Inspection on 01/07/08 for Rushymead

This inspection was carried out on 1st July 2008.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Rushymead 04/06/09

Rushymead 10/07/07

Rushymead 19/07/06

Rushymead 28/11/05

Rushymead 16/05/05

Rushymead 05/01/05

Rushymead 20/09/04

Rushymead 12/02/04

Rushymead 15/09/03

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Rushymead Tower Road Coleshill Amersham Bucks HP7 0LA Lead Inspector Joan Browne Unannounced Inspection 1st July 2008 09:00 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 Rushymead DS0000023016.V367671.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. Rushymead DS0000023016.V367671.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rushymead Address Tower Road Coleshill Amersham Bucks HP7 0LA 01494 727738 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) rushymead@aol.com The Michael Batt Charitable Trust Manager post vacant Care Home 28 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Rushymead DS0000023016.V367671.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (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) 2. Dementia (DE). The maximum number of service users to be accommodated is 28. Date of last inspection 10th July 2007 Brief Description of the Service: Rushymead is a care home providing personal care and accommodation for twenty older people with physical frailties and eight with mental frailties. The Michael Batt Charitable Trust owns the home, which is a registered charity. The home is located in the village of Coleshill some two miles south of Amersham. Public transport and local amenities are not easily accessible. The building has been adapted for use as a residential care home for over twenty years and was first registered in 1991. It consists of three floors ground, first and second floor. There are twenty-six single rooms and one double room. Five bedrooms have en suite facilities and there is a passenger lift. The gardens are extensive and well maintained. The current scale of charges range from £662.00-£834.00 per week. Additional charges are made for chiropody, hairdressing, newspapers, toiletries and optical services. Rushymead DS0000023016.V367671.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 1 star. This means that people who use this service experience adequate quality outcomes. This unannounced site visit, which forms part of the key inspection to be undertaken by the Commission for Social Care Inspection, (CSCI) was undertaken by Joan Browne on 1 July 2008 in the presence of the home manager and lasted for approximately eight hours commencing at 09:00 hours and concluding at 17:00 hours. The CSCI Inspecting for Better Lives (IBL) involves an Annual Quality Assurance Assessment (AQAA) to be completed by the service, which includes information from a variety of sources. This document initially helps to prioritise the order of the inspection and identify areas that require more attention during the inspection process. The Commission received this document in good time. The information contained in this report was gathered from residents’ care plans, records kept by the home, a tour of the premises, and discussions with residents, relatives and care workers. Questionnaires were sent to residents, health and social care professionals and staff but the results were not available at the time of writing this report. They will however, be considered as part of the Commission’s ongoing regulatory responsibilities for registered services. Eight requirements were made and these can be found at the end of the report in the requirements section with fuller discussions in the text of the report under standards 7, 27, 30, 36 37 and 38. Nine practice recommendations have been made and fuller discussions of these can be found in the text under standards 1,7, 9, 26, 27, 30 and 33. We (the commission) would like to thank all the residents, visitors and care staff who made the visit so productive and pleasant on the day. The final part of the visit was spent giving feedback to the manager about the findings of the visit. What the service does well: The care needs of prospective people to use the service are assessed prior to their admission to ensure that identified needs can be met. Rushymead DS0000023016.V367671.R01.S.doc Version 5.2 Page 6 People using the service have a choice as to how they spend their day and activities are provided. People have a choice of meals, which are of a high standard and are served in pleasing surroundings. The home has a complaints policy and procedure and people using the service have confidence that any concerns raised would be addressed. People live in a home that is clean and fresh, which mean that the environment is well maintained. Recruitment procedures are thorough to ensure that people using the service are cared for by staff who have been appropriately recruited. What has improved since the last inspection? What they could do better: The home must have a consistent practice in place to ensure that care plans for people using the service are kept under review. Any restrictions on choice and freedom for people using the service must be agreed in a multi-disciplinary forum and supported by a care plan to ensure that individuals’ dignity is not breached. The home must ensure that people using the service diverse health needs are promoted and met. Their dependency levels must be kept under review and the appropriate staffing hours provided. Rushymead DS0000023016.V367671.R01.S.doc Version 5.2 Page 7 Mandatory training for all staff must be kept updated to ensure that they are competent and skilled to perform their duties. The home must develop a formalised supervision framework to ensure that staff are appropriately supervised. The broken filing cabinet must be replaced to ensure individuals’ files are stored securely and to promote confidentiality. To ensure that people using the service safety is promoted and to prevent them from any unnecessary risks of harm the fire panel records must be appropriately maintained. To ensure that staff know what to do if there is a fire and to protect people using the service safety they must participate in regular fire drills. 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. Rushymead DS0000023016.V367671.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 Rushymead DS0000023016.V367671.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): 3 People who use 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 care needs of prospective people to use the service are assessed prior to admission, which should ensure that individuals’ diverse needs would be met. EVIDENCE: The home has a statement of purpose however, the document requires reviewing to reflect the new manager’s details and the Commission’s current details. This was discussed with the manager during the inspection. A recommendation is made for the document to be updated. The home’s annual quality assurance assessment (AQAA) reflected that prospective residents’ needs are assessed prior to admission. We were told that the manager or deputy manager carries out the assessment. The home ensures that the prospective resident and their relative are involved in the process. Rushymead DS0000023016.V367671.R01.S.doc Version 5.2 Page 10 The care documentation for a resident recently admitted to the home was examined. There was evidence that the home had undertaken a preadmission assessment. We observed that some sections on the pre-admission assessment form were not completed. For example, the sections relating to continence care, sleeping routine, interests and hobbies were not completed. However, information relating to these identified needs was addressed in the care plan. A copy of the assessment summary undertaken through care management was available. We were told that as part of the assessment process any referrals made via a placing authority the home would request a copy of the assessment summary and care plan before admission. We spoke to a resident that was recently admitted to the home. He said that he was very happy with the care that he was receiving and staff were helpful and made him feel at home. The home does not provide intermediate care. Rushymead DS0000023016.V367671.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): 7, 8, 9 & 10 People who use 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. The home needs to have a consistent practice in place to ensure that all care plans are kept under review. Any restrictions imposed on people’s choice and freedom should be supported by a detailed care plan to ensure their dignity is not breached. EVIDENCE: The home uses a standardised care-planning format, outlining individuals’ long term and short-term goals. Three care plans were examined and they contained information detailing how individuals’ health, personal and social care needs would be met. In the files examined there was a supplementary person centred care plan detailing how individuals wish for staff to support them with their diverse needs. Risk assessments relating to tissue viability, nutrition, moving and handling and prevention of falls were in place. The home’s annual quality assurance assessment (AQAA) stated that care plans were reviewed monthly. We were told that individuals’ long- term goals were reviewed six-monthly and short- term goals monthly. We observed that Rushymead DS0000023016.V367671.R01.S.doc Version 5.2 Page 12 the practice of reviewing the care plans monthly on all units was not consistent. On one particular unit the care plans were not being reviewed monthly. Work to develop the supplementary person centred care plans on this particular unit was still in progress. A requirement is made to ensure that there is a consistent practice in place for care plans to be kept under review. It is further recommended that the management team develop an effective auditing system to ensure that plans are current detailing how individuals’ health and personal care needs should be met sensitively. We observed that staff were using a restraint belt to protect a particular resident’s safety. The home had obtained written permission from the resident’s relative to use the belt. However, there was no evidence seen that the decision to use the belt was discussed and agreed in a multi-disciplinary forum. There was no care plan in place detailing the action that should be taken by staff when using the belt. Because the use of the restraint belt could be perceived as a restriction on the individual’s liberty. It is required that a care plan be put in place detailing the use of the belt to ensure the individual’s safety is protected and promoted. Evidence that the use of the belt was agreed and discussed in a multi-disciplinary forum should be documented. The AQAA reflected that residents were registered with two general practitioners’ practice and the home gets support from the district nurses. Aids and equipment needed to promote continence is sought and acted upon. Equipment necessary for the promotion of tissue viability is provided. We were told that there were no residents in the home with pressure damage on the day of the visit. Residents were able to access dental, optical and chiropody treatment when required. The home uses a monitored dose medication system. The medication administration record (MAR) sheets were checked and no unexplained gaps were noted. Records examined for medication entering and leaving the home were appropriately maintained. We were told that there were no residents assessed as able to self-administer their medication. The home ensures that controlled medication is recorded in a register and stored appropriately. On the day of the inspection there were no residents prescribed for controlled medication. We noted that the medication storage cupboards on the units were being used to store non-medication items such as stationery. To comply with best practice it is recommended that the cupboards should only be used to store medication items. We observed that the list of staff members’ names authorised to administer medication required updating because some staff members were no longer working at the home. It’s recommended that the list should be updated to ensure that it is current. Staff were observed interacting with residents in a friendly but respectful manner. Rushymead DS0000023016.V367671.R01.S.doc Version 5.2 Page 13 Personal care, medical examination and treatment are provided in residents’ bedrooms. Residents are able to have a telephone to use in their own room if they wish to. On the day of the inspection residents’ attire was clean and tidy with attention to detail. We observed that staff did not wear name badges to enable visitors and residents with memory impairment to be sure of whom they are speaking with. A recommendation is made for staff to be provided with name badges to enable residents and relatives to be sure of whom they are speaking with. In discussion with residents who were able to understand the questions, they told us that they were treated with respect and dignity, and that they are able to make their own choice. Rushymead DS0000023016.V367671.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use 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. Arrangements are in place to ensure that people using the service are able to make choices about their life style. Nutritional meals are provided in pleasing surroundings. EVIDENCE: The annual quality assurance assessment (AQAA) stated that the home employs an activity organiser three times weekly. Regular outings to garden centres, parks and other places of interests such as, pub lunches and theatre trips are arranged. Every other Friday there is an inter-denomination service in the home for those residents who wish to promote their spiritual and religious needs. We were told that outside entertainers are booked regularly to perform in-house. A barbecue and Christmas party is arranged yearly and families and friends as well as the trustees for the home are invited to attend. We observed that up to date information on activities provided was not displayed in the home to enable residents to be aware of the activities on offer. It is recommended that the home display the activity programme to enable residents to be aware of the activities on offer. Some residents spoken to confirmed that activities are provided three times weekly. Rushymead DS0000023016.V367671.R01.S.doc Version 5.2 Page 15 There are no restrictions on visiting and the residents spoken to said that they could entertain friends and family whenever they wished. Two relatives spoken to during the inspection said that staff always made them feel welcome and provided them with refreshments. Information about local advocacy services was displayed on the notice board. Residents are encouraged to bring personal possessions with them when they move into the home and some bedrooms seen were personalised with their personal belongings. The home ensures that residents are provided with three meals daily. Hot and cold drinks and snacks are available at all times and offered regularly. Lunch was observed on one unit. The tables were covered with tablecloths and the appropriate cutlery, crockery and condiments were provided. Residents had a choice of chicken curry with rice or sausages, with mashed potatoes and vegetables. Residents said that the food was very good, tasty and the right amount was offered. Lunch was a sociable occasion and residents were observed chatting to each other. There were no residents in need of special diets on religious or cultural grounds at the time of the inspection. Residents requiring assistance with eating were provided with assistance in a discrete and sensitive manner. Rushymead DS0000023016.V367671.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): 16 & 18 People who use 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. Staff awareness around restraint issues needs to be improved. This should ensure where there are restricted limitations to people using the service choices they are formalised in a multi-disciplinary forum to ensure that their human rights and safety are not breached. EVIDENCE: The home has a complaints policy in place. Residents spoken to said that they were aware of how to make a complaint but had not had the need to make a complaint because they were happy with the care provision. Relatives spoken to during the inspection said that they were also aware of the complaints procedure but had not had the need to use it. A record is maintained of complaints received. The Commission has not been made aware of any complaints about the service. There have been no referrals made to the local authority under their safeguarding procedure. Staff spoken to confirmed that they had undertaken training in the safeguarding of vulnerable adults. They were aware of the action that should be taken if they suspected or witnessed an incident of abuse. We observed that staff were using a restraint belt for a particular resident to promote the individual’s safety. There was no evidence that staff had fully recognised the extent in which they were limiting the individual’s choice. Their understanding around restraint issues were limited and focussed on keeping the person safe. It is acknowledged that permission to use the belt had been obtained from a relative. However, there was no written evidence that a risk assessment had been undertaken and the arrangement to use the restraint Rushymead DS0000023016.V367671.R01.S.doc Version 5.2 Page 17 belt was discussed and agreed in a multi-disciplinary forum involving the individual where possible, and any other professionals such as the care manager or the general practitioner. Rushymead DS0000023016.V367671.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): 19 & 26 People who use 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 is well maintained which should ensure that the environment is fully able to meet people using the service diverse needs. EVIDENCE: The home is set in secluded grounds and has been adapted for its present use. It is well maintained with large and attractive gardens that are kept tidy. Wheelchair users are able to access the grounds safely. There were no outstanding requirements in relation to the local fire service and the environmental health officer visits. The outstanding requirement from the previous key inspection to replace the floor covering in the conservatory unit had been complied with. The floor covering in a particular bedroom to eliminate the offensive odour was also replaced. Bedrooms vary in size and some have en suite facilities. Residents are made aware that they can bring small items of furniture and personal belongings if they wish to. Some bedrooms seen were personalised. Rushymead DS0000023016.V367671.R01.S.doc Version 5.2 Page 19 Bathrooms and toilets were fitted with the appropriate aids and adaptations to promote individuals’ independence and were well maintained. The laundry area was clean and tidy and fitted with the appropriate washing machines with the specified programming ability to meet disinfection standards. On the day of the inspection the home was clean, pleasant and hygienic with no offensive odours. The home has complied with the requirement made at the previous key inspection to update its infection control policy in line with the Department of Health issued guidance. It is recommended that those residents who use the hoist regularly, suitable arrangements to prevent the spread of infection are in place to ensure that slings are not shared. We observed that not all staff had undertaken updated training in infection control. This is commented in more detail under standard 30. Rushymead DS0000023016.V367671.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): 27, 28, 29 & 30 People who use 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. The home needs to ensure that staffing numbers are kept under review and there are enough trained, competent and experienced staff to promote the health and welfare of people using the service. EVIDENCE: A review of the staff rota demonstrated that the number of staff on duty to provide care and attention to residents for any twenty-four hour period was as follows: four carers in the morning and in the afternoon and three at night. The manager and deputy manager were supernumerary to the rota. A cook and kitchen assistant are available from early morning to afternoon. The laundry assistant, two domestics and the maintenance person are available daily. The home’s annual quality assurance assessment (AQAA) stated that eight residents required two people to assist them with their care, and with prompting and supervision to eat meals. The manager has since confirmed that only four people require the assistance of two members of staff and that the staffing hours provided were appropriate to meet the needs of the residents. However, a staff member spoken to said that there was just enough time to see to resident’ personal care needs and as a result some care plans were not being appropriately maintained. A requirement is made to ensure that the dependency levels of the residents are kept under review and that the staffing hours provided are appropriate to meet individuals’ diverse needs to promote their health and welfare. Rushymead DS0000023016.V367671.R01.S.doc Version 5.2 Page 21 We observed that staff members were not wearing name badges to enable residents with memory impairment to be aware of whom they were speaking to. A recommendation is made to ensure that staff wear name badges. This should enable residents with memory impairment to be aware of whom they are speaking to. The home’s annual quality assurance assessment (AQAA) reflected that 70 of the care staff had achieved the NVQ level 2 and 3 in direct care. This means that the home has exceeded the 50 target of care staff holding the national vocational qualification (NVQ) in level 2. The files for two staff members who were recently recruited were examined and it is pleasing to report that they contained the appropriate documents as detailed in Schedule 2 in the Care homes regulations. Evidence that PoVA first checks and enhanced criminal record clearances had been obtained was seen. The staff members recently appointed said that they had received an induction training and were shadowed for a few days by an experienced member of staff. However, there was no record of the content of the induction training in the files examined. A recommendation is made in this report for a record to be maintained of staff induction programme to ensure that there is a formalised training and staff receive training appropriate to the work they are to perform. The training matrix seen reflected gaps in three staff members moving and handling updates. Seven staff members required updated training in infection control. There was no record seen to validate that staff had undertaken updated training in fire safety awareness. A requirement is made for mandatory training for all staff to be kept updated. This should ensure that all staff receive updated training to enable them to perform their duties effectively. Staff spoken to said that they were satisfied with their work and felt supported by the management. We were told that the home is now part of a training cluster group in the area and staff would be able to access some core training. It is anticipated that gaps in the home’s mandatory training programme would be addressed and staff’s knowledge enhanced. Rushymead DS0000023016.V367671.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 People who use 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. The home’s quality assurance systems need to be formalised to ensure that the home is run effectively and is proactive in improving outcomes. Records and procedures relating to health and safety need to be appropriately maintained to ensure people using the service safety is not compromised. EVIDENCE: The manager has been in post since April 2008. She previously managed a domiciliary care agency and holds the registered manager’s award (RMA) and the national vocational qualification (NVQ) level 4 certificate. She has not yet applied to the Commission to be registered but intends to do so. The manager is accountable to the board of Trustees. Care staff and ancillary staff Rushymead DS0000023016.V367671.R01.S.doc Version 5.2 Page 23 are accountable to the manager. Staff spoken to said that the manager was approachable and supportive. Evidence was seen to demonstrate that regular regulation 26 monthly visits take place and records of visits were being maintained. The home’s annual quality assurance assessment (AQAA) reflected that there was a formal system in place to ascertain the views of the residents and their relatives. This involved sending out surveys to residents and their relatives. We were told that surveys were sent out in March 2008 but at the time of the inspection they had not been analysed. The AQAA also stated that as a result of listening to people who use services further changes were being planned. The AQAA stated the following: “We are also planning to commence formal residents meetings and invite relatives for an informal coffee morning. Notes from these meetings will be recorded.” At the time of the inspection formal residents’ meetings had not taken place. However, the manager met with residents to discuss menu choices. We were told that the home does not have an annual development plan. The manager told us that she intends to meet with carers at least quarterly to obtain their views and share information. At the time of the inspection visit a general staff meeting had not yet been held. However, a meeting had taken place with the kitchen and domestic staff and night carers. The annual quality assurance assessment (AQAA) was returned to us by the date it was requested. Not all sections of the AQAA were completed. It was brief and gave very little information and there was minimal evidence to support any of the claims made within it. From our observations and information obtained on the day of the inspection visit it was evident that work was still in progress to develop an effective quality assurance and quality monitoring systems based on the views of people using the service. The organisation must improve on the practice in place to ensure that care plans are kept under review and an effective auditing system is developed. Any form of restraint that is used to protect and promote the safety of people using the service must be supported by a detailed plan of care. Fire safety records must be appropriately maintained to promote individuals and staff’s safety and to ensure that the service provided is effective, well-managed and positive outcomes for people using the service are achieved. The home does not manage residents’ finances on their behalf. A small amount of personal allowance is left by family members to cover items such as, hairdressing and chiropody. Records of transactions are maintained and receipts are given for all money received and expenditure incurred. A random selection of transaction sheets were checked and found to be correct. Rushymead DS0000023016.V367671.R01.S.doc Version 5.2 Page 24 The annual quality assurance assessment (AQAA) stated that the home had a supervision framework in place. However, some staff spoken to said that they had not received one to one formal supervision for some time. It is required that the home develops a formalised supervision framework to ensure that staff are appropriately supervised. We observed that the filing cabinet on one particular unit was broken. This meant that residents’ files were not stored securely. A requirement is made to ensure that that the filing cabinet is replaced. The fire panel records were examined and we noted some gaps in the recording of weekly entries between the periods 28 March to 11 April 2008, 16 May to 30 May 2008, 30 May 2008 to 13 June 2008. There was no written evidence to confirm that fire drills for day and night staff had been undertaken. The fire risk assessment for the building had been reviewed in December 2007. A requirement is made for the fire panel records to be appropriately maintained to prevent residents from being harmed and to ensure their safety is promoted. All staff must participate in regular fire drills to ensure that they know what to do if there is a fire. The main kitchen was clean and tidy and in a satisfactorily order. Food temperature records were being maintained. We noted that the home had a food safety inspection by the local food safety officer and was given a silver award for good food standards. Rushymead DS0000023016.V367671.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 2 3 X X 3 3 X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 2 2 Rushymead DS0000023016.V367671.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(2)(b) Requirement The home must have a consistent practice in place to ensure that care plans are kept under review. Any form of restraint that is used to protect and promote people using the service safety must be supported by a detailed care plan. The dependency levels of people using the service must be kept under review and the staffing hours provided must be appropriate to ensure that individuals’ diverse health needs are promoted and met. The mandatory training for all staff must be kept updated to ensure that they are competent and confident to perform their duties. This is an unmet requirement of the previous inspection and a new timescale has been set. The home must develop a formalised supervision framework to ensure that staff are appropriately supervised. The broken filing cabinet must DS0000023016.V367671.R01.S.doc Timescale for action 31/08/08 2. OP7 15(1) 31/08/08 3 OP27 12(1)(a) 31/08/08 4. OP30 18(c)(i) 31/08/08 5. OP36 18(2) 31/08/08 6. OP37 12(4)(a) 31/08/08 Page 27 Rushymead Version 5.2 be replaced to ensure people’s records are stored securely and confidentiality is not breached. 7 OP38 13(4) The fire panel records must be 31/08/08 appropriately maintained. To ensure that people using the service safety is promoted and to prevent them from any unnecessary risk of harm. All staff must participate in 31/08/08 regular fire drills. To ensure that they know what to do if there is a fire to protect people using the service safety. 8 OP38 13(6) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 1. 2. 3. 4 5 6 7 OP1 OP7 OP7 OP9 OP9 OP26 OP27 The home’s statement of purpose should be reviewed to ensure that it reflects the current manager’s details and the Commission’s details The home should develop a formalised auditing system to ensure that the care plans are up to date and people using the service diverse needs are met. Any restrictions on choice and freedom to promote people using the service safety should be discussed and agreed in a multi-disciplinary forum and reflected in the care plan. To comply with best practice guidelines the medication cupboards on the unit should store only medication items. The medication staff signature list should be updated to ensure that it is current. People using the service requiring regular use of the hoist should be supplied with their own slings to minimise the potential risk of the spread of infection. Staff should wear name badges to enable people with memory impairment to be aware of whom they are DS0000023016.V367671.R01.S.doc Version 5.2 Page 28 Rushymead 8 OP30 9 OP33 speaking to. To ensure that staff receive the appropriate training to care for people using the service a formalised written induction programme should be developed and available for inspection purposes. The home should develop effective quality assurance and quality monitoring systems to ensure that it is providing good outcomes for people using the service. Rushymead DS0000023016.V367671.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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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