Inspection on 22/09/09 for Rushall Mews

This inspection was carried out on 22nd September 2009.

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

Rushall Mews 09/02/10

Rushall Mews 23/09/08

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Rushall Mews New Street Rushall Walsall West Midlands WS4 1JQ Lead Inspector Amanda Hennessy Key Unannounced Inspection 22nd September 2009 10:30 DS0000071321.V377741.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rushall Mews Address New Street Rushall Walsall West Midlands WS4 1JQ 03701924060 03701924061 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.housing21.co.uk Housing 21 Ms Gloria May John Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Rushall Mews DS0000071321.V377741.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 categories: Old age not falling within any other category (OP) 26 The maximum number or service users to be accommodated is 26. 2. Date of last inspection 23rd September 2008 Brief Description of the Service: Rushall Mews is a purpose built establishment providing intermediate care for up to twenty- six older people. Intermediate care is short term care with an aim to improve people’s daily living skills and enable them whenever possible to return home. Care and support is usually provided for up to six weeks as a maximum. The home is separated into four units Chelsea, Linley, Kensington and Avon. Each unit has its own lounge come dining room, kitchenette and bathing facilities for dependent people. All bedrooms are single. Kensington has twelve bungalows with people having their own bed sitting room and kitchen. The home is situated in Rushall close to local amenities and is on a main bus route. Limited car parking is available at the home. The home has pleasant and sheltered gardens. The service user guide seen identified that there is no charge for intermediate care. The fee information given applied at the time of the inspection; persons may wish to obtain more up to date information from the service. Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. The means the people who use this service experience adequate quality outcomes. This unannounced inspection was carried out over two days, by two Inspectors. Mrs Amanda Hennessy visited for one day and Mr Ian Henderson Pharmacy Inspector visited on the second day. The home had twenty-three people staying there at the time of the inspection. Our time spent visiting the service was eleven hours. As it was unannounced neither the service nor the provider knew we were going. Information for the report was gathered from a number of sources: a questionnaire- Annual Quality Assurance Assessment (AQAA) was completed by the Home Manager and was sent to us before the inspection; we looked at the premises, records and documents. We had discussions with staff and people who live at the home to gain their views on what it is like to live in and receive care at the home. We looked at how the service has responded to any concerns, how it protects people from abuse and how staff are recruited and trained. We also looked at the number of staff available to care for people at the home. Four people who were staying at the home were ‘case tracked’ this process involves establishing people’s experiences of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes of the care that they receive. Tracking peoples’ care helps us understand the experience of people who use the service. What the service does well: The home offers a specialised Intermediate Care service. People have a support plan to asssist them to maximise their abilities and activities of daily living to assist them to return home. People told us that their stay at Rushall Mews had been very positive: “They have helped me have the confidence to get around on my own again” and “I can get in and out of bed on my own now, they have told me I will be able to go home soon.” “All the care staff have been very kind and they cannot do enough for you.” Another person told us: Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.2 Page 6 “They have help me since I broke my wrist. I have really appreciated the stay here but I am looking forward to going home tomorrow now.” Throughout the day a good rapport was observed between people staying at the home and staff, both the care staff and the healthcare professionals who work at Rushall Mews. All of the people we spoke to said that the food is very good. “We always have a choice and the food is very good.” The physical environment, its cleanliness and facilities are excellent and enable people to be independent. A visitor told us: “I have been a carer and cannot fault it here, it excellent here it always clean.” The home has robust staff recruitment and selection, which minimises the risk of unsuitable people working at the home and protects people living there. What has improved since the last inspection? What they could do better: The management of people’s medicines must be improved to ensure that people consistently have the medicines that they are prescribed. The management of people medicines currently does not safeguard people living in the home. Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 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 Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Required information is available to enable people to decide that they would like to have rehabilitation at the service. EVIDENCE: The home provides required information (a statement of purpose and service user guide) about the services they offer which include an explanation of what “intermediate care” is. The service user guide is given to people when they come to stay at the home and is available in all bedrooms. The service user guide is also available in large print and braille. Rushall Mews is a purpose built establishment providing intermediate care for up to twenty- six older people. Intermediate care is short term care with an aim to improve people’s daily living skills and enable them whenever possible Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 Page 10 to return home. Care and support is usually provided for up to six weeks as a maximum. The home has a multi- disciplinary team of Physiotherapists, Occupational Therapists, Community Nurses and Social Workers to support people in their aim to return home and assist their rehabilitation. There are weekly meeting when people have an opportunity to discuss their progress with all Professionals who are involved in their support. People who are considered suitable for intermediate care are informed of the service offered at Rushall Mews and can decide if they want to go there for rehabilitation. People who wish to be considered for rehabilitation at Rushall Mews have an overview assessment of their needs which is sent to the home. When people are admitted they discuss their support needs with care staff and alongside a full assessment by a therapist,from this their support plan is developed. The environment is appropriate to meet the needs of peole requiring intermediate care. Bedrooms are of an appropriate size to accommodate various equipment needed. There is a dedicated therapy room where equipment is located to support the rehabilitation programme and there is a weekly extend/falls programme in addition to other daily activities.The home has one unit (Kensington) that has bungalows providing people with a bed sitting room with kitchenette and their own toilet. This excellent facility enables people to live more independently whilst also having the support of staff if they need it. Staff undertake the training which provides them with knowledge and skills required to deliver a rehabilitation programme. Occupational Therapist, Physiotherapists and Nurses are all based within the building to ensure a timely response to people’s needs Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Support plans identify peoples individual needs, choices and capabilities and are drawn up and reviewed alongside the individual. The management of peoples medicines needs to be improved to ensure that people consistently have the medicine that they need and are prescribed for. EVIDENCE: The home use Walsall’s ‘single assessment process’ for care planning to address people’s support needs. We found that support plans have been improved since our previous inspection to more fully identify people‘s capabilities alongside their needs and choices. Staff told us that they sit with people to discuss their support needs and goals for their stay, when they first come into the home and then on a weekly basis. It is from this discussion that people have their support plan developed. Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 Page 12 During people’s stay at Rushall Mews people are temporarily assigned to the a Doctor allocated to the Intermediate care programme. The Doctor visits weekly for a general surgery and will also visit when necessary. When people leave Rushall Mews their medical care will return to their own and original Doctor. Support plans detail all professionals who are providing support such as Physiotherapists, Occupational Therapists, Social Workers, Doctors Community Nurses alongside the homes staff. People we spoke to told us how successful their rehabilitation had been: “I was frightened of falling again but they have helped me and now am walking around on my own again.” “I can get out of bed on my own now.” “I am so much better I am hoping to go dancing when I go home.” People’s progress and the effectiveness of their support plan is reviewed at a weekly meeting, with the person and all professionals involved in their support plan. The pharmacist inspector visited Rushall Mews on the 23rd September 2009 as part of the key inspection to fully assess the way the home was managing medicine on behalf of the people who used the service. In summary the medicines management systems within the home were found to be poor and were not safeguarding those living in the home. We found that the medication records were poor for recording the receipt, administration and disposal of medicines. We found that the home had a rather complicated system for ordering and receiving medicines, which on the whole did not record the quantity that had been received by the home. The home did carry out a weekly stock count but these counts did not correspond with the start of the Medicine Administration Record (MAR) charts and did not always record the stock of all medicines prescribed to the people. The home must ensure that they have an accurate record of all medicines along with the quantities received into the home. We found that the MAR charts were all handwritten but were not being double checked for accuracy by a second member of staff. We found some anomalies between the directions written on the MAR charts and the directions written on the dispensing label attached to the medicine. Even though the home had a witness system in place (a second member witnessing and signing a second MAR chart to confirm administration had taken place) there were still gaps in the signatures confirming that administration had taken place. We found that where variable doses had been prescribed the records did not always show what quantity had been given. Where medication had not been administered and a generic abbreviation had been used the lack of defining some of these abbreviations meant that the reason for the non-administration was not evident. Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 Page 13 We found some concern with the administration of medicines during the case tracking of some of the people who used the service. We found that a person had been prescribed some strong pain relievers and on the MAR chart it stated that one capsule should be administered four times a day but one the dispensing label attached to the box of the medicine it stated that one capsule should be administered three times a day. We found looking at the current MAR chart that the home had been administering the medicine four times a day, which at this point appeared to contradict the instructions made by the person’s doctor. However we found that the person had recently had a stay in hospital and had been discharged with information for the home to administer the medicine on a four times a day basis. We found that without any medical intervention the dose had been reduced to three times a day on the 20th September 2009, which was concerning given the information available to staff. We also found that the administration of a weaker pain reliever had also been reduced to three times a day when the prescribing information indicated a four times daily administration. We found that another person had not had any of their water tablets for a period of three days because the home had allowed them to become out of stock. We found that the home had a practice of administering homely remedies. We found a number of concerns with this practice the first being that the home had not checked with the people’s doctors that the administration of homely remedies was safe and did not interact with any of their prescribed medication. The second concern was that the home had obtained their supply of homely remedies by reusing medication that had been prescribed to named people, this practice contravened the Medicines Act 1968 and the Manager agreed to stop this practice immediately. We expected to find people who were using the service to be self administering all or part of their medication, we were not disappointed. However we had some concerns about the risk assessments, monitoring and security of the medicines. We examined some risk assessments and found them to be incomplete and they only focused on the people self administering their medication. We found that there did not appear to be any formal monitoring taking place to ensure that these people were administering their medication as prescribed. We also found that some of the medicines were not being kept secure and therefore other people and visitors using the service had access to these medicines. We found when looking through the care records that there did not appear to be any information about how and when to administer when required medicines safely and effectively. We found that the care staff involved in the administration of medicines had all received training in the safe handling of medicines. All of the staff were undertaking a refresher course on the safe handling of medicines. We found that the home did not have an ongoing assessment programme to ensure that the care staff were administering medication safely and in accordance with the homes policies and procedures. In light of the issues identified during the Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 Page 14 inspection the assessment of the staffs’ competency to administer and handle medicines safely must be carried out as a matter of urgency. We found that the Controlled Drugs held within the home were not being stored in a cabinet that complied with the Misuse of Drugs (Safe Custody) Regulations. We found that the home was using a Controlled Drugs register to record the receipt, administration and disposal of Controlled Drugs. On close examination of this record we found that the home was not administering a Controlled Drug as it had been prescribed by the doctor. A person who had been prescribed some pain relieving patches, which were to be changed every three days. We found that these patches were not always being changed on the third day. We found that since 10th August 2009 there had been 4 occasions where the patch had been changed after 4 days, one occasion where the patch had been changed after 2 days and one occasion where the patch had been changed after 5 days. It calculated that out of the 12 changes of the patches 6 of the patches had been changed after the wrong time period. We found that one of the factors that could have been contributing to this issue was that the reminders to changes the patches were being recorded in the home’s diary and the MAR chart was not being used at all the remind and record the administration of these patches. We found that the home was not monitoring the temperatures of the medication fridges properly. The current arrangements mean that there is no guarantee that the medication that had been and was being stored in these fridges were being stored at the correct temperature. The manager was informed that that the maximum and minimum temperatures of the fridges where medication was being stored must be measured and recorded on a daily basis. The homes induction programme includes a section on treating people with respect. People told us that they are treated with respect. We observed staff to knock before entering bedrooms and toilets and interact in a friendly and open way using people’s choice of name. All rooms are single and have door locks to also give additional privacy should people want it. Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have the opportunity to make choices about their life at the home and maintain relationships with friends and relatives. EVIDENCE: People have formal and informal activities provided as part of their rehabilitation programme.They may have a programme of activiites that may include exercises or support to make a hot drink or a snack. People told us that they spend their day: “doing my exercises, reading, watching television, chatting, or sometimes we play bingo, scrabble or a board game.” Activities include: games and quizzes. Exercise sessions are held daily, with a large session for everyone on a Monday morning with drinks afterwards. People told us: Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 Page 16 “Yes I go for my exercises , its great fun we were kicking the ball around and had a whisky and lemonade afterwards.” Social events are arranged throughout the year. The next forthcoming event to recognise: “National Older Persons Day” was being arranged for the end of September. Different foods, a display of memorable events and staff will dress up in clothes to represent the different decades. The service has a hairdresser who attends weekly. Visitors are able to visit the service at any reasonable time in the day, although are asked as a courtesy to avoid mealtimes. Visitors told us that they are always made welcome and were able to visit when then wanted The Home has a four-week rolling menu. There are at least three meal choices available at each mealtime, with snacks and drinks available throughout the day. There is a dining area for each unit where people staying in that unit are able to have their meals if they want to. People using the service confirmed that they always have a choice offered and can have their meals at the dining table if they prefer their own bedroom. People told us: “The food is excellent” and, “You could not beat the food here at the best restaurants.” Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are listened to and can feel assured that the home will act in their best interests and protect them from harm. EVIDENCE: The complaints procedure is included in the Service User Guide (which is available in each bedroom) and is also displayed in the home. The home has had seven complaints in the last year, two of which they upheld. There is an appropriate record of complaints that have been received and investigations of the complaints that were undertaken. We have not received any complaints about the home in the last year. People all told us that they know how to make a complaint: “I would tell the staff or the Manager.” The service has made one Safeguarding referral. The Staff we spoke to said that they would highlight any concerns to whoever is in charge of the shift or the manager. Staff we spoke to told us that have all had “Safeguarding” training and had an awareness of what constitutes abuse. Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 Page 18 The service has appropriate recruitment processes to minimise the risk of unsuitable people working at the home. Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides excellent accommodation which is clean and well maintained and has required facilities and aids to provide intermediate care and meet people’s needs. EVIDENCE: The home is separated into four units: Linley, Chelsea, Avon and Kensington. Chelsea, Linley. Avon have been completed refurbished since our last visit, all units provide pleasant and comfortable accommodation. Bedrooms are all single and are generously proportioned. Kensington has been has twelve self contained bedsits in “bungalows and a further two bedsits Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 Page 20 within the unit . All bedsits have a kitchen area and have their own toilet and have shared access to a bathroom. The bed sit units are equipped with varying domestic appliances to provide as near to home practice facilities and enable a more effective rehabilitation programme. The home has Physiotherapists and Occupational Therapists onsite with therapy rooms to also assist people to regain their independence. There are plesant sitting areas oustide where people staying at the home said they enjoy spening their time when the weather is good. The home is clean and tidy throughout. Visitors told me: “I am really impressed the cleanliness is excellent,” and “its really homely here, I can’t fault it.” There are good arrangements to minimise the risk of cross infection with gloves, aprons, liquid soap and paper towels available throughout the home. Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has good arrangements in place for the recruitment, number and training of staff. EVIDENCE: The home is staffed with appropriate numbers and skill mix to meet people’s needs. People living at the home were very complementary about staff ”The staff are very good and they are pretty quick when I ring for them.” “They are all very good.” “They have fabulous staff.” “Everyone is so nice and caring.” Staff told us: “We may have just four clients so we are able to get to know them better.” “We provide a good service and free hospital beds.” Staff we met spoke positively about support and training they receive and were knowledgeable about peoples’ needs. We observed good interaction between staff and people living at the home. Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 Page 22 The home has thirty- three of its thirty-five care staff with a care qualification (minimum of National Vocational Qualification level 2), which is an excellent achievement. The manager has also told us that all those currently without a care qualification are registered to commence this award. In addition to their in-house training and care qualification all care staff attend the “COHORT” Training which is delivered by Health Care Professionals. The “Cohort” training, enables staff to work effectively with people who need to use the intermediate care service. The COHORT training is ongoing and the Manager has told us that all new staff will be able to access this training. This gives confidence that staff are knowledgeable and understand peoples’ care needs. Staff recruitment and selection is completed to the required standard. All staff files seen contained appropriate checks such as criminal records checks and references. The Manager also keeps a record of the interview. We were told that new staff have, induction training that meets the “Skills for Care” standards. Records of staff induction were available. Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has effective leadership and appropriate health and safety practices that keep people safe. EVIDENCE: The home’s manager has been successful in her application to be the registered manager for the home since our last inspection. The Home Manager has more than thirty years experience in managing a care home. The Home Manager is assisted by an experienced management team. Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 Page 24 The manager holds frequent staff meetings and maintains a record to ensure that staff are kept updated and informed of changes and areas of development. The home has a quality assurance programme. It is positive that other home managers from the Housing 21 organisation come in to audit practice based on the National Minimum Standards. Areas such as health and personal care, the environment and staffing are reviewed and when appropriate actions are identified for a development plan for the home. We were told that surveys are sent to all people who are discharged from the service, these surveys are returned directly to Housing 21 head office. Mrs Clements told us that she will be sending out surveys shortly, so that she can identify improvements that people feel are needed. The homes Annual Quality Assurance assessment (AQAA) was sent to us when we asked and gave us a reasonable account of the services provided and identified areas for development. We were told that surveys are sent to all people who are discharged from the service, these surveys are sent directly to Housing 21 head office. The manager told us that a report is being made of the responses to the surveys and it will be available shortly. The home does not act as appointee for people using the service. There are appropriate arrangements in place when people request it to keep small amounts of money for services such as hairdressing and chiropody. There is a record of all transactions and receipts are available to confirm the transactions. It was also positive to be told that checks of the safe contents are undertaken at each shift change. Staff told us that they receive supervision but not always at the recommended frequency. Records of supervision we looked at showed us that it covers all aspects of practice. The home has an up to date health and safety policy for safe working practice with a range of risk assessments. Staff receive training and regular updates in all mandatory training. We were told that all staff have had training in Housing 21 policies and procedures since the change of the homes ownership. Maintenance contracts were randomly selected and were found to be up to date. Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 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 3 x 3 x x 4 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x x x 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 Page 26 Are there any outstanding requirements from the last inspection? No 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 Regulation 13(2) Requirement Timescale for action 22/10/09 2 OP9 13(2) 3 OP9 18(1)(a) 4 OP9 13(2) Accurate, complete and up to date records must be kept of all medication received administered and disposed of to ensure that medication can be accounted for and is given as prescribed. 22/10/09 Appropriate information relating to medication must be kept, for example, in risk assessments and care plans to ensure that staff know how to use and monitor all medication including “as directed”, “when required” and self administered medication so that all medication is administered safely, correctly and as intended by the prescriber, to meet individual health needs. To ensure that staff are suitably 22/12/09 qualified, experienced and competent to safely administer medication before they administer medication to people who use the service. To make arrangements to ensure 22/10/09 that medication is stored securely and at the correct DS0000071321.V377741.R01.S.doc Version 5.3 Rushall Mews Page 27 5 OP9 13(2) 6 OP9 12(1) temperature recommended by the manufacturer. To make arrangements to ensure 22/12/09 that controlled drugs are stored securely in accordance with the requirements of the Misuse of Drugs Act 1971, the Misuse of Drugs (Safe Custody) Regulations Amended 2007 and the guidelines from the Royal Pharmaceutical Society of Great Britain. To ensure that there is an 22/10/09 effective system in place to request obtain and retain adequate supplies of prescribed medicines for people so that they can be given them as and when prescribed. 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. Refer to Standard OP9 OP9 OP9 Good Practice Recommendations When medicines are prescribed when required instructions should be available to tell staff when it should be given. Two staff should sign to confirm the accuracy of handwritten entries of medicines on the medication record. When a variable dose of medicines is prescribed, the amount of medicine administered should be recorded. Rushall Mews DS0000071321.V377741.R01.S.doc Version 5.3 Page 28 Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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