Inspection on 03/10/07 for Rosglen

This inspection was carried out on 3rd October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Rosglen 30/09/09

Rosglen 01/10/08

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Rosglen 2 Highfield Range Darfield Barnsley South Yorkshire S73 9BQ Lead Inspector Mrs Jayne White Key Unannounced Inspection 3 October 2007 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 DS0000069572.V349732.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. DS0000069572.V349732.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosglen Address 2 Highfield Range Darfield Barnsley South Yorkshire S73 9BQ 01226 752238 01226 752238 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) Just Global Limited Miss Sharon Mary Moore Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (9) of places DS0000069572.V349732.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 9 NA New owners were registered on 29 May 2007 2. Date of last inspection Brief Description of the Service: Rosglen is a care home providing personal care and accommodation for 9 older people. Just Global Limited bought the home in May 2007. The home is situated in Darfield, Barnsley. It is close to a bus route and there are shops, including grocers, hairdressers, chemist, post office and newsagents in the village. The home is single storey. It has 5 single and 2 double rooms. Communal areas include two lounge areas and a dining room. There is a central kitchen and laundry. There are some bathing facilities. Information about the home, including the service user guide is available in the entrance hall. This includes the most current CSCI report about the service. The manager said the fee was £341.50. Additional charges are made for newspapers/magazines, hairdressing, toiletries and chiropody. DS0000069572.V349732.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector visited on the first day between the hours of 8:15 and 13:45 without giving any notice. Another visit was made the next day between 12 noon and 14:00, which the home had been told about. Also taken into account was other information received by CSCI about the service since the last inspection. This included an Annual Quality Assurance Assessment (AQAA). An AQAA is a document completed by providers. It gives them the opportunity to tell the CSCI how well they think they are meeting the needs of people using their service. Before the inspection, surveys were sent to a range of people, asking them about the home. Two came back from people that lived at the home, one from a representative of a person that lived there and two from staff. The inspection process included talking to five people living at the home, two members of staff, the manager and the owner. It also included inspecting parts of the building, reading some records and observing care practices. The inspector wishes to thank the people living at the home, staff and manager for their time and co-operation throughout the inspection process. What the service does well: People’s admission into the home was well managed. They said they received enough information about the home and had their needs assessed before moving in. This meant both the home and themselves could be sure their needs would be met. Staff said, “communication between them is very good and care plans are always up to date”, “I am really enjoying my job at Rosglen it is a lovely little home and I feel that all the residents receive excellent care”, “Rosglen cares for every person individually and offers them excellent care but also makes Rosglen as near to their real home as possible always making their needs a priority. Also all members of staff have very good relationships with each other” and “the service always listens to and discusses service users needs”. Observation of care practice and discussions with people on the whole confirmed the comments that had been made by staff. Generally people were assisted to make some choices and decisions in their daily life and social activities, particularly where they were able to make their wishes clear. DS0000069572.V349732.R01.S.doc Version 5.2 Page 6 In general people spoke positively of the staff that were employed to care for them. They said, “nothing is too much trouble”, “they’re good, there’s no problems there”, “staff are very good, but they’re always busy” and “staff are kind and treat me with respect”. What has improved since the last inspection? What they could do better: Ensure staff know the systems to be followed for safe systems of working, including medication and moving people. Maintain the privacy and dignity of people by keeping bedroom doors closed when people are sleeping and allowing them to wake up when they are ready. Promote people’s independence and control by providing a choice at the main meal and enabling people to pour their own drinks and put condiments on their food. Have dedicated people for cooking and serving meals to improve the quality and give care staff more quality time to concentrate on their caring role. Document in the complaints record when people have complained or grumbled to demonstrate the complaint has been taken seriously and appropriate action taken. This will demonstrate the owner and manager are acting on what people say. It will also show they have taken appropriate action to safeguard people and improve the service. Use the Department of Health guidance ‘Essential Steps’ to assess current infection control management at the home. Appropriate training in infection control could then be established. This would ensure staff were up to date with current knowledge to control the spread of infection. This is important as staff provide care, cook, clean and complete laundry duties. DS0000069572.V349732.R01.S.doc Version 5.2 Page 7 Make sure all recruitment checks have been completed before staff commence work to ensure people are not placed at risk of abuse. Ensure robust and effective management systems are in place to safeguard people and staff. This includes quality assurance systems designed to improve the service, servicing and maintenance of equipment, fire safety and a review of accidents. Also that the training staff have received is sufficient if there was an accident or medical emergency. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000069572.V349732.R01.S.doc Version 5.2 Page 8 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 DS0000069572.V349732.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcome for standard 3 was inspected. The home did not provide an intermediate care service. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People received information they needed to choose a home and had their needs assessed before they moved in. This meant both the home and themselves could be sure their needs would be met. EVIDENCE: The AQAA stated the manager completed an assessment of the person prior to their admission, to ensure the service could meet their needs. The file of one person was inspected. It contained an admission assessment, but this was not very detailed. However, a good plan of care had been put together from the information. This suggests more information had been obtained than had been documented in the assessment. DS0000069572.V349732.R01.S.doc Version 5.2 Page 10 Surveys returned by people and discussions with them confirmed they received enough information before they moved in. This enabled them to decide if the home was right for them. One commented, “I had a weeks free stay”. DS0000069572.V349732.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 7, 8, 9 & 10 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care that people received reflected what assistance they needed. Generally, they were treated with respect, dignity and privacy. EVIDENCE: One care plan was inspected on a sample basis. The plan contained good information. There was sufficient detail on the plan for staff to be clear about the care to be provided. This enabled carers to have clear information about what they needed to do to meet a person’s health, personal and social care needs. The daily report confirmed they followed this plan for meeting the person’s health and personal care needs. Risk assessments were in place. Monthly reviews of care plans needs to be considered. DS0000069572.V349732.R01.S.doc Version 5.2 Page 12 Records of healthcare visits were maintained. These confirmed staff communicated with other healthcare professionals, so that the health care needs of people were maintained. Surveys from people said they always or usually received the care and medical support they needed. This was confirmed in discussions with them. Surveys from staff and discussions with them confirmed they were always given up to date information about the needs of the people they cared for. They said, “communication between staff is very good and care plans are always up to date”, “I am really enjoying my job at Rosglen it is a lovely little home and I feel that all the residents receive excellent care”, “Rosglen cares for every person individually and offers them excellent care but also makes Rosglen as near to their real home as possible always making their needs a priority. Also all members of staff have very good relationships with each other” and “the service always listens to and discusses service users needs”. Observation of care practice and discussions with people confirmed the comments that had been made by staff. The AQAA stated all people had a medication assessment to see if they were able or wanted to keep and look after their own medication. The AQAA stated the service’s improvements had included more staff being trained in the safe handling of medication, but also to have all staff trained as something they could do better. Medication was given to people on individual trays, in individual medication pots with a drink of water. Staff gave people sufficient time to take their medication, helping them to do this where necessary. One person dropped one of their tablets on the floor. Staff were unclear what to do and how to record this. A gap had been left in the record. This meant when this happened the person was not given that medication, which could be crucial in maintaining their health. Inspection of the home’s medication storage confirmed there was a separate locked room for storing medication. Medication was securely stored. Observation of care practice confirmed staff were aware of the need to treat people with respect and dignity. There was clear and respectful communication between people and staff, for example, at mealtimes. Discussions with people, however, indicated that this was not always the case. This was discussed further with the owner. When the inspector arrived there was a door to a person’s room left wide open. The person was still in bed, asleep. This does not respect the person’s dignity. DS0000069572.V349732.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcome for standards 12, 13, 14 & 15 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Generally people were assisted to make some choices and decisions in their daily life and social activities, particularly where they were able to make their wishes clear. EVIDENCE: The AQAA stated that this service considered that introducing a staff activity organiser and providing training was something they could do better. Staff surveys also said more activities in the home was an improvement they felt the service could make. The AQAA also stated the service encouraged people to get involved with their preferred interests and hobbies. It stated the service takes on board people’s dislikes to activities or events and tries to reach the best possible outcome for all parties. Additionally, the AQAA stated families and friends were also encouraged to get involved with activities and social contact. The AQAA said all social contacts and activities are recorded in the care plan. DS0000069572.V349732.R01.S.doc Version 5.2 Page 14 The admission assessment inspected identified dominoes and TV as something the person liked to do. The person was observed sat in the lounge watching TV, but this was on at all times during the visit. The plan did not indicate that the person had been asked if they wanted to play dominoes. The care plan record confirmed visits from friends and family as the only activity specific to the person’s own individual leisure and social interests and pursuits. Discussions with the person said there wasn’t a lot to do during the day, but they enjoyed the company. They confirmed they had visits from their family. A number of people were able to express their views about the opportunities they had for maintaining and developing their skills and interests. They were mainly positive about their lifestyle within the home. In surveys they expressed there was always or sometimes activities they could take part in. One said, “we go for meals out” and “we have many visitors such as singers and open days”. Other discussions with people identified some people preferred spending time in their room. They said they liked to keep themselves busy and alert by reading, doing crosswords, listening to radio and watching TV. One person said they enjoyed the conversations with other people and also doing crosswords and reading. People confirmed there had been a summer fayre and that the manager was in the process of arranging a trip out with the proceeds. One person said they had continued going out to the club at night. During the visit people were observed both spending their time in the lounges, with the TVs on or in their own rooms. People who were able did walk around the home as they wished. People said visitors could come when they like and that they could go and visit them if they wanted. The AQAA stated meetings were held frequently with people regarding meals so that what each person liked was taken into account and the menu agreed with them. Surveys returned by people stated they always or usually liked the meals at the home. Discussions with people identified meals were satisfactory. Their comments included “some days, better than others”, “we used to get a cooked breakfast, but it suits me now to have cereal and toast” and “sometimes they’re awful”. Discussions with people confirmed staff were expected to be ‘jack of all trades’ – they cared, cooked and cleaned for people. Inevitably this meant staff that were cooking had no specific culinary skills. This could explain why some meals were enjoyed by people, but not others, depending on who was cooking. A discussion with the manager identified no one person was cooking because of staff shortages. A menu board had now been displayed in the dining room. This was quite high on the wall for people to be able to see clearly. This did not matter on the first DS0000069572.V349732.R01.S.doc Version 5.2 Page 15 day of the visit as the meal displayed was from lunch time the day before. Discussions with people identified they did not know what the lunch time meal would be that day. They said they didn’t get a choice, unless they didn’t like the meal. One person provided their own food because they didn’t like some of those served or preferred something different. Providing a choice would enable people to feel as if they still had some control over what they ate. Meals were served in an unhurried way, giving people time to eat. Breakfast was served when people wished and at this meal they were observed being given the cereal they preferred. There were some people able to pour themselves a drink and butter their toast, but staff did this for them. Providing teapots and condiments for people would enable people to maintain control over aspects of their life where they were able. Some cups that people were drinking from were stained and marked and therefore did not look clean. DS0000069572.V349732.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. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 16 & 18 were inspected. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There was a complaints procedure that people had access to and felt confident using. People felt they were protected from abuse and had their rights protected, but how staff sometimes spoke to people indicates this might not always be the case. EVIDENCE: The complaints procedure was displayed so that people were aware of how to make a complaint and who would deal with it. There was a complaints record and no complaints had been recorded since the new provider had been registered. However, discussions with people identified they had raised concerns. Although the conduct of staff was not part of the concern, how they spoke to people was a concern. This was because the tone and manner of how people are spoken to can be abuse. This was discussed with the owner, as it wasn’t clear any action had been taken. In survey responses, people confirmed that they were aware of how to complain and who to speak to. Staff surveys also confirmed they knew what procedures to follow if someone had concerns about the service. DS0000069572.V349732.R01.S.doc Version 5.2 Page 17 Discussions with people confirmed they would speak up if there was something they weren’t happy about. The majority said they had no complaints or grumbles. The majority of people felt the new owners listened when they did have anything to say. The AQAA confirmed there were policies/procedures/codes of practice in place to protect people from abuse. However, the concern about how staff speak with people indicate these may not be vigorously followed. Staff training records confirmed they had received training in the safeguarding of adults. DS0000069572.V349732.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 19 & 26 were inspected. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. On the whole, the environment was clean and comfortable for people. EVIDENCE: This is a small home. Since the registration of the new owners there had been some redecoration of the premises. New carpets had been provided in all the bedrooms. Discussions with people confirmed this. They said they had not chosen the colour or carpet but they were happy with the outcome. Signs and numbers had been added to doors. This made it much clearer for people to find their own room and the toilet and bathroom areas. DS0000069572.V349732.R01.S.doc Version 5.2 Page 19 The lounge and dining area were clean and comfortable. They offered sufficient space for the number of people that used them. People were able to personalise their own rooms with pictures, photographs, ornaments and furniture. Access around the home was good. Inspection of records noted the hoist for the bath had not passed its service and therefore people were not able to have a bath. Discussions with people indicated this was not a problem for them as they were able to have a shower. Discussions with the manager took place of how the bathroom area might be improved. Discussions with people confirmed on the whole they were pleased with their living environment. Two people that shared a room confirmed they had been consulted about this. They said the arrangement works well and a curtain is provided to maintain their privacy. Improvements had been made to the garden area including cutting back trees, pebbling some areas and providing garden furniture. Access remained difficult with the majority of people needing assistance, because of steps and uneven ground. Also, there were aspects of the grounds that were untidy and did not provide a good immediate impression of the home. DS0000069572.V349732.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 27, 28, 29 & 30 were inspected. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There was an experienced and stable staff team that were carrying out caring, cooking, cleaning and laundry duties because of staff shortages. This was affecting the quality of some of the duties undertaken by staff. EVIDENCE: Generally, people spoke positively about the care they received. In their surveys people said on the whole staff listened and acted on what they said. They confirmed there were staff always or usually available when they needed them. This was also confirmed in discussions with them. Discussions with people about the staff employed to care for them included comments such as “nothing is too much trouble”, “they’re good, there’s no problems there”, “staff are very good, but they’re always busy”, “you only have to buzz and they’re there” and “staff are kind and treat me with respect”. People said they felt it wasn’t right that staff had to care for them, clean and cook. They said it didn’t seem right that they helped people to go to the toilet and then cooked meals – it made them “cringe”. People said because staff had DS0000069572.V349732.R01.S.doc Version 5.2 Page 21 to do everything they sometimes forgot to empty bins and clean sinks, but this was important. Comments by people were confirmed when observing staff. Staff were very busy helping people with their care needs. A number needed a lot of help and required the assistance of two people when being assisted to move or transfer. This meant other than when assisting people at this time or when providing assistance at meal times they spent no time with them pursuing their leisure and social interests. Staff did go between assisting people with care needs and cooking. They were seen to wear aprons specifically available for the kitchen, over their caring uniforms when working in the kitchen. However, paper towels were not available in the staff toilet, which is good practice to control the spread of infection. The manager had obtained the Department of Health guidance ‘Essential Steps’ to assess current infection control management at the home. The AQAA stated there were always two members of staff on duty. This was observed and confirmed by people living there. Training opportunities were provided. Surveys from staff said when they started work their induction on the whole had covered everything that they needed to know to do the job. They said they always or usually felt they had the right support, experience and knowledge to meet the different needs of people using the service. They said, “I was given a very good induction showing me all aspects of my job and I was told anything I was unsure of to always ask for help” and “I feel I am learning new things all the time to widen my knowledge and experience”. The AQAA stated 57 of staff had obtained their NVQ Level 2 in Care, with 43 working towards it. It also stated training in moving and handling, fire safety, food hygiene and first aid training were in place. It said 75 of staff hold a safe food handling certificate and two staff have training in the control of infection. A plan of training confirmed this. The manager confirmed she was the person on shift being the designated person for first aid. When asked who would be the designated person when she wasn’t on shift, was not determined, as other staff completed an emergency first aid course. A risk assessment was not in place to determine that this was satisfactory to safeguard people. Observation of staff practice identified the training they had received was not always put into practice. This included medication (see health and personal care) and moving and handling people. People were observed being moved without brakes being applied to wheelchairs when transferring people. Also moving people by holding them up under their arms and twisting them into their chair. This is poor practice, unsafe and can lead to injury of both the DS0000069572.V349732.R01.S.doc Version 5.2 Page 22 person being moved and the member of staff. It was suggested to the manager to involve an occupational therapist in identifying the most appropriate way to move some people, including the provision of appropriate equipment. The home had a recruitment policy. Inspection of the recruitment process confirmed relevant recruitment information was obtained including an application form, two written references, making sure that any gaps in employment history were accounted for and a criminal records disclosure (CRB) and where applicable a POVA (protection of vulnerable adults) first check. However, the CRB had not been issued until after the person had commenced employment and the file did not demonstrate a POVA first check had been obtained. This meant the recruitment process may not be sufficient to safeguard people from abuse. DS0000069572.V349732.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 31, 33, 35 & 38 were inspected. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Generally there were systems in place to manage the health, safety and welfare of people and staff, but these were not always satisfactory to safeguard them. EVIDENCE: The manager had many years experience within the caring profession. She was working towards a Registered Managers Award. The manager had a good knowledge of the needs of people and she was committed to providing a good quality service. There was a relaxed and friendly atmosphere within the home. DS0000069572.V349732.R01.S.doc Version 5.2 Page 24 There had been improvements in the implementation of a quality monitoring systems. Surveys had been carried out but an action plan from those results had not been developed. The new owners had not completed any reports of their findings of the quality of the service provided. They said that generally they felt people were happy. The inspection process confirmed this. However, this level of intervention would not determine what improvements were needed to improve the life of people living there. The AQAA stated records of monies and transactions were now kept on site. This was not the case. The owner said no monies were held on site because apart from one person families dealt with this. The owner confirmed she was an advocate for one person. She said the person had their own account which monies were paid in to. Fees were then paid by direct debit, as were all fees. Dates for the servicing of equipment had not been confirmed in the AQAA. Inspection of these identified there was no confirmation of these for electrical circuits, portable electrical appliances, fire extinguishers, fire alarm and emergency call equipment. The hoists had been serviced and the bath hoist had failed. These were brought to the attention of the owner and manager for them to action. When the building was inspected fire exits were free from obstruction. The fire risk assessment was dated 27.07.04. It was noted that all people living at the home were not on the current list of people there. This is important, as the home and the emergency services need up to date information so they take appropriate action in an emergency. Accidents were being recorded, but there was no indication these were reviewed to identify improvements to the service as a result of them. This may help to prevent further accidents. In one case, an accident had been the direct result of staff completing cleaning duties and leaving their equipment where it was because someone needed assistance. DS0000069572.V349732.R01.S.doc Version 5.2 Page 25 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 3 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 DS0000069572.V349732.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NA STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 OP28 OP30 OP38 Regulation 13 (2) Requirement Staff must know the procedure to be followed when tablets are dropped on the floor. This will ensure people get all their prescribed medication and appropriate records are maintained. All complaints made by people must be recorded, investigated and appropriate action taken. This will demonstrate complaints are taken seriously and appropriate action is taken to safeguard people and improve the service. Staff must receive infection control training so that they are up to date with current knowledge to control the spread of infection. People must be moved safely. This includes: • Brakes being applied to wheelchairs when transferring people • Not holding people up under their arms. Timescale for action 03/10/07 2. OP16 OP18 13 (6) 22 (3) 03/10/07 3. OP28 OP30 OP38 18 (1) (c) (i) 30/04/08 4. OP28 OP30 OP38 13 (4) (c) 03/10/07 DS0000069572.V349732.R01.S.doc Version 5.2 Page 27 5. OP29 19 (1) (b) (i) 6. OP33 26 7. 8. OP38 OP38 OP27 13 (4) 13 (4) (a) Staff must not commence work until all recruitment checks have been completed. This will ensure people are not placed at risk of abuse. After consultation with stakeholders of the service the owners must prepare a written report on their opinion of the standard of the care provided. This should identify any improvements that may be necessary and any action that needs to be taken with timescales. Servicing and maintenance of all equipment must be up to date. When accidents or incidents occur they must be reviewed. This will enable any improvements or action that needs to be taken to improve the service and keep people safe. 03/10/07 03/11/07 03/11/07 03/11/07 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. 3. 4. Refer to Standard OP10 OP15 OP15 OP19 OP38 Good Practice Recommendations Bedroom doors must remain closed when people are asleep to maintain their privacy and dignity. Provide a choice at the lunch time meal to enable people to maintain some control in choosing a meal they wish to eat. Teapots and condiments should be provided to enable people to pour their own drinks and apply condiments to food. This would promote their independence. Discuss with people how the bathroom might be improved. This should make the bathroom more accessible to them and a bath something they could enjoy. DS0000069572.V349732.R01.S.doc Version 5.2 Page 28 5. 6. OP27 OP27 OP15 OP38 OP28 OP30 OP38 OP28 OP30 OP38 OP33 7. 8. 9. 10. OP38 Paper towels should be provided in toilet areas. This follows good practice guidelines to control the spread of infection. Employ a dedicated cook. This should improve the quality of meals that suits all people, provide more time for care staff to concentrate on caring duties and reduce the risk of the spread of infection. Complete a risk assessment that identifies what training is sufficient for staff to safeguard people when there is an accident or medical emergency. Assistance should be sought from an occupational therapist to determine the most appropriate way of moving people safely. An action plan should be developed as a result of consulting with stakeholders about the quality of the service provided. This should improve the quality of care provided for people. The fire risk assessment should be reviewed and the roll call to demonstrate it continues to be fit for purpose, so that people are kept safe. DS0000069572.V349732.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000069572.V349732.R01.S.doc Version 5.2 Page 30 - 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. 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