Inspection on 01/08/05 for Russell Court

This inspection was carried out on 1st August 2005.

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

Russell Court 20/06/07

Russell Court 21/06/06

Russell Court 09/01/06

Russell Court 29/12/04

Russell Court 05/07/04

Russell Court 24/02/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Russell Court Overfield Road Russells Hall Estate Dudley West Midlands DY1 2NY Lead Inspector Cathy Moore Unannounced 1 August 2005 st 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 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. Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Russell Court Address Overfield Road, Russell Hall Estate, Dudley, West Midlands, DY1 2NY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01384 813375 01384 813377 Dudley Metropolitan Borough Council Acting manager - Andrew Green Care Home 32 Category(ies) of Dementia - over 65 years of age (9), Learning registration, with number disability (1) Mental disorder, excluding learning of places disability or dementia (2), Old age, not falling within any other category (23) Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: All requirements contained within the registration report dated 7 January 2003 are met within timescales contained within the action plan agreed bwtween Dudley MBC and the NCSC. Day care provision must not encorach on the facilities, satffing or services provided to residential service users. By 31 September 2003 all radiators within areas accessed by service users shall not exceed 43oC. ( All radiators have since been guarded). 2 M.D and 1LD placements are terminated . New service users must be within the categorey of OP or DE(E) ( Up to 9 places DE (E) ). Date of last inspection 29.12.04 Brief Description of the Service: Russell Court is a purpose built home, owned and managed by Dudley Local Authority. The home is registered to provide care to a maximun of 32 service users at any one time. Registration categories approved are primarily for older people and nine places to older people who have a diagnosis of dementia. The home offers 32 single occupancy bedrooms, all have en-suite facilities which comprise of a hand wash basin, walk in shower and toilet. The accommodation is divided into four units. Two units are situated on each of the two floors. Each unit provides eight bedrooms and has a comfortable lounge/ dining area and a joining kitchenette. A passenger lift is available to enable access to both floors. Ramped access to and from the home is available. The home has one assisted bath on the ground floor and a number of assisted toilets. Overall the home is maintained in terms of, flooring and furniture to a good standard. The home has a generous size garden and a number car parking spaces. The home offers open visiting times between 7A.M and 11P.M. Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted out by one inspector between 08.30 and 18.15 hours. The inspection was the first of the homes two statutory inspections for this inspection year. The premises were randomly assessed which included two bathrooms, two toilets, Priory and Manor units, four bedrooms, the conservatory area and corridors. Two service users’ were selected for case tracking. This process included the perusal of their personal records, care plans, daily notes and risk assessments, speaking to them in detail and assessing their bedrooms. Two other service users were spoken to in detail, five others in less detail. The breakfast time and medication administration were observed on Manor unit. One staff member was interviewed and two staff files assessed. The manager and one senior were involved in the inspection process. What the service does well: The home is owned and managed by Dudley MBC, it has access to a wide network of guidance and support. The manager and staff appear motivated, interested in their work and are keen to provide a good service to the residents’ in their care. The atmosphere of the home is warm, welcoming and friendly. The premises are of a good standard, decorating work and replacement of furniture is being carried out within a structured programme. One new staff member stated that she felt supported by the other staff, senior team and manager. Positive comments were received from residents’ and included “ This is a lovely home, with a lovely atmosphere. The staff are lovely, especially the manager”. “My bedroom is like a little home to me. I like being able to do my cleaning in my room it keeps me happy and feeling young”. “The meals are very good”. Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 6 “ The home overall is good”. “ The home is very clean”. “ The home is clean and tidy”. “ The staff are excellent, very caring and considerate. “”I can go to my room for privacy any time I want to”. “ Everything is good about the home, I haven’t found any faults”. What has improved since the last inspection? The home was without a permanent manager for some considerable time. The present manager has been in post since December 2004. One resident and one senior commented about the positive changes to the home since the manager commenced employment in respect of structure, processes, leadership and direction. Improvements have been made to record keeping in respect of daily entries made on residents’ files and the obtaining of staff records and documents required by Regulation. Considerable advancement has been made in respect of quality monitoring processes. New care plan and risk assessment processes are being established to replace existing formats. Lounge chairs and dining room furniture have been purchased and provided in Abbey and Manor units. Recruitment of staff to fill vacancies has continued. Three new staff have been appointed. Eighty percent of the staff have received regular supervision. A large proportion of requirements from the last inspection/ previous inspections have been addressed and met. Improvements have been made regarding arrangement of staff mandatory training. Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3,4,5 Residents’ contracts/ terms and conditions are not adequate and require revision and development. No resident moves into the home without having their needs assessed or being assured that these can be met. Residents’ and representatives know that on entering the home their needs will be met. Prospective residents’ are given the opportunity to visit the home prior to admission to assess for themselves the quality and services provided by the home. EVIDENCE: A terms and conditions document was included on each residents’ file viewed. The fee applicable was not detailed on these documents. The documents are in the process of being reviewed in line with current guidance and good practice. An assessment of need (Domiciliary assessment) was included on each resident file viewed. The information contained on these documents was satisfactory. There was evidence of resident involvement by means of signature. Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 10 There was evidence in the form of a letter to demonstrate that prospective residents receive written confirmation that their needs can be met by the home. Residents’ are given the opportunity to visit the home prior to their admission to enable them to make their own assessment of the quality and services provided by the home. One resident commented “ They showed me around the home and gave me a choice of two bedrooms”. Another commented, “ I came and looked around. I picked my own bedroom. They gave me a choice of two different ones”. There were however, no records available in respect of individual residents’ visits or the outcomes of these visits. Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11 Residents’ care plans require further development to ensure that all health, personal, social needs and other needs are met. Health care/ personal care needs require more attention to ensure that these are met in full. Greater diligence must be made in respect of personal care. Medication systems require greater adherence to policy and development to prevent risks to residents’. Further development is required to enhance resident respect and dignity. Residents’ can be assured that they will be treated with sensitivity and respect at the time of their death. EVIDENCE: There was no care plan was in operation for one new resident admitted on the 21 July 2005. Care plans did not always reflect the full range of needs pertinent to each individual resident, examples being how personal care, medical needs or medication needs will be addressed or met. Overall instruction to staff in the care plans was basic. Residents’ spoken to were not aware that they had a care plan. There was no evidence to suggest that they involved in reviews of their care plans. The care plan in respect of one resident whose health has deteriorated significantly had not been reviewed adequately to reflect this deterioration. The manager was able to demonstrate that a new care plan format has been developed and will be put into full operation shortly. Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 12 Records in respect of daily care provided to one resident’ whose needs had changed significantly, had not been completed since 19 July 2005. One resident’s teeth were observed as needing to be cleaned. There was no evidence available to demonstrate that staff determine from residents’ their preferences in respect of how they want their personal care delivered examples being, a bath or shower or preferred times for bathing or showering morning or evening. One resident commented, “ I would prefer a bath to a shower”. Improvements have been made in respect of record keeping to evidence the accessing of healthcare services which was inadequate previously. One resident provided documentary evidence of her eye test that was carried out on 11 January 2005. Three residents’ commented that they do not need to see a dentist as they have dentures. The manager informed that all residents’ should have access to regular dental checks to identify any early abnormal conditions of the mouth. Risk assessment processes have developed somewhat. To enhance this further a new risk assessment tool has been produced which the manager confirmed will be put into operation in the near future. There was evidence to demonstrate that input had been secured from the Falls Prevention Team who run a ‘ sloppy slipper campaign’ and provide and give advice on preventative measures in respect of falls such as hip protectors. Good practice was observed in respect of medication administration in that the staff member responsible washed his hands before commencing and stayed by the resident to ensure that they actually took their medication before signing the medication record. A contract was available between the home and their pharmacy provider. Two medication audits have been carried out by the pharmacy provider, one in March and one in June 2005. The few issues identified from these audits have been addressed. An approved pharmaceutical guide dated September 2004 was available. A number of shortfalls were identified during the medication observation. There were a number of staff signature gaps on the medication records. Diclofenic for one resident was not signed for on the 21 or 28 July 2005 at 12.30 hours or Co- codamol for another resident during the period of 12- 20 July 2005. There was inconsistent evidence that medication belonging to new residents’ had been confirmed by their doctor. At least three medications had been prescribed to take ‘ as directed’ with no clear instructions. A number of prescribed creams were detailed on the medication records but were unavailable, or prescribed creams were seen in the medication cupboard but not recorded on the medication record. Prescribed cream was seen in one residents’ bedroom. There was no evidence that he self applied this cream. He did not have a key for his lockable cupboard. Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 13 One resident’s medication record stated that she self medicated her Combivent inhaler. Yet her risk assessment revealed that she was not safe to self medicate. Staff responsible for medication have either completed or are well advanced in their accredited medication training. There was no evidence to demonstrate that a decision had been determined from each resident whether or not they want a male or female carer to provide their personal care. One male resident commented” I’m not bothered who provides my care”. A female resident commented, “ I don’t want males, I’ve told them. I like/ have females. I don’t think it’s right”. There was little evidence to suggest that the preferred name of each resident is determined and recorded. One resident commented, “most of the time they call me what I want to be named. Occasionally they have used a very shortened name that I don’t like”. A payphone is available in a relatively private area of the reception hall. Additional phone lines have been provided in the lounges. All bedrooms are single occupancy with en-suite facilities to promote and maintain privacy and dignity. Toilet and bathroom doors assessed had lockable facilities that work. One staff member when asked commented, “ We cover residents’ with towels when washing them to promote dignity and ensure that doors are shut for privacy”. Preferences of each resident have or are in the process of being determined in respect of death and dying/ funeral arrangements. Where required relatives have been asked to provide this information. Sixteen staff have recently received bereavement/ care of the dying training. Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 Although progress has been made further work is required to ensure that residents’ find the lifestyle they experience in the home matches their expectations and satisfies their social, cultural, religious and recreational needs and choices. Residents are very much encouraged and enabled to maintain contact with family and friends and the local community. Further development is required to ensure that the dietary and nutritional needs of each resident is met. EVIDENCE: Written evidence was available to demonstrate that resident meetings are held on a regular basis. This was confirmed by one resident who said, ” We do have meetings sometimes”. Another said “ One staff member does meetings with us, she asks what we want”. There was little evidence to suggest that those who are unable to attend to themselves are asked their preferred routines, rising and retiring times. One resident said,” The staff just get me up”. Another commented“ They come into my room and say time to get up. I can choose what time I go to bed”. There was written evidence to demonstrate that activities are provided on a regular basis. A programme of events and outings was seen on the notice Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 15 board. August 2005 planned outings included a trip to the Safari Park and a day at Dunstall Park races. Every two weeks an external exercise provider visits the home and encourages the residents’ to partake in gentle exercise. The home has a day care facility which the residents’ can attend if they want to. On-going in-house activity provision appeared to be restricted especially for those who are more frail or are unable to join in group activities. One resident said, “ I like playing draughts, I have not played since I came in here”. “ Another resident commented, “ I do not want to do anything, activities are provided though for those who want to join in “. Activity participation tick charts are not being completed consistently. Visiting times are open and flexible between the hours of 07.00 and 23.00 hours. One resident commented” My son lives abroad but phones me regularly. My sister and brother- in -law visit often”. Another said, “ When my visitors come we sit in the lounge, we could go in my bedroom though if we wanted to”. A resident commented ” Sometimes the staff take me to the shop”. Another said, “ I don’t like to go out, if I want anything from the shop the staff fetch it for me”. The breakfast was observed on Manor unit. Residents’ were offered a choice of cereals and hot or cold milk. They can choose a selection of cooked breakfasts. Each table was provided with a teapot, milk and sugar for residents’ who are able to serve themselves. Comment cards in respect of meals are completed daily by residents’. Meal comments included ”nice and lovely”. A monthly analysis of the comment cards is carried out by the manager. The main meal of the day is served at teatime. Copies of menus are available on each unit. Staff ask the residents’ what they would like for their main meal, to aid this process a large print pictorial book is used to enhance understanding of those who require this. One resident said “ I like and have egg and toast every morning, I have sandwiches for my lunch, a cooked meal and pudding at tea time and tea and biscuits before I go to bed. If I wanted anything else I can”. Another said, “ You can have as many cups of tea or other drinks a day as you want. I always choose Horlicks or Ovaltine before I go to bed”. She further said, “ Once I was hungry in the night and I asked for a sandwich and they did me one”. There was no evidence of special diet offered or special care plan for one resident who is being prescribed Atorvastatin to reduce cholesterol. There were no processes in place to record the daily food consumption of residents’ Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16. Dissemination of complaints information must be maintained to ensure that all residents’, relatives and other stakeholders are aware of and how to access the complaints processes. EVIDENCE: Dudley MBC has a corporate complaints procedure. Work has been undertaken in-house to make the complaints procedure more appropriate to residents’ living in the home. The complaints procedure seen has a 28-day deadline. Formats are available in a pictorial format. Three residents’ spoken to were not aware of the complaints procedure. This shortfall had already been identified by the manager by speaking to residents about making complaints. One resident when asked if she was aware of the complaints procedure replied, ”No, but I would tell them if I had a complaint. Everything has been alright so far”. Another said “ Knowing me, if I had a complaint I would go straight to the office”. Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,25 (Excluding the present hot water temperature problems) residents’ live in a safe, well-maintained environment. Residents, have access to safe and comfortable indoor and outdoor space. Suitable lavatories and washing facilities are provided in general. Assisted bathing facilities are lacking on the first floor. Development is needed to ensure that all residents’ have safe, comfortable bedrooms which meet their individual needs and choices. The hot water system must receive the necessary remedial work to ensure the safety and well- being of residents’. EVIDENCE: The home has a routine maintenance programme in respect of décor and replacement of furniture and fittings. Overall the home is satisfactory in terms of décor, furniture and fittings. Some work however, is needed, (examples being six bedrooms requiring redecoration. There are generous gardens to the rear which the residents’ use in the nice whether. The home has ramped access and a range of aids and adaptations to enhance safety and independence including a passenger lift. Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 18 The home is registered to provide care to a maximum of 32 residents’ at any one time. The home is unitised internally, into four separate living and sleeping sections offering accommodation to a maximum of eight residents’ on each. Each section has its own lounge/ dining area and kitchenette. In general areas of the home viewed appeared to be adequately maintained in terms of décor, furnishings, lighting and flooring. Individual units are comfortable and have domestic furnishings and fittings making it feel homely. New easy chairs and dining furniture has been purchased and provided in Manor and Abbey units. Flooring and décor in these units are acceptable. All bedrooms provided are single occupancy with en-suite facilities (walk in shower, hand wash basin and lavatory). Four bedrooms were assessed. In general these were of a reasonable standard. One resident did not have a key to his door or lockable facility. He did not have a bedside lamp and the window restrictor in the en-suite was not working properly. Six bedrooms are in need of redecoration. The hot water system has been changed recently which has caused a number of control valves to cease functioning. This creating potential hazards of infection transmission where hot water temperatures are too low 35oC and scalding where they are too hot 57oC. Radiators throughout the home are guarded and lighting is domestic in style. Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28,29 On-going monitoring is required to ensure at all times residents’ needs are met by the correct numbers of care staff. Record keeping in respect of recruitment has improved considerably giving greater assurance of residents’ protection. EVIDENCE: Evidence from staff rotas revealed that in general adequate staffing numbers are being provided six care staff in the morning and five in the afternoon. There have been exceptions where these numbers of staff have not been provided. When short of care staff domestic staff cover these posts. One resident commented, “ The staff are excellent. Very caring and considerate”. Another resident commented” I have to wait sometimes for staff “. 48 of staff have attained an N.V.Q level 2 or above in care. Staff recruitment procedures, particularly being able to evidence staff documents and processes has improved. A copy of a CRB/POVA list check and all other records were available for two new staff members. One staff member however, had not detailed her full past employment history. Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,36,38. Processes are near completion to ensure that the home is run in the best interests of the residents’. Finance procedures in respect of key holding require review. Further development particularly in terms of frequency is required to ensure that all staff are appropriately supervised. More attention is needed to ensure that the health, safety and welfare of residents are promoted and protected. EVIDENCE: Significant advancement was noted in terms of the homes quality assurance monitoring processes. Procedures have been developed, questionnaires and comment cards put into operation to determine resident views on their care and the services provided. Work remains to gain views from other stakeholders. Key holding processes are in need of a review as keys as being taken off the premises overnight. Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 21 Staff supervision processes have improved with over 80 of staff now receiving formal supervision. Access to and attendance on mandatory training has improved. A training matrix has been produced and in general staff have either attended or arrangements have been or are being made for them to attend training. It was identified that one staff member is serving food although she has not got a valid food hygiene certificate. A timescale has not been provided in respect of the work required to the homes fixed electrical wiring. Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 4 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 3 3 2 3 x 2 1 x STAFFING Standard No Score 27 2 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x x 2 x 2 2 x 2 Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5(1)(b) Requirement The registered person and manager must ensure that the weekly fee applicable to each service user is detailed on their individual terms and conditions. Timescale for action 20.08.05 2. OP2 5(1)(b) (c ) 3. OP5 12(2) Timescale of 25.1.05 not met. The registered person and 01.09.05 manager must ensure that the contract/ terms and conditions document is updated and revised in accordance with current guidance and practice. The registered person and 20.08.05 manager must implement a system whereby a record of all prospective service users introductory visits to the home is made. Timescale of 10.1.05 not fully met. The registered person and manager must ensure that a care plan is produced for each service user as per standard 7. Timescale of 29.1.05 not fully met. The registered person must ensure that each service users 4. OP7 15(1) 10.08.05 5. OP7 15(1)(b) 15.08.05 Page 24 Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 care plan is reviewed monthly or when changes occur. Timescale of 10.1.05 not fully met. The registered person and 15.08.05 manager must ensure unless it is impracticable that the residents are fully involved in their care plan production and any reviews. The registered person and 01.09.05 manager must; Review and expand service user plans to include long and short term goals, all aspects of care (social needs, diabetic care, oral hygiene, personal care, pressure area care, incontinence etc). Timescale of 10.1.05 not fully met. This also to include any risks or concerns due to poor physical health, behaviour etc. The registered person and manager must ensure that care plans detail full instructions to staff detailing what must be done, how, when, by whom and how often. The registered person and manager must confirm a situation that arouse in respect of (J) whilst at a previous home and take any action deemed necessary. The registered person must ensure and encourage all residents to have regular dental checks for diagnostic and preventative purposes. The registered person and manager must ensure that a nutritional and tissue viabilty assessment is carried out in respect of all new residents. The 6. OP7 15(1) 15(2)(a) (c )(d) 7. OP7 15(1) 8. OP7 15(1) 15.08.05 9. OP8 12(1)(a) 13(2)( c). 10.08.05 10. OP8 13(1)(b) 01.09.05 11. OP8 12(1)(a) 13(2)(c ) 01.08.05 Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 25 12. OP8 12(1)(a) 13(2)( C) 13. OP8 12(1)(a) results from these assessments particularly where there are risks must be reflected in residents care plans. The registered person and manager must ensure that the rating score is detailed on each dependancy assessment tool document to inform staff what dependancy level each resident has. The registered person and manager must ensure that records are maintained to indicate the personal care delivered to each service user on a daily basis. Timescale of 29.12.05 not fully met. The registered person and manager must ensure that all service users receieve a falls risk assessment and that this is reviewed on a regular basis. Timescale of 10.1.05 not fully met. 10.08.05 01.08.05 14. OP8 13(2)(a) 01.08.05 15. OP8 13(2)(a) The preferred method of personal care (bath or shower) must be determined in respect of each resident, be reflected in there care plan and honoured wherever possible. The registered person must 30.08.05 ensure that all residents are weighed monthly. In general this is being done however, one resident ( E.K) had not been weighed in July. The registered person and manager must ensure that all staff receive training in diabetes awareness. Timescale of 20.1.05 not met. 16. OP8 12(1)(a) 18(1)(a) 01.09.05 Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 26 17. OP8 12(1)(a) 13(1)(b) The registered person and manager must ensure that all service users over the age of 75 years of age plus receive an annual medical review from their doctor. Timescale of 25.1.05 not fully met. The registered person and manager must purchase/ obtain an approved tool for cutting tablets where tablets have been prescribed to give half. The registered person and manager must ensure that certificates are available to confirm that staff have receieved accredited medication training. The registered person and manager must ensure that (E.H) medication record is amended to reflect the recent risk assessment which revealed that she is not safe to self medicate. this applies to the Combivent inhaler. The registered person and manager must confirm with each residents doctor where applicable the prescribed topical preperations required. Those that are required must be: Detailed at all times on the residents medication record,and be signed for after application. Be suitably stored at all times either by the resident if they have been assessed as safe to self medicate or by the staff. Where topical preperations are no longer required and are on site, these must be returned as per procedures to the pharnacy 01.10.05 18. OP9 13(2) 10.08.05 19. OP9 13(2) 10.08.05 20. OP9 13(2) 01.08.05 21. OP9 13(2) 10.8.05 Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 27 provider. 22. OP9 13(2) The registered person and manager must ensure that all medication records are signed at the point of administration. The registered person must purchase suitable thermometers to be placed in the medication cupboards to ensure that medication is not stored above 25oC. Daily recordings must be made thereafter. The registered person and manager must request that the homes pharmacy provider gives a view on the suitability of the cupboards used to store medication in the home . They must be asked to record the outcome/ their view on the next medication audit report. A copy of which must be provided to the CSCI office. The registered person and manager must check with a reliable source (doctor) the medication , dosage, frequency of administration of prescribed medication for each new service user admitted to the home. This must then be included on the service users care plan. Timescale of 25.1.05 not met. The registered person and manager must ensure that a section is available in each residents care plan in respect of medications. This must be maintained and updated when there are any changes to medication. Timescale of 25.1.05 not met. The registered person and manager must request that doctors prescribe using precise 01.08.05 23. OP9 13(2) 20.08.05 24. OP9 13(2) 09.05 25. OP9 13(2) 15.08.05 26. OP9 13(2) 10.08.05 27. OP9 13(2) 01.09.05 Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 28 28. OP9 13(2) 29. OP9 13(2) 30. OP10 12(4)(a) (b) 31. OP10 12(4)(a) (b) 32. OP12 12(2) 33. OP12 12(1)(b) 12(4)(b) 16(2)(m) (n) instructions rather than As directed. Where As directed is presently detailed on medication records/ medication boxes these must be changed with the monthly ordering by consultation with the doctor and / or pharmacy provider. The registered person and manager must ensure that the frequency of any medication is not changed unless the doctor has approved this. (This applies to one residents analgesics. The registered person and manager must ensure that a section is specifically dedicated in the medication cupboard to store topical preperations. These must be stored away from oral medications. The registered person and manager must ensure that the preferred name of each resident is determined, recorded and used. The registered person and manager must determine from each resident their preferred gender of staff in respect of personal care delivery. This must be recorded on their personal file and adhered to. The regisistered person and manager must ensure that preferred daily routines (rising and retiring times, meal times, bathing/ showering times etc) are determined in respect of each resident be reflected in their care plan and honoured whenever possible. The registered person and manager must perform an audit of service users preferences/ interests to ensure that activities provided are appropriate to the needs of the service users. 01.08.05 20.08.05 15.08.05 15.08.05 01.09.05 01.09.05 Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 29 Timescale of 25.1.05 not met. 34. OP12 12(1)(b) 12(4)(b) 16(2)(m) (n) 35. OP12 16(2)(m) (n) The registered person and manager must ensure that individual activity/ stimulation programmes are produced and provided to residents who are frail, unable or who would prefer this one to one attention. The registered person must ensure that the activity participation tick chart in respect of each resident is diligently and consistently completed. The registered person and manager must ensure that all residents special dietary needs are identified and that a plan is produced. (low fat diets, low cholesterol diets, diabetics, diets for residents with poor appetites, weight loss or who are at risk nutritionally or otherwise). The registered person and manager must ensure that the daily food consumption in respect of all residents is recorded. Initial priority must be given to those who have a poor appetite or are nutritionally or otherwise at risk. The registered person and manager must ensure that the dessemination of information regarding complaints procedures to residents is continued. The registered person and manager must ensure that the homes maintenance programme continues to: Ensure that the six highlighed bedrooms are redecorated. The replacement of furniture continues. Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 30 01.09.05 01.08.05 36. OP15 12(1)(a) 17(1)(a)Schedule 3(m). 10.08.05 37. OP15 17(1)(a)Schedule 3(m) 17(2)_ Schedule 4 (13). 20.08.05 38. OP16 22(2) 01.08.05 39. OP19 23(2)(b) 23(2)(d) 04/06 40. OP21 23(2)(j) That carpet edgings are secured in rooms 10,17,25 and 29 etc as programme ( in order of priority). The registered person and manager must ensure that an assisted bathing facility is provided on the first floor. The registered person and manager must ensure: That all residents who have been assessed as safe to, and want to, are provided with a key to their bedroom door. That all residents are provided with a key to their lockable cabinet and that these are in good working order. The registered person and manager must ensure that bedroom 33 is provided with a suitable bedside lamp. The registered provider and manager must ensure that all window restrictors on the first floor (including the en-suites) are in good working order. The registered person and manager must ensure that hot water temperatures throughout the home are maintained within the range of 38oC - 43oC. That a timescale be provided to the CSCI detailing when the required work to the hot water system will commence and will be completed. In the interim risk assessments must be carried out to prevent infection transmission due to 01.10.05 41. OP24 12(4)(a) 16(2)(l) 01.09.05 42. OP24 16(2)(e) 10.08.05 43. OP24 13(4)(a) 10.08.05 44. OP25 08.08.05 Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 31 water temeratures being too low and scalding due to water temperatures being too high. Immediate requirements followed by a serious concern letter were issuedby the CSCI to this effect. 45. OP27 18(1)(a) The registered person and manager must ensure that adequate care staffing levels are maintained at all times to prevent impinging on domestic or other staff hours. The registered person and manager must ensure that a full past employment history is obtained from each prospective staff member (This to include the names of all previous care homes) before they commence employment. The registered person and manager must continue with the progress made in respect of quality monitoring systems. The registered person and manager must review, after consultation with their finance department the key handover process. Particularly the fact that keys are being taken off the premises at night. The registered person and manager must continue with progress made in respect of the supervision of staff. All staff, including night staff, must receive 6 supervisions in any 12 month period . The registered person and manager must ensure that all staff who cook, prepare or serve food have a valid food hygiene certificate. For confirmation seek advice from EHO. 01.08.05 46. OP29 19(2) 01.08.05 47. OP33 24(1) 01.08.05 48. OP35 13(2) 16(2)(l) 01.09.05 49. OP36 18(2) 01.09.05 50. OP38 16(2)(j) 01.08.05 Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 32 51. OP38 13(2)( c) 18(1)(a) 52. OP38 13(3) 53. OP38 13(4)(a) ( c) The registered person and manager must continue to ensure staff receive all mandatory training required. The registered person and manager must ensure that a copy of the homes water test results ( arranged for 2.8.05 ) are forwarded to the CSCI The registered person and manager must provide the CSCI with a timescale detailing when the work required on the five year fixed electrical wiring report will be attended to. 01.08.05 01.09.05 20.08.05 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. Refer to Standard OP8 OP33 Good Practice Recommendations The registered person and manger should retain upon each service uesrs file a copy of their continence assessment. The registered person and manager should consider how to obtain feedback from stakeholders in the community. Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 33 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Russell Court E55 S41844 Unannounced Russell Court V 241772 010805 Stage 4.doc Version 1.40 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!