CARE HOMES FOR OLDER PEOPLE
Riverside Cambourne Way Monk Bretton Barnsley South Yorkshire S71 2NR Lead Inspector
Mrs Jayne White Unannounced Inspection 22nd November 2005 08:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Riverside DS0000064882.V272972.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. Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Riverside Address Camborne Way Monk Bretton Barnsley South Yorkshire S71 2NR 01226 296416 01226 296416 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) www.parklanehealthcare.co.uk Park Lane Healthcare (Riverside) Limited Mrs Jaqueline Steeples Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The Manager works full-time supernumerary (37 hours) over and above the hours provided for care. 6th April 2005 Date of last inspection Brief Description of the Service: Riverside is a care home providing personal care and accommodation for 40 older people. The home is situated at the head of a cul-de-sac on Camborne Way, Monk Bretton, on the edge of an estate of modern houses and bungalows. Shops and other amenities, including a main bus route are close to the home albeit at the top of a steep incline. Accommodation is on one level and provides single and double bedrooms. The home stands in its own grounds and consists of a lawned area to each side and rear. There is a car park to the front. Mr Christopher Mitchell took over ownership of the home on 18 November 2005. Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over seven and three quarter hours from 8:15 to 16:00. Opportunity was taken to make a partial inspection of the premises, inspect a sample of records, observe care practices and talk to residents, relatives, staff and the manager. The majority of residents and staff were seen during the inspection and the inspector spoke in more detail to five of the staff on duty about their knowledge, skills and experiences of working at the home, four of the thirty four residents about their views on aspects of living at the home and two relatives. What the service does well: What has improved since the last inspection?
A new owner has been registered. This has resulted in the implementation of some policies and procedures including medication and recruitment and the production of a statement of purpose and service user guide. Also, radiator guards have been fitted to all radiators and pre set valves unaffected by water pressure and which have fail safe devices have been fitted to water outlets for the safety of residents’. The records of the supervision of staff was now more detailed and staff were aware of the supervision process.
Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 6 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. Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcome for standard 2 was inspected. The contract/terms and conditions did not include sufficient information for the resident to know under what conditions they would live at the home. EVIDENCE: Two residents’ files were inspected to ensure contracts/terms and conditions were in place. On one the contract/terms and conditions was blank. The other contract/terms and conditions identified the fee to be paid and was signed by the client and advocate. It did not include all the details recommended by the standard. Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 7 & 9 were inspected. The residents’ health, social and personal care needs were well documented in the care plan to ensure that staff had the information required to meet residents needs, but care is required to ensure the record of care provided links with the plan. The system of administering medication was considered safe, but the medication was not always administered as directed. Further attention was required to improve the storage of some medication. EVIDENCE: Details on care plans had improved and were supported by associated documentation including risk assessments. The daily record of care provided did not always link to the care to be provided in the care plan. Administration of medication to service users was observed and was considered to be safe. Inspection of the medication records noted instructions regarding the administration of medication was clear, but was not administered in accordance with instructions. Controlled drugs and drugs to be returned to the pharmacy were not safely stored. Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 10 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): The outcomes for standards 12 & 15 were inspected. Residents on the whole were generally happy with their lifestyle within the home. Residents received a wholesome, appealing and balanced diet in pleasant surroundings at times convenient to them, but their comments about the meals were not enthusiastic. EVIDENCE: Residents were observed to spend time in the lounges, whilst others chose to spend their time in the privacy of their bedroom. Discussions with residents demonstrated they spent their time in different ways. An activity co-ordinator was employed to undertake activities with residents. Discussions with residents’ identified there had been some trips out of the home and the activity co-ordinator said they tried once a month to either have a trip out or have an entertainer come to the home. Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 11 The dining room was clean and welcoming. Comments from residents about their meals included “meals are alright”, “don’t like the potatoes and some of the modern food” and “pretty good, some days better than others”. There was a four week menu. The inspector was told the cook had recently formulated these. The menu demonstrated choice for the breakfast, tea and supper meals. The main meal of the day was a set menu. Staff said if residents didn’t like the meal an alternative would be offered. Discussions with residents demonstrated not all residents understood this. The breakfast meal was observed. Residents were given time to eat their meal. Residents said they got sufficient to eat and didn’t need to ask for snacks. Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcome for standard 16 was inspected. There was a simple, clear and accessible complaints procedure and residents and/or their advocates were confident that if they had a complaint it would be listened to, taken seriously and acted upon. EVIDENCE: The complaints procedure ensured that residents and/or their relatives were aware of how to make a complaint and who would deal with them. Residents stated that they were satisfied with the care provided and said that they didn’t have any complaints. Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 19, 20, 23, 25 & 26 were inspected. The environment within the home was on the whole well maintained and clean, providing a comfortable environment for residents to live. EVIDENCE: The home was clean and tidy, which promoted a comfortable and homely environment. The home was decorated in a comfortable and welcoming manner including homely touches of pictures and ornaments. Residents’ spoken with said the home was comfortable and they were settled at the home. There were a number of lounges and a large dining room for residents to use that were all on one level providing sufficient sitting and dining space. In general, the home was well maintained and suited residents’ needs; however, there are a number of previous requirements carried forward about the environment. The new owner had taken over the home last week. Discussions with him about his plans for the home during the registration process were positive and it is expected that these requirements will be met.
Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 14 There were sufficient toilet, washing and bathing facilities, which were close to residents’ bedrooms and communal areas. A sample of toilet and bathroom areas were inspected and paper towels and bins were provided. Water temperature records identified water was maintained at a safe level. During the registration process the new owner ensured all radiator guards were fitted and pre set valves unaffected by water pressure and which have fail safe devices were fitted to water outlets for the safety of residents’. Laundry facilities were sited away from all food preparation and storage areas. Inspection of the laundry identified systems were in place to ensure clothing was returned to the correct resident. A sluicing facility was provided. Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 28, 29 & 30 were inspected. There had been improvements in the recruitment information obtained for new staff but further detail was required in order to fully protect residents. There was a staff training programme in place to equip staff with the knowledge and skills to complete their role in a competent manner and meet the needs of the residents’. EVIDENCE: The new owner during the registration process demonstrated the recruitment policy/procedure that would be in place. The recruitment process was discussed with a number of staff and all said they had completed an application form and had an interview. A sample of two staff files’ were inspected. A comprehensive recruitment process had not been followed including demonstrating clearly a full employment history, the date when the CRB had been applied for, the date a POVA first check was issued and that the staff member did not commence work until this had been received and previous employment references. A training and induction programme for staff was in place to enable them to meet the assessed and changing needs of service users. Staff confirmed that they had attended various training courses that included fire, health and safety, moving and handling, first aid, infection control, medication and food hygiene. Certificates of training were placed on the personnel file. Twenty eight per cent of staff had achieved their NVQ level 2 in Care, with another eight either on the course or due to start the course.
Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standards for 31, 33, 35, 36, 37 & 38 Residents continued to benefit from the management approach of the home although a formal quality assurance system was not in place to demonstrate this. Systems were in place to safeguard residents’ financial interests. The manager was ensuring staff were being supervised. Improvements were required with some of the records kept by the home to safeguard residents’ rights and best interests. The safety and welfare of residents’ were not wholly promoted and safeguarded, as comprehensive recruitment practices were not in place and medication was not stored safely. EVIDENCE: Discussions with residents and their advocates demonstrated the manager promoted an atmosphere of openness and respect where residents and their advocates felt their opinions mattered.
Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 17 It is important that consultation with residents about their health and personal care, interests and preferences are formalised by a quality assurance system. The manager confirmed this was not in place. Residents’ were able to maintain control over their finances if they wished and had the capacity to do so. The financial records of two residents’ were inspected. Written records of all transactions were maintained with a receipting mechanism and signatures of two persons. Written records and monies balanced. There was a secure facility for the safekeeping of monies and valuables on behalf of the resident. Two staff records were inspected. Supervision was being completed. The inspector inspected a sample of the records that the home was required to keep. These have been commented upon throughout the report and where necessary requirements made. Records were securely stored. Safety posters were on display. When the building was inspected no fire exits were blocked. The fire alarm, emergency lighting and fire fighting equipment had been serviced. Fire training and/or drills for staff were in place. Servicing of gas and electrical systems and equipment were in place. Risk assessments were in place for the risk of legionella and water temperatures were checked and a record maintained. Notifiable incidents were being reported as required by the regulations. Also please see outcome for standard 9, medication practices and 29 recruitment practices. Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 2 X X 3 X 3 3 STAFFING Standard No Score 27 X 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 2 2 Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 19 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 OP2 Regulation 5 & 17 Requirement Where a placing authority determines residents’ funding arrangements the home’s contract/terms and conditions must identify this. Previous timescales of 31/01/05 and 30/06/05 not met. The daily record of care provided must link to the care identified in the care plan. Medication must be administered in accordance with instructions unless there is a documented reason not to do so. Previous timescale of 30 June 2005 not met. All medication must be stored safely. Previous requirement 30/06/05 not met. The outside door and window frames must be included in the programme of redecoration. Previously required since 30/09/04. Adaptations must be made to doors leading outside so that residents who are independently mobile are able to go outside
DS0000064882.V272972.R01.S.doc Timescale for action 31/01/06 2 3 OP7 OP9 15 & 17 13 31/01/06 31/01/06 4 OP9 OP38 OP19 13 31/01/06 5 23 31/12/06 6 OP20 23 30/04/06 Riverside Version 5.0 Page 20 7 OP20 23 8 OP20OP38 13 & 23 9 OP20 23 10 OP9 OP38 19 11 OP33 24 without asking for assistance. Previous timescale of 31/03/05 and 30/06/05 not met. To include in the programme of routine maintenance the renewal of the lounge carpet in lounge 2. Previously required since 30/09/04. Strip light covers must be replaced on the corridor areas. Previously required since 30/09/04. The handrails in the corridor areas must be restained. Previously required since 30/09/04. A thorough recruitment procedure must be followed and this must be demonstrated on individual staff files together with information required by the regulations and standards. Previously required since 30/09/04. A system for reviewing and improving the quality of service provided by the home must be implemented and include other stakeholders of the service. Copies of any review subject to the implementation of any findings from the system must be available to residents and the CSCI. Previously required since 1/04/02. 30/04/06 31/01/06 31/12/06 31/01/06 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 21 1 2 3 OP2 OP15 OP15 The contract/terms and conditions should include all details identified in the standard. That a choice of meal is offered at lunch time. That residents are consulted on the menu and their preferences are included. Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Riverside DS0000064882.V272972.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
