Inspection on 10/09/08 for Rushey Mead Manor

This inspection was carried out on 10th September 2008.

CSCI found this care home to be providing an Poor service.

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

Rushey Mead Manor 05/10/09

Rushey Mead Manor 07/04/09

Rushey Mead Manor 14/01/09

Rushey Mead Manor 02/10/07

Rushey Mead Manor 12/12/06

Rushey Mead Manor 03/05/06

Rushey Mead Manor 18/10/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Rushey Mead Manor 30 Coatbridge Avenue Rushey Mead Leicester LE4 7ZS Lead Inspector Diane Butler Unannounced Inspection 10th September 2008 09:30 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 Rushey Mead Manor DS0000064260.V371223.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. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rushey Mead Manor Address 30 Coatbridge Avenue Rushey Mead Leicester LE4 7ZS 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) 0116 2666606 0116 2660708 Midland Healthcare Ltd Vacant Care Home 40 Category(ies) of Dementia (17), Mental disorder, excluding registration, with number learning disability or dementia (17), Old age, of places not falling within any other category (40), Physical disability over 65 years of age (5) Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No one falling within category OP may be admitted into Rushey Mead Manor where there are 40 persons of category OP already accommodated within this home. No one falling within category PD(E) may be admitted into Rushey Mead Manor where there are 5 persons of category PD(E) already accommodated within the home. No person to be admitted to Rushey Mead Manor in categories MD or DE when 17 persons in total of these categories/combined categories are already accommodated in this home. No person to be admitted to Rushey Mead Manor in categories OP, PD(E), DE or MD when 40 persons in total of these categories/combined categories are already accommodated in this home. No person who requires nursing care are to be admitted into Rushey Mead Manor in categories OP, DE, MD or PD(E) when 20 persons in total of categories/combined categories are already accommodated in this home. 2nd October 2007 5. Date of last inspection Brief Description of the Service: Rushey Mead Manor is registered to accommodate forty older people in need of residential or nursing care. The home has a multicultural service user group and the staff team is also multicultural. Both English and Asian diets are catered for. There is a small temple and chapel situated in the building. Accommodation is on three floors with a lift and stairs for access. There are thirty-eight single bedrooms and one double bedroom. Two of the single bedrooms and the double bedroom have ensuite facilities. There are five lounges, two dining rooms, and one smoking room. The home is situated close to Leicester City Centre with good transport links and other local amenities. Current charges range from £331.00 to £550.00 depending on care needs and additional charges are in place for personal items such as newspapers, toiletries, and chiropody treatment. Details of what additional charges service users can expect to pay can be found in the service user guide, which is given to all service users either prior to, or on arrival at Rushey Mead Manor. A copy of the latest Inspection report is available at the home, or it can be accessed via the CSCI website: www.csci.org.uk. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 5 Further information about the home is available from the acting manager. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use the service experience poor outcomes. This was an unannounced visit, which took place over a seven and a half hour period in September 2008. On the day of the visit there were twenty five service users residing at the home and the acting manager was on duty. We were joined for part of the visit by an ‘expert by experience’ (a person who has experience of what it is like to live in a home) who spent time talking to service users and their relatives to gain their thoughts of the service provided. When undertaking key inspections the Commission for Social Care Inspection (CSCI) focuses upon outcomes for service users and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting three service users and tracking the care they received through looking at their records, speaking with them when possible and discussion with staff on duty at the time of the visit. Where communication was difficult observation was used to evidence whether care needs were being met. Eight visitors and five service users were spoken with during the visit. Further planning for this visit included checking the service history of the home and the last Inspection report and looking through the AQAA document (Annual Quality Assurance Assessment), which was submitted to the Commission for Social Care Inspection prior to the visit. The AQAA document is the main way that providers inform us of how well their service is delivering good outcomes for the people using it. What the service does well: Service users needs are assessed prior to them moving into the home. Two menus are offered to the service users on a daily basis, one Asian, one English. Both menus offer a choice at every mealtime and meals can be taken ether in the main dining area, one of the lounges within the home or in the service users own room. Service users are treated with dignity and respect at all times and care workers support them to be as independent as possible. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 7 Visiting is strongly encouraged; visitors are always made welcome and made to feel part of the home. What has improved since the last inspection? The acting manager has worked hard to implement a number of new systems and is committed to raising the standard of the home in the future. The Service User Guide and been reviewed and the acting manager is in the process of reviewing the Statement of Purpose document. New needs assessment documentation has been developed. This is now used when assessing all prospective service users and includes a more thorough cultural needs assessment and nutritional screening tool. The acting manager is in the process of developing and reviewing policies and procedures; these include the complaints procedure, abuse policy, health and safety policy, medication policy and infection control policy. New lighting has been installed in the reception area and some decoration has been carried out within the home. PVC covers have been placed on a number of doorways to protect the woodwork from damage from wheelchairs. Down stairs curtains and a number of carpets have been cleaned and a new cleaning schedule is in place. Alcohol gel, aprons and gloves are readily available on each floor of the home and new soap dispensers have been installed. A new menu has been developed and all pureed food is served separately providing a more appealing looking meal. A new raised sensory bed has been developed within the rear garden area and sensory equipment has been purchased for use in the home. Staff supervision sessions have been commenced. This provides the staff with the opportunity to meet and talk with the acting manager about any issues they may have or to identify any training needs. Relative questionnaires have been developed and the acting manager has commenced distributing these to gather relative’s views on the service being provided. Sky television is now available for the service users to enjoy with both English channels and Asian channels available. A number of training courses have been provided since the last inspection visit. This includes Moving and handling, food hygiene, Wound care and Protection of Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 8 Vulnerable Adults. All staff are currently completing distance learning training in Health and Safety with ‘Skills for Care’ and once this is completed training in dealing with dementia and further safeguarding training will be completed. A monthly accident audit is now carried out. This provides the acting manager with details of all accidents in the home and identifies any patterns or trends that are occurring that can be looked into and addressed. What they could do better: Ensure that all risks presented to the service users are contained within the risk assessment documentation. Nurses and care workers need to be aware of all the current risks to the service users and the actions to take to minimise those risks. Ensure that the service users care plans are accurate and kept up to date. Nurses and care workers need to have up to date information to enable them to care properly for the service users in their care. Ensure that accurate records are kept of all medication administered to service users to ensure that medication is administered safely, correctly and as prescribed. Ensure that professional bodies and other parties involved in the care of the service users are consulted when decisions regarding a service users mental capacity are made. Ensure that all staff are appropriately trained in the moving and handling of service users and practice safe systems of moving and handling on a daily basis. Service users need to be safe when being transferred in a wheelchair. Ensure that service users bedrooms are kept free from offensive odours. Ensure that all parts of the home to which service users have access too are so far as possible free from hazards to their safety. Service users need to be kept as safe as is reasonably practicable. This includes any areas of the home not currently in use. Ensure that all areas of the home are kept clean and reasonably decorated and kept in a good state of repair both internally and externally. Service users need to be provided with a comfortable and homely place to live. Provide all service users with an up to date terms and conditions document. This would ensure that all parties are aware of their terms and conditions of residency. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 9 Provide all service users and/or their relatives with the reviewed service user guide. This would ensure that all parties were aware of the aims and objectives of the home and details of the formal complaints procedure. Provide service user and relative meetings, this would be another way of obtaining their thoughts and views of the service being provided. Contact the local fire officer with regard to the fire risk assessment and the current practice with regard to the locking of the front and the rear doors. This would ensure that the home was working in line with best practice as recommended by the local fire department. 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. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 10 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 Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 11 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): 1,2,3,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are assessed prior to moving into the home to ensure that their care and nursing needs can be met. EVIDENCE: Both a Statement of Purpose and Service User Guide are in place. These documents, which are in the process of being reviewed, include the aims and objectives of the home, charges made for services provided and details of how to make a complaint should service users and/or their relatives be unhappy about something. Prospective service users and/or their relatives are invited to look around the home to see what facilities are available and whether it would be the right place for them to live. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 12 One relative confirmed this though stated that he hadn’t received any information about the home. The acting manager stated that it was her intention to provide a copy of the new service user guide to all current service users and/or their relatives to ensure they have up to date information about the home. The acting manager explained that all prospective service users are assessed prior to moving in or in the event of an emergency on the day of their arrival to ensure that their care and support needs can be met. A needs assessment is completed and an assessment of need is also obtained from the service users social worker. The acting manager has developed new assessment documentation, which now includes a more comprehensive section on the cultural needs of the prospective service users. It was noted that the main assessment sheet was more of a scoring assessment with the person circling 1,2 or 3 depending on the need of the service user. This is then followed up with any specific information within that area. The more thorough this information, the clearer the picture of the persons needs would be. On checking three files all included a pre admission assessment and evidence was seen of the acting manager visiting prospective service users in order to complete the assessment prior to their moving in. It was noted in two files that although a terms and condition of stay was in place neither included what the service user was being charged. It was also noted that the relevant signatures to agree the terms and conditions were not included. The acting manager stated that a new Terms and Conditions document had recently been produced for all new service users. A discussion took place regarding the possibility of all service users receiving new contracts to ensure that all appropriate information was included. Intermediate care is not currently provided at Rushey Mead Manor. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 13 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): 7,8,9,10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Lack of accurate information on service users health care needs could put them at risk. EVIDENCE: Three service user files were checked and all were found to include a copy of their care plan and individual risk assessments. New care plans have been developed since the last inspection and those seen had been reviewed on a monthly basis with a thorough evaluation completed. Risk assessments seen had also been reviewed monthly these included moving and handling assessments, dependency assessments, nutritional assessments, risk of falls and assessments on the use of equipment including specialist beds and bed rails. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 14 It was noted on closer inspection that not all care plans or risk assessments included all the support provided to the service users or the risks that some of these actions presented. This included for one service user the fact that due to immobility, when transferred in a wheel chair the footplates were not used. This was discussed with the acting manager who immediately addressed the error and included this in both the care plan and the risk assessment documentation. For a second service user it was evident that they had suffered an injury to their right foot, this had been dressed by the nurse on duty but had not been included in the care plan documentation, this was again addressed by the acting manager. On briefly checking the paperwork for another service user it was noted that they had MRSA and a risk assessment was in place for this. On checking the care plan this was not included. On speaking with the acting manager she was not aware of anyone currently in the home having MRSA, though on speaking with the senior carer they were aware of the service user having this. On further investigation we were informed that the service user had had MRSA, but prior to moving into the home, this had been treated prior to moving into the home and the service user no longer had this infection. A discussion took place with regard to why, if they no longer have this infection it is written on the risk assessment documentation, which is being reviewed monthly. The acting manager stated that this would be looked into. On speaking with the acting manager following this visit, we were informed that a swab has since been taken from the service user in question to ascertain whether they have MRSA and disciplinary proceedings are being carried out with three staff members in connection with the shortfalls identified. Daily records checked showed that healthcare professionals were being involved in the service users care including the local GP. Medication records were checked and were found to be in order. Medication had been appropriately signed into the home and medication had been signed for when given, with the exception of one occasion when it was noted that the staff member had signed to say that they had administered the medication but on checking the tablet box it was noted that the tablet was still there. On checking service user files it was noted that some included a medication consent form, which stated that the service user did not have mental capacity to make their own decisions with respect to their medication. The acting manager had signed this document but no evidence was in place to show that other professional bodies involved in the service users care or any other parties had been involved in reaching this decision. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 15 Controlled medication was being appropriately stored and records including two signatures were being kept. Service users spoken with stated that they were well cared for and relatives spoken with were satisfied with the care their relatives were receiving. Comments received included: “The care is fine, the only problem I have is that English isn’t always spoken in mums room”. “Staff know what to do and when, and they do it very well”. It was noted that two of the service users spoken with during the visit had very dirty fingernails and one service users jumper was very dirty. When the dirty jumper was mentioned to a member of staff they said to the service user “I told you to put your washing out for us”, which suggests that the service user may need more support to maintain their appearance. Interaction between service users and staff was very positive on the day of the visit with staff members speaking to service users in a respectful, friendly and supportive manner. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 16 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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with a varied diet, which meets their individual needs and preferences. EVIDENCE: Service users are offered choices on a daily basis; these include when to get up and what to wear, (one service user explained that they got up at 11am each day), where and how they wish to spend their time during the day and what and when to eat. Specific religious and cultural needs are met. A cultural needs assessment is completed either prior to moving into the home or on admission to the home and preferences in daily living are identified and supported. The acting manager stated that care staff currently provide activities twice a day. This was confirmed on speaking with the staff on duty, and during the visit the Asian service users were lead in song whilst the English service users were encouraged to join in a game of ball. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 17 On checking the activities book it was noted that an activity is provided twice a day, though it was noted that watching TV was recorded on a number of occasions. Whilst talking to a number of service users when asked whether there were normally activities provided one explained “There are none”, whilst two informed us that they had been taken out on a visit from the home”. Service users now have access to Sky television, providing Asian channels in one of the lounges whilst English channels are available in another lounge. There are two cooks working at the home and two menus are offered to the service users on a daily basis, one Asian, one English. Both menus offer a choice at every mealtime and the meals served on the day of the visit looked nutritious, appealing and hot. The menu on the day of the visit offered Fagots or beef stew with potatoes, sprouts and mixed vegetables and cabbage and potato curry or aubergine and spinach curry with toor dhal, chapatti and rice. Comments received during the visit included: “The food is very good” “The midday meal is always good”. “Only the dinner is good”. Special diets such as diabetic, soft or liquidised diets are catered for and supplements are provided if needed. When preparing a soft or liquidised meal the cooks ensure that each item is liquidised separately, not altogether, making the meal look more appealing. Residents are weighed on a monthly basis and have a nutritional assessment in their care plan to ensure that their dietary needs are met. On checking one service users records it was noted that they had lost a considerable amount of weight in a five month period. This was discussed with the acting manager who explained that the service user had been in and out of hospital on a number of occasions and had lost weight on return to the home on each occasion. A further nutritional assessment had been carried out and the acting manager explained that if a loss of weight were identified on the next weight check then she would contact the dietician who is involved in the service users care. Visiting is strongly encouraged. Relatives and friends were seen visiting throughout the day and all confirmed that they are able to visit at any time and are always made welcome. One visitor explained “Im always made welcome”. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 18 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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and relatives are confident that concerns will be taken seriously and acted upon. EVIDENCE: A complaints procedure is in place. A copy of this is displayed in the reception area of the home and is included in the service user guide, which is given to all new service users. Whilst talking to relatives visiting the home, although all were aware of whom to talk to if they had any concern, none were aware of the formal complaints procedure. This was discussed with the acting manager who suggested giving all relatives a copy of the revised service user guide, which includes a copy of the complaints procedure. The acting manager stated that she has received one complaint since the last inspection in October last year. This was confirmed on checking the complaints book. This complaint, which regarded the general care provided to a service user was acknowledged, looked into and a written response was sent to the complainant. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 19 Service users and/or their relatives spoken with were confident that any issues raised would be dealt with appropriately. One relative explained, “I spoke to xxxx [the acting manager] and told her my feelings and she acted on it which was brilliant”. All staff received training in the safeguarding of vulnerable adults in December last year and the acting manager stated that the owner was in the process of arranging refresher training in this area. The acting manager is aware of the procedures to follow with regard to the protection of the service users and all care workers spoken with were aware of the actions to take, should they suspect any form of abuse. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 20 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): 19,20,21,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further improvements to the environment would provide the service users with a more comfortable and homely place to live. EVIDENCE: Accommodation at Rushey Mead Manor is provided on three floors. The acting manager explained that not all areas of the home are currently in use; this includes the second kitchen and a number of bedrooms on the first floor. It was noted that the wing currently not in use remained accessible to all service users. Prior to this visit Leicester PCT (Primary Care Trust) had raised a concern with the CSCI regarding the cleanliness of Rushey Mead Manor. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 21 Areas of concern included: Dirty curtains, windows and woodwork, the condition of some carpets, walls with missing plaster, the strong smell of urine in some areas of the home, the condition of the walls in the reception area and corridors and the floors in the toilets and kitchen. On speaking with the acting manager we were informed that actions had been taken to address a number of the issues identified and further work was being carried out to further improve the environment. During the visit it was evident that steps had been taken to address some of the shortfalls identified, and the acting manager acknowledged that more work was needed to improve the current accommodation. The reception area and dining room were bright and tidy and the communal areas of the home were free from odours. The woodwork in the areas seen on this occasion were clean though it was noted that some windowsills behind the secondary double glazing in the dining room were still in need of repainting and the carpet needed cleaning were food had been trodden into it. A number of bedrooms were seen during the visit and it was noted that one had a strong smell of urine present. The acting manager was informed of this and steps were taken to have the carpet cleaned straight the way. On checking the communal toilets and bathrooms it was evident that some of these were in need of attention. The floor in one bathroom was very poor and there was no curtain up at the shower, the grouting around the shower was also in need of attention. In the toilets on the ground floor both light shades were broken and it was noted that the majority of toilets/bathrooms were without curtains/blinds. Guards have been fitted to some of the doorways to protect the woodwork from being further damaged by wheelchairs though it was noted that some were still to be fitted, the acting manager explained that these were to be done. On checking the small lounge on the ground floor it was noted that one wall had some plaster missing where furniture had been knocked up against it. The flooring between the front door and the reception area is in need of some attention and the flooring in the medical room was sticky when walked on. The kitchen floor was also sticky; the acting manager explained that this was possibly due to a service user who makes their own drinks spilling it on the floor. The acting manager explained that the owner was in the process of replacing both the front door and the door to the rear of the home, which sit either side of the reception area. This will ensure that the wires that lead to the doorbells, Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 22 which are currently hanging loose will be attended to. It was also noted that staff currently keep the doors locked by using a key thus limiting access to and from the home for service users and their visitors. This will also be addressed when the new doors are fitted. The acting manager stated that she was aware of the shortfalls within the environment and a maintenance programme is in place to address the issues. The maintenance programme was not available during the visit. ‘Danicentres’ which hold gloves, aprons and alcohol gel are now situated on each floor for staff to use and soap dispensers have been replaced. A sensory flowerbed has been developed in the garden to the rear of the home and sensory equipment is on display in the dining area. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 23 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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are trained and competent to do their jobs. EVIDENCE: Staffing levels currently provide a registered nurse and three carers on duty during the day; if the acting manager is the registered nurse on duty then a senior care worker is also on duty. Nighttime support is provided by one registered nurse and two care workers. Service users spoken with felt that there were enough staff on to meet their needs and all said there was always a member of staff when you need one. Care workers spoken with felt that there was enough staff on to enable them to carry out their duties without feeling rushed. Three staff files were checked and were found to include all the necessary checks including a POVA 1st (Protection of Vulnerable Adults) check and CRB (Criminal Records Bureau) check and two references, (though two of the files were too whom it may concern references). Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 24 The acting manager stated that all new staff complete formal ‘first steps’ induction training, this was confirmed on looking through staff files and on speaking with care workers on duty during the visit. A number of training courses have been provided since the last inspection visit in October 2007. This includes Moving and handling, food hygiene, Wound care and Protection of Vulnerable Adults. All staff are currently completing distance learning training in Health and Safety with ‘Skills for Care’ and once this is completed training in dealing with dementia and further safeguarding training will be completed. The acting manager and senior care worker are Moving and Handling trainers and we were informed that Moving and Handling training is being completed the week following this visit. Eight care workers have completed their NVQ (National Vocational Qualifications) level 2 and three care workers are due to start their NVQ level 2 and NVQ level 3 next week. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 25 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): 31,33,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health, safety and welfare of the service users is not always promoted or protected. EVIDENCE: The acting manager has been in post since April of this year and stated that it is the owner’s intention to submit an application for her registration in the near future. She is a registered nurse and has seventeen years experience in care management. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 26 Service users and relatives stated that the acting manager is approachable and feel happy talking to her if they have any issues. One relative explained, “The home has improved 200 since she’s been here [the acting manager]. Care workers spoken with stated that the acting manager was always available for help and advice should they need it. One care worker explained, “You can talk to the manager, she is always available, she sometimes stays till 8.00pm and she told us if we have a problem any time we can call her, even Saturdays and Sundays”. Money kept on behalf of two service users was checked. Both were found to be in order with the appropriate signatures, records and receipts in place to ensure that the service users finances are safeguarded. Staff meetings are held on a regular basis to enable the acting manager to gain the staffs view of the service they currently provide and supervision sessions have also commenced. Service user meetings or relative meetings are not currently held though the acting manager has commenced sending out questionnaires to relatives to gather their thoughts on the service provided. On the day of the visit four had been returned all of which included positive comments. Policies and procedures for the health, safety and welfare of the service users are either in the process of being reviewed or developed and the acting manager explained that these are made available to all staff. During the visit it was noticed that on two occasions a care worker was seen transporting service users in a wheelchair without using the footplates. This was discussed with the acting manager and on identifying the service users in question we were informed that one of the service users were unable to use the footplates as it was too painful for their legs. This was not included in the care plan or risk assessment documentation. With regard to the second service user the acting manager stated that there was no reason why the footplates had not been used. We were informed that this would be addressed with the individual care worker and all staff would be reminded in the forthcoming training. The acting manager reinforced that failure to follow moving and handling policy would result in disciplinary action for all concerned. The fire risk assessment was checked during the visit due to their being an incident in the home at the end of last year. It was recommended that the acting manager contact the local fire officer to ensure the suitability of this document and its contents. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 27 Issues around infection control were brought to the attention of the CSCI following a visit by Leicester City PCT. The acting manager explained that staff have now completed training in infection control and an infection control policy has been developed. Appropriate protective equipment is available and all workers on the day of the visit were using these appropriately. There was a friendly atmosphere during the visit and the interactions between care workers and service users were relaxed and informal and service users were treated with respect and dignity throughout. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 28 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 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 X X X 2 2 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 2 X 3 3 2 2 Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 29 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 OP7 Regulation 15(2)(b) Requirement The registered person shall: Keep the service users plan under review. The registered person must ensure that the service users care plan and associated documents are accurate and up to date. Nurses and care workers need to have up to date information to enable them to care properly for the service users in their care. 2 OP8 13(4)(C) The registered person shall ensure that: Unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. The registered person must ensure that risk assessments are carried out when a risk is identified and these are kept up to date and accurate. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 30 Timescale for action 24/09/08 24/09/08 Care workers need to be aware of all the current risks to the service users and the actions to take to minimise those risks. 3 OP9 13(2) The registered person shall make 24/09/08 arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home. The registered person must ensure that accurate records are kept of all medication administered to service users to ensure that medication is administered safely, correctly and as prescribed. 4 OP9 12(a) The registered person shall ensure that the care home is conducted so as To promote and make proper provision for the health and welfare of service users. The registered person must ensure that all relevant professional bodies and other parties are involved when decisions are made regarding a service users mental capacity. The registered person shall 01/12/08 having regard to the number and needs of the service users ensure thatThe premises to be used are kept in a good state of repair externally and internally. All parts of the care home are kept clean and reasonably decorated. The registered person must Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 31 01/10/08 5 OP19 23(2)(b) (d) 6 OP26 13(3) ensure that service users are provided with a comfortable and homely place to live. The registered person shall make 24/09/08 arrangements to prevent infection, toxic conditions and the spread of infection at the care home. The registered person must ensure that the premises are kept clean, hygienic and free form offensive odours. The registered person shall make 19/09/08 suitable arrangements to provide a safe system for moving and handling service users. The registered person must ensure that staff move and handle service users in an appropriate and safe manner. 7 OP38 13(5) 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 Refer to Standard OP1 Good Practice Recommendations The registered person should provide all service users and/or their relatives with an up to date Service User Guide, which includes a copy of the formal complaints procedure. The registered person should provide all the necessary information including current charges in the Terms and Conditions document. The registered person should ensure that all areas of the home not currently used are made safe and/or secure. The registered person should provide service user/relative meetings. The registered person should contact the fire officer to confirm suitability of the current fire risk assessment and DS0000064260.V371223.R01.S.doc Version 5.2 Page 32 2 3 4 5 OP2 OP19 OP33 OP38 Rushey Mead Manor current practices with regard to the locking of the front and the rear doors. Rushey Mead Manor DS0000064260.V371223.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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