carried out for all residents on admission with reviews on a regular basis. (Timescale of 31/10/04 and 31/08/05 Not Fully Met) To devise and implement Key Worker System, with the full involvement of staff and service users, using guidance such as Local Government Management Board (LGMB) Key-working training pack (Timescale of 31/10/04 and 31/10/05 Not Fully Met) To ensure records are maintained to provide evidence of an adequate nutritional food intake on a daily basis
DS0000024970.V267826.R01.S.doc 3 OP7 15(1) 01/02/06 4 OP8 13(1)(4) 14(2) 01/02/06 5 OP8 13(1) 17(1) 01/02/06 6 OP8 12(1) 13(1) 01/02/06 7 OP8 13(1) 17(2) sch 4 01/02/06 The Hollies & Bloomfield Version 5.0 Page 27 8 OP9 13(2) (Timescale of 14/10/04 and 31/08/05 Not Fully Met) 1) To ensure that medication keys handover signature sheet is accurately completed at each shift change. (Timescale of 14/10/04 and 31/08/05 Not Fully Met) 2) To ensure that all staff responsible for the administration of medication date and sign the homes medication policy / procedures (Timescale of 14/10/04 and 31/08/05 Not Fully Met) 1) To ensure blood glucose monitoring procedures are only carried out by staff with current training and deemed competent by district nurses 2) To obtain up-to-date training from the district nurses for all staff who may undertake blood glucose monitoring procedures 3) To ensure there are no gaps in the MAR (medication administration records) sheets. Where medicines are not administered, the appropriate non-administration code must be used. 4) To ensure that there is an up to date list of staff authorised to administer medication. 5) To undertake regular spotcheck on the quantities of medication, with records, noting the date, whether the quantities tally and the signatures of the two staff who carried out the check. 01/01/06 9 OP9 13(2) 01/02/06 10 OP12 16(2) The registered person must
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Version 5.0 Page 28 The Hollies & Bloomfield 11 OP14 13(6) 12 13 14 OP14 OP14 OP18 13(6) 13(6) 13(6) 18(1)(c) continue to ensure that the activities made available to service users are flexible, varied and in accordance with service users expectations, preferences and capacities. (Timescale of 31/11/04 and 30/09/05 Not Fully Met) To ensure property inventories of service users property are drawn up on admission and thereafter kept up to date. (Timescale of 31/10/04 and 31/08/05 Not Fully Met) To ensure items such as hearing aids are included on inventories (DN & LB) To proactive display advocacy information in the home To provide all staff with awareness / training relating to: Restraint / non-physical intervention from an accredited trainer (Timescale of 31/10/04 and 31/10/05 Not Fully Met) To review the situation between two residents, where there is discord and devise a resolution to avoid DN feeling picked on 1) To establish a written maintenance and refurbishment programme. To forward a copy to the CSCI. (Timescale of 31/10/04 and 31/10/05 Not Fully Met) 2) To carry out a written risk assessment with regard to the use of stair gates which are fitted to first floor stairways. (Timescale of 31/10/04 Not Fully Met) Lock on stair gate not working on 27/07/05 or on 23/11/05 01/02/06 01/01/06 01/02/06 01/02/06 15 OP18 13(6) 01/01/06 16 OP19 23(2)(a) (b)(c) (e) 01/02/06 17 OP19 23(2)(a) 1) To renovate / redecorate
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Version 5.0 Page 29 The Hollies & Bloomfield (b)(c) (e) damaged areas of main corridors, skirting boards, doors, providing measures to protect high maintenance areas though out the home (Timescale of 31/10/05 Not Fully Met) 2) To improve the decor in The Hollies dining room, including the stained ceiling tiles (Timescale of 31/10/05 Not Fully Met) 3) To rectify the exposed threshold strips in The Hollies lounge and Bloomfield divided lounge (Timescale of 31/10/05 Not Fully Met) - On order 4) To improve the decor in Bloomfield dining room, including stained ceiling (Timescale of 31/10/05 Not Fully Met) 5) To provide a call point in the Bloomfield lounge (Timescale of 31/10/05 Not Fully Met) 6) To devise a written risk assessment as an interim measure and means of monitoring need for call point in Bloomfield lounge 7) To provide Mrs S with a key for her bedroom door (Timescale of 31/10/05 Not Fully Met) 8) To rectify the hot water temperature in room 11 (low temp) and not working in room 30 (Timescale of 31/10/05 Not Fully Met) 18 OP20 12(1) To ensure that the volume of radios and TVs in communal rooms is at an acceptable level
DS0000024970.V267826.R01.S.doc 01/01/06 The Hollies & Bloomfield Version 5.0 Page 30 19 OP22 14(1) 23(2) 23(2)(b) 20 OP25 to the residents using those rooms at any time To arrange for a reassessment of ED needs to be carried out by an appropriately qualified occupational therapist 1) To carry out a written risk assessment with regard to the practice of locking service users’ bedrooms during the daytime. Awaiting suite of sub-master keys. (Timescale of 31/11/04 and 30/09/05 Not Fully Met) 01/02/06 01/02/06 21 OP26 13(3) 16(2) 23(2) 13(3) 16(2) 23(2) 22 OP26 The laundry walls must present a 01/02/06 readily cleansable surface. (Timescale of 31/10/04 and 31/10/05 Not Met) 1) To devise and implement a 01/02/06 risk assessment and control measures for manual sluicing (where this cannot be avoided) (Timescale of 31/10/04 and 30/09/05 Not Met) 2) To devise and implement clinical waste guidelines and a documented risk assessment (Timescale of 31/10/04 and 30/09/05 Not Fully Met) 3) To provide a liquid soap dispenser in the Bloomfield bathroom (Timescale of 30/09/05 Not Fully Met) 23 OP26 13(4) 24 OP27 18(1)(a) To ensure that used linen / clothing is not deposited and left on the floor, and specifically outside the ground floor sluice room. Provide documentary evidence that an agreement remains in place with the CSCI office, Halesowen for the home to be staffed with two competent, trained senior carers as part of the team of five carers on each
DS0000024970.V267826.R01.S.doc 23/11/05 01/02/06 The Hollies & Bloomfield Version 5.0 Page 31 25 OP27 18(1)(a) wakeful day shift and one senior carer plus two care staff on night shifts (Timescale of 31/7/04 and 30/09/05 not fully met) To expand staff rotas to include: 1) Service user dependencies and occupancy levels (or provide alternative means for this information) 2) Total hours worked by each person 3) Total care hours provided each week 4) Managerial hours 5) Catering hours 6) Domestic hours 7) Laundry hours (Timescale of 30/09/04 and 31/08/05 Not Fully Met) Agree to create additional posts of senior care assistant, with the requirement of at least NVQ 2 care award, up to date mandatory training, and adequate experience of the care of older people; in sufficient numbers to provide two on each day shift and one on each night shift. (Timescale of 31/07/04 and 30/09/06 Not Fully Met) To provide recent photographs of newly employed staff on their personnel files To forward to the CSCI satellite office -Halesowen copies of valid work permits for all overseas staff, which are specific to the Hollies & Bloomfield or documentary evidence that existing work permits have the approval of the Home Office, to enable staff to work at the Hollies & Bloomfield. (Timescale of 14/10/04 and 30/09/05 Not Fully Met) To provide documentary
DS0000024970.V267826.R01.S.doc 01/01/06 26 OP27 18(1)(a) 01/02/06 27 28 OP29 OP29 17(2) Sch 2&4 19(1) 17(2) Sch 2&4 19(1) 01/02/06 01/03/06 29 OP30 17(2) 01/02/06
Page 32 The Hollies & Bloomfield Version 5.0 Sch 2&4 19(1) 30 OP30 18(1)(c) 23(4) evidence from the Training Organisation for Personal Social Services (TOPSS) relating to the accreditation of qualifications held by the overseas nurses, demonstrating their equivalent value to the NVQ awards. (Timescale of 14/10/04 and 31/10/05 Not Fully Met) All staff (continue to) receive training appropriate to the work they are to perform, this to include: 1) First aid 2) Moving and handling (including use of hoist) 3) Health and Safety (inc COSHH) 4) Responding to abuse 5) Values and attitudes (for care staff) 6) Dementia care 7) Restraint (Timescale of 31/10/04 and 31/10/05 Not Fully Met) 01/02/06 31 OP30 17(2) 32 OP35 24 To remove from public display the framed fire safety training certificate for JH - no longer employed at the home 1) To confirm with the homes insurers the maximum amounts of residents monies, which may be held in the homes safe 2) To encourage residents / or their representatives to place any large amounts of money in appropriate bank accounts 1) To progress formal documented supervisions sessions for all care staff (Timescale of 31/10/04 and 31/10/05 Not Fully Met) 2) To devise and implement a documented annual schedule of 01/12/05 01/02/06 33 OP36 18(1)(c) 01/02/06 The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 Page 33 34 OP38 13(4) 23(2) 35 OP38 13(4) 18(1)(c) 36 OP38 13(4) supervision sessions, to be displayed to encourage staff participation in the process (Timescale of 31/10/04 and 31/10/05 Not Met) To ensure that staff do not wear jewellery, watches, nail polish and that they have short nails and appropriate flat ‘covered in’ footwear. (Timescale of 31/10/04 and 31/10/05 Not Fully Met) To ensure that any staff who have not received training to use Blood Glucose equipment cease to carry out the procedure with immediate effect (Timescale of 27/07/05 Not Fully Met) To rectify the defective lock on the Bloomfield stair gate (Timescale of 27/07/05 Not Fully Met) To provide documentary evidence that approved risk assessment awareness training has been arranged for all staff to be delivered within an identified timescale. (Timescale of 31/10/04 and 27/07/05 Not Fully Met) 01/01/06 23/11/05 01/01/06 37 OP38 13(4) 18(1)(c) 01/02/06 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 OP17 OP18 Good Practice Recommendations The home should provide all residents with information as to how to access appropriate advocacy services. That staff signatures are obtained to demonstrate their awareness of the local authorities multi-agency procedures for the protection of vulnerable adults
DS0000024970.V267826.R01.S.doc Version 5.0 Page 34 The Hollies & Bloomfield 3 OP18 4 5 OP37 OP38 Any incidents involving violence against staff should be documented on separate violence at work forms as well as the accident records. It is recommended that staff signatures be obtained to demonstrate their awareness of the homes policy. Residents or their representatives should sign the printed statements to acknowledge their awareness of their rights to access their records. That consideration be given to the issue of security of the clinical waste receptacle, which should be locked be held in a secure area. The Hollies & Bloomfield DS0000024970.V267826.R01.S.doc Version 5.0 Page 35 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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