Inspection on 21/06/06 for Russell Court

This inspection was carried out on 21st June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 09/01/06

Russell Court 01/08/05

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 Russell Hall Estate Dudley West Midlands DY1 2NY Lead Inspector Mrs Cathy Moore Unannounced Inspection 21st June 2006 07:05 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 Russell Court DS0000041944.V299641.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. Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Russell Court Address Overfield Road Russell Hall Estate Dudley West Midlands DY1 2NY 01384 813375 01384 813377 tony.cooksey@dudley.gov.uk N/K Dudley Metropolitan Borough Council 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) Andrew Green Care Home 32 Category(ies) of Dementia - over 65 years of age (9), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (22) Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All requirements contained within the registration report of 7 January 2003 are met within the timescales contained within the action plan agreed between Dudley Metropolitan Borough Council and the National Care Standards Commission. Day care provision must not encroach on the facilities, staffing and services, provided to residential service users. By the 31 September 2003, all radiators within areas accessed by service users shall not exceed 43 degrees celsius. In the interim, following risk assessments, strategies are implemented to safeguard service users. Service users to include up to 22 OP, 9 DE(E) and up to 1 MD. When service user category of MD`s placement is terminated new service users must be accommodated within the categories of OP or DE(E) as appropriate. 09/01/06 2. 3. 4. Date of last inspection 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 maximum of 32 service users at any one time. Registration categories approved are primarily for older people with nine places for 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 washbasin, 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. Russell Court overall, is maintained in terms of flooring and furniture to a good standard. The home has a generous size garden and a number of car parking spaces. Russell Court offers open visiting times between 7AM and 11PM. The weekly fees for Russell Court range from £355-£450. Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector on one day between 07.05 and 21.00 hours. Information prior to the inspection was gathered from what had been sent to the Commission since the last inspection and 15 completed resident questionnaires. The premises were randomly assessed which included looking at the gardens, living areas, three bedrooms, toilets, bathrooms, the kitchen and laundry. Eight residents, three staff and one relative were spoken to during the inspection. The acting manager was involved in the whole inspection, two seniors in part. Four resident files were looked at to assess their care plans and health/personal care records. Three staff files were looked at to assess recruitment processes and training. Medication systems, quality assurance and health and safety processes were also all assessed. What the service does well: The home is purpose built it. It has generous sized gardens and car parking space. The layout of the home divided into four units makes it feel comfortable and homely. Each has it’s own living and dining space. Bedrooms are all single occupancy with en-suite shower, hand washbasin and toilet facilities. The home was found to be clean and free from offensive odour. One resident commented;” Always very, very clean”. On the whole residents were content. One said;” I am very happy here. Another said;” I love it here. I went to another home and asked to come back”. The home internally is generally well maintained. It has ramped access and a shaft lift to make access easier and safer to both floors. The home provides a range of information to help new residents decide if the home will be alright for them. One resident commented;” I had all the information I needed”. Another commented;” I made the right decision”. Visiting times are open and flexible. Residents are actively encouraged to maintain contact with family and friends. One visitor said;” I visit nearly everyday. The staff make me feel welcome”. The staff team are motivated, committed to providing a good service to the residents’ in their care. They are caring, kind and friendly. Staff observed during the inspection were polite to the residents and gave them choices Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 6 wherever possible. One resident commented;” Nothings too much trouble for the staff”. Over 50 of the staff team have achieved N.V.Q level 2 or above in care. All staff who have a responsibility for medication have received accredited medication training. Staff receive, one to one supervision on a regular basis. Staff recruitment processes and screening was found to be good. The organisation is in the process of having all staff Criminal Record Bureau checks repeated for those whose last check was done three or more years ago. What has improved since the last inspection? What they could do better: Care planning and health / personal care provision needs to be improved to ensure that all residents needs are fully met. Medication systems need some ‘fine tuning’ to ensure that they are safe. The home must explore and improve areas highlighted in this report where residents’ have suggested that they are not satisfied examples being; activities and some meals. Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 7 Complaints and protection issues need improvement to ensure that complaints can be made and dealt with adequately and that if an allegation of concern is reported that this is also dealt with properly with guidance in place to ensure that residents’ are safe. The garden needs a general tidy up and routine maintenance regularly afterwards. Overall, monitoring and quality assurance systems needs more development and attention. 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 DS0000041944.V299641.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 Russell Court DS0000041944.V299641.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. The overall outcome for this group of standards is judged to be good. It is clear that residents are given adequate information about the home before they are admitted including the offer of a pre-admission visit. Contract/terms and condition documents/fee structures need further development to ensure that residents’ are fully informed. Assessment of need processes seen are of a good standard, however, there was a lack of confirmation to prospective residents’ that their needs can be met. EVIDENCE: The homes’ entrance hall displays a range of information which includes the homes’ statement of purpose, service user guide and the last inspection report accompanied by the providers response to the report. Eleven of the fifteen completed resident questionnaires received confirmed that they had; ‘ received enough information about the home before they moved in to enable them to decide if the home would be right for them’. Four however, responded as ‘No’ to this question. Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 10 Of the four resident files examined three contained a ‘contract’. To evidence this further an impressive fifteen of the fifteen completed resident questionnaires received confirmed that they had received a contract. The one resident who had not been issued with a contract was staying at the home for ‘respite’ or -short term care. The manager confirmed that there is no contract in place appropriate for this purpose. Contract content needs attention as information is not fully clear about what is included in the fee and what is not. It does not detail the room number applicable to the individual resident. Although it is extremely positive that the acting manager has provided on the file of each resident the precise charge to them, the full range of fees is not available in the home for general information. Assessment of need documentation seen was satisfactory, it is positive that there was evidence available to confirm that each resident had been involved in this process. Good practice was seen in that assessment documentation from the residents’ ‘funding’ authority had been obtained and retained on their file. From discussion with the acting manager it was clear that residents are invited to visit the home prior to their admission. Although he did say it is not often they accept this offer, it is usually their next of kin who visits. Russell Court DS0000041944.V299641.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. The overall outcome for this group of standards is judged to be adequate. Care plan structure and content needs further development as does health and personal care, medications and issues around last wishes to ensure that all residents’ receive the full care and support they require. EVIDENCE: Although care plans have improved over the last year further improvements are needed to ensure that they contain all needs, choices and goals in respect of each resident. For example; the home had determined that the religion followed by one resident was Catholic however, there was no reference to this in the care plan. Further, one resident frequently suffered from incontinence which was noted in daily notes at least five times yet again, there was no reference to this in the care plan. It was noted that for one resident who had deteriorated the care plan had been inadequately reviewed, this was partly addressed however, once the issue had been raised during the inspection. Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 12 It was extremely disappointing to discover for one resident accommodated for respite care there was no care plan at all. It was encouraging however, that a care plan specifically for diabetics has been produced since the last inspection. Weight monitoring needs further development. It is positive that processes are in place to some extent for residents’ who are felt to be at risk through weight loss. Yet there are no processes in place for residents’ who have gained significant weight . It was noted from records that one resident had gained weight. The family had shown concern over this. Yet no action had been taken by the home. Similarly, a resident who is insulin dependant has gained weight since January 2006. On observation she was short of breath and ‘wheezy’. She said that her mobility had got worse and showed her swollen knee saying; “ It is arthritis”. She also stated that she had in the past had a stroke. Again, there was no record of action taken to rectify the weight gain or protect her health due to the weight gain. It was disappointing to discover that the resident admitted for respite care had not been weighed on admission. No baseline measurement was therefore available to prove weight loss ,weight gain or weight remaining static during the stay. The home has five residents accommodated who have diabetes, three of whom need insulin to control this yet, although requirements have been made previously only a minority of staff have received diabetes awareness training. There was no evidence that these residents’ are being offered service from a specialist optician qualified to treat people with diabetes. It is positive that documents are being used to record health care visits such as doctors and district nurses. It was noted however, that there was a lack of recording of when the chiropodist visits residents’. It was positive to see documentation in operation to assess residents’ concerning tissue viability and nutrition. It is also positive that the doctor had been asked to assess a resident who is frequently falling in turn a referral has been made to the falls prevention team. The question ‘Do you receive the care and support you need ‘ is asked in a Commission questionnaire used . Out of fifteen responses thirteen, responded to this question as ‘Always’ , one ‘Usually’ and one ‘Sometimes’. Resident comments were also received which included;” Quite pleased with the care and support I’m getting” and “Nothings too much trouble for the staff”. Another question asked is; ‘Do you receive the medical support you need?’. Of the fifteen responses received twelve answered as; ‘Always’ , two as ‘Usually’ and one as ‘Sometimes’. It is positive that all staff responsible for medications have received accredited medication training. The homes’ medications are provided by a large well known pharmacy provider who carries out regular audits of the homes’ medication systems. It is pleasing that a photo of each resident is attached to Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 13 their medication record to increase safety by better identification when administering medications. A number of shortfalls were identified which need to be rectified to ensure medication safety. Medication systems were assessed by auditing three residents’ medication. Two were found have correct balances in terms of the number of tablets booked in against signatures for administration and the number of tablets left. One however, was not correct for two medications prescribed. The staff example initial list for administering medication has not been kept up to date. The homes’ medication policy does not require staff to report any medication errors to the Commission as it should. It is extremely positive that the preferred form of address for each resident is determined and recorded on their care plan and that residents’ are asked their preference about opposite gender staff providing their personal care. Three male staff are employed to give a choice of who provides their care. Staff observed during the inspection were heard speaking politely to residents and giving them choices wherever possible. All bedrooms are single occupancy with en-suite facilities to aid privacy and dignity. It was disappointing that the determination of the last wishes for a number of residents have not been explored. This extremely important for residents who have cultural needs or for residents for example, who are Catholic and it may be their wish to receive last rites. Russell Court DS0000041944.V299641.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. The overall outcome for this group of standards is judged to be adequate. Further improvement and development is needed regarding activities and meal provision. Residents’ are helped to exercise choice and control over their lives and are very much encouraged to maintain contact with family and friends. EVIDENCE: Feedback from completed resident questionnaires received suggest that improvement is needed. To the question ‘Are there activities arranged by the home that you can take part in?’ two of the fifteen respondents answered ‘Always’, two’ Usually’ and eleven as ‘Sometimes’. One resident spoken to during the inspection said that she” Did not do anything”. Another resident however, proudly showed some drawings that she had done. Evidence was available to demonstrate that the acting manager has acknowledged that there is a shortfall concerning activity provision and had engendered some improvement. The balcony area in the home has been cleared and is being used as an activity area where various sessions are being held such as painting and drawing. The acting manager further confirmed that different activity groups are being set up hopefully to ensure that residents who are differently able are provided with appropriate activities. A number of residents participate in activities provided by the homes’ day care facility. One resident spoke about the church provision she attends twice a week and the African Caribbean Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 15 befriending day centre service she attends also twice a week. Two other residents’ views on activity provision were; “ I would like to go out more to Southampton or somewhere” and “ Stuck in here all the time it’s depressing”. It must be highlighted that the staff do provide seasonal activities and hold events for special occasions for example; an engagement party held for two residents’ who have recently got engaged. It was positive to see records made of residents’ preferred rising and retiring times and preferences concerning baths or showers. The home has open, flexible visiting times. Residents are encouraged to maintain contact with family and friends. One visitor said;” I visit nearly every day. The staff make me feel welcome”. Bedroom viewed all held a range of residents’ personal effects ranging from a plasma screen television to pictures and ornaments. Information about advocacy services was on display on the notice board for residents’ to access if they want to which is positive. A question in the Commissions resident questionnaire used asks; “Do you like the meals?”. Of the fifteen responses received five answered as ‘Always’, ten ‘Usually’ and one ‘Sometimes’. Comments were received about meal provision as follows; “Cannot grumble,” Very enjoyable”. “ I love the meals”. “I do not like English food”, “ not really”, “ Yes I enjoyed that”. Satisfaction with food is therefore mixed and needs some further exploration. The home has a set menu that operates over a four week cycle. The menu details four main meals a day which are interested and varied. A picture system is in place to enhance menu understanding for residents’ who need this. The food stocks in the home were plentiful and of a good quality. There was plenty of fresh fruit, salad and vegetables. Food stocks were varied and included; canned food, frozen food, cheese, fish, different meats, cold meats, white and brown bread , breakfast cereals, eggs, crisps and biscuits. The cook confirmed that she does wherever possible add additional fruit and vegetables to the cooking/meals. A discussion was had with the manager about the possibility of increasing resident fruit and vegetable in take by providing fruit and vegetable smoothies. Lunch consisted of sandwiches, pork pie salad and cake. The main meal of the day was served at teatime and consisted of either cheese and vegetable bakes or roast beef followed by pie and custard. Two choices are provided for each meal. Each unit has it’s own dining area, the maximum number of residents catered for on each is eight which makes it feel very homely. Tables seen were nicely laid with the required condiments. Staff were on hand to give assistance where needed. Three residents’ of African Caribbean origin live at the home. One clearly stated that she did not like the food provided another said the she did like the mix of English and African Caribbean food. Meals twice a week are ‘purchased in’ for both from the African Caribbean Centre in Dudley. Russell Court DS0000041944.V299641.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The overall outcome for this group of standards is judged to be poor. Further developments, improvement and clarity is needed concerning complaints and protection to ensure that residents’ views are fully responded to and that no resident is at risk of abuse. EVIDENCE: A A4 sheet was seen on the notice board outside of the office detailing Dudley Social Services corporate complaints procedure. This did not however, inform complainants of the different stages of complaint management, give a 28 day deadline for responding to complainants or detail the phone number/address of the Commission. Although this information was produced in different languages it has not been produced in a format appropriate to the needs of all residents’ for example; pictorial. Work is needed to communicate complaints procedures more as the following was identified from completed resident questionnaires received by the Commission’. Of the fifteen responses received nine confirmed that they ‘Always’ know how to make a complaint. Two ‘ Usually’. Three’ Sometimes’ and one ‘Never’. One relative spoken to said;” My daughter would deal with things like that-she has brought things to mind”. No complaints or concerns have been received by the Commission. One complaint has been received by the home from a resident. Although staff were able to verbally describe how this complaint was dealt with there was no written record of action taken or written response to the complainant. It was concerning that following an allegation of verbal abuse the staff member concerned had been allowed to return to work without the acting manager Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 17 being informed of the outcome of any investigation or prevention/ risk reducing strategies being put into place. A serious concern letter was issued by the Commission for this situation to be addressed further. One relative when asked about his observations of staff attitude and behaviour during his visits replied; “ I have watched programmes on the television about bad things happening in homes’, it is not like that here. I have never seen or heard anything bad”. Dudley Council’s Multi-agency policies and procedures were seen on the shelf in the acting managers office there was however, no evidence available to demonstrate that staff have read these. It is positive that a quick reference flow chart was on display on the notice board giving staff most of the information they need to deal with an allegation or incident of abuse. Missing information identified was the names and telephone numbers of all social services main offices and the instruction to report to the CSCI any allegations or incident of abuse. It was noted that not all staff have received abuse awareness training. Russell Court DS0000041944.V299641.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,24,26. The overall outcome for this group of standards is judged to be good. Although work is needed to tidy the garden and keep it maintained thereafter and minor work is needed internally generally, the home is well maintained, safe, comfortable and homely with a friendly warm atmosphere. EVIDENCE: The home was purpose built and is relatively new being opened in the 1990’s. It is a large detached property divided internally into four units. Each unit has its own living and dining space, bedrooms, bathroom and toilets. Generally, internal space is bright, safe, comfortable and homely. New easy chairs, dining room tables and chairs have been provided within the last year or so on some units. Paintwork mainly in corridors and landings would benefit from being repainted. The acting manager is aware of the homes’ redecorating needs and has a programme available. Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 19 The garden areas whilst they have potential and are well positioned require attention. Weeds and moss were seen among paving slabs and in borders. Garden benches require re-varnishing. Bedrooms viewed are comfortable and safe. All are of single occupancy and have en-suite facilities which include a shower, hand washbasin and toilet. To date auditing of bedrooms against resident wishes has not been addressed in as much detail as it should. It is positive however, that all residents have been asked if they require a key to their bedroom door. Seven bedrooms have been redecorated since the last inspection. Since the last inspection the acting manager has been auditing the cleanliness of the home and monitoring cleaning schedules. He has recently appointed an evening cleaner to clean entrance hall areas, corridors and the day care facility. This work has had a positive outcome on the homes’ cleanliness. Overall the whole home was found to be clean, including carpets in main areas. There were no offensive odours detected. Feedback from residents confirmed these findings. Fourteen of the fifteen responses from questionnaires confirmed that the home is; “ Fresh and clean”. Comments received from residents about the homes’ cleanliness included; ” Definitely- spotless”, “ Always very, very clean. I wouldn’t stay if it wasn’t.” One resident said;” I like to clean my own room- the domestics keep the rest of the home clean”. Minor shortfalls were identified in that there was a lack of information about the containing of infectious disease that may at some point be present examples being; sickness or MRSA and laundry was seen stored in bags direct on the laundry floor rather than in a trolley. The laundry is well equipped. It has two washing machines one of which has sluice disinfectant cycles. The laundry floor was of a good standard. It is positive that the majority of staff ( in all roles ) have received infection control training. Russell Court DS0000041944.V299641.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The overall outcome for this group of standards is judged to be good. Generally resident needs are met by the numbers and skill mix of staff. Residents’ are in safe hands at all times and are supported by the homes’ recruitment processes. Further developments are needed in respect of staff training. EVIDENCE: The home has experienced problems with staff vacancies. The situation is improving as two new staff have been recruited on zero hours to cover for holidays , sickness and training. A new senior has also been appointed. Generally staffing is provided as follows; AM 5 to 6 care staff plus a senior. PM 5 staff plus a senior. Night 2 staff. Domestic, catering and laundry staff are also provided every day. During the week the acting manager is also on duty in the home. Staff numbers do however, vary at times. There was evidence on site to demonstrate that staffing hours are being determined by using the approved ‘Residential Forum’ calculation of care hours tool. For the size and layout of the home only providing 2 night staff is questionable. Relatives it was said; “have raised concerns”. The situation must be monitored and further explored. Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 21 The question, ‘Are the staff available when you need them?’ was asked in a resident questionnaire. Of the fifteen respondents seven stated; ‘Always’, seven as ‘Usually’ and one as ‘sometimes’. Further comments were received to this question which included;’ Yes always’, “ Staff always there when I need them”. One relative did say however;” sometimes when I visit it can be ten minutes before I see a staff member on the unit”. It is positive that approximately 53 of the staff have achieved N.V.Q level 2 or above. Three staff files were perused and these were found to contain the required information in terms of screening and documentation. It is extremely positive that the organisation has taken the initiative to have staff Criminal Record Bureau checks repeated for those that were last done three years ago. There was evidence of induction processes for staff. The acting manager has produced a new training matrix for easy identification of training received and training needed. The home at the present time does not provide a training plan for each staff member, as it should. Russell Court DS0000041944.V299641.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. The overall outcome for this group of standards is judged to be adequate. The registered manager has been on secondment away from the home for at least nine months preventing long term plans being made. Further developments are needed concerning quality assurance and health and safety to ensure that services benefit the residents and that they are safe at all times. EVIDENCE: The manager has been on secondment for nine months. Whilst the home has been well managed it has prevented long term plans being put into place. The acting manager commented a number of times; “ if the home was to be my responsibility long term I would do..”. The registered manager however, is due to return to the home on 1 August 2006. It was pleasing to learn that at least two seniors are at present working towards their certificates in management, Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 23 which the organisation has made a mandatory requirement for this level of staff. There was evidence of work undertaken in relation to quality assurance. An annual plan was on display in the home. Resident and relative questionnaires have been used and audits have been carried out concerning medication and cleaning. It was interesting to hear the acting managers plans to commence meetings for relatives where issues about the home in general can be raised and discussed. Further developments are needed to gain the views of community stakeholders and to ensure that a full audit system is in place against all of the National Minimum Standards with processes to determine non-conformance and implement corrective actions. It was noted that it has been some considerable time since the Commission has received a Regulation 26 visit report from the registered person. Staff files with the exception of one demonstrated that good levels of one to one supervision are being provided to staff at least 6 times per year. Inventories were seen for most residents detailing their personal possessions which is positive. However, these did not always detail large items brought into the home examples being; furniture or televisions. The management of resident finances was found to be satisfactory. The money is held in a safe. The acting manager carries out regular audits of the money. Two signatures were available for each transaction and individual receipts are issued by the chiropodist and hairdresser. Three residents money were checked which were found to be correct against recorded balances. Generally, health and safety matters were adequate, however some shortfalls were identified. Fire/fire drill training has not been carried out to the required frequency and there are a small number of gaps in mandatory training ( mostly new staff) that the acting manager is trying to address. There were no records to prove that bedrail checks are being carried out . Additional fly screens for kitchen windows have not yet been provided although this was required following a past Environmental Health inspection and the last CSCI inspection report. It was noted that ‘short life’ products in the kitchen are not all being date labelled when opened. There are no thermometers to measure air temperatures in food storage cupboards although food colouring labels read; ‘ store between 10 and 20oc’. The level of cleanliness in the kitchen was found to be satisfactory which is pleasing. A random assessment was carried out in respect of checks and services to equipment required and the following was found; Hoists serviced in May 06, water bacterial test August 05, PAT tests May 06 and fire fighting equipment service May 06. There was however, no evidence of a service to the home’s fire alarm system. Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 24 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 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 x 18 1 3 3 x x x 2 x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 2 3 x 2 Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 25 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 OP2 Regulation 5(1)(b) (c) Requirement Timescale for action 01/08/06 2 OP2 5(1)(b) (c) The registered person and manager must ensure that the full range of weekly fees are prominently displayed within the home. 01/08/06 The registered person and manager must ensure that the contract/ terms and conditions document is updated and revised in accordance with current guidance and practice. Timescale of 01/03/06 not met. The contract does not detail the room number applicable to the resident. It is not clear what is and what is not included in the weekly fee. A section is included on the document but is not being addressed adequately. Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 26 3 OP2 5(1)(b) (c ) 4 OP4 14(1)(d) 5 OP7 15(1) 6 OP7 15(1)(b) The registered person and manager must ensure that that a suitable contract/ terms and conditions document is produced and issued to residents’ accessing respite services. The registered person and manager must ensure that each prospective / new resident is issued with a letter confirming that the home can meet their needs. ( or cannot meet their needs as applicable). The registered person and manager must ensure that a care plan is produced for each resident before/ or as soon as possible after admission as possible. (A care plan was not available for a resident who had been admitted nearly 2 weeks ago for respite care- this issue was mostly addressed before the inspection concluded). The registered person must ensure that each service users care plan is reviewed monthly or when changes occur. Timescales of 10.1.05, 15/8/05 and 25/01/06 not fully met. 01/08/06 01/07/06 22/06/06 01/07/06 Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 27 7 OP7 15(1) The registered person and manager must; Review and expand service user plans to include long and shortterm goals, all aspects of care (social needs, oral hygiene, personal care, pressure area care, incontinence etc). Timescales of 10.1.05,01.09.05 and 25/01/06 not fully met. This also to include any risks or concerns due to poor physical health, behaviour, religion, dementia etc. 25/07/06 8 OP8 12(1)(a) 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. Timescales of 29.12.05, 01/08/05 and 01/02/06 not fully met. 01/07/06 9 OP8 12(1)(a) 18(1)(a) The registered person and manager must ensure that all staff receive training in diabetes awareness. Timescales of 20.1.05, 01.09.05 and 01/02/06 not met. 01/08/06 10 OP8 12(1)(a) 13(4) The registered person and manager must ensure that all residents’ accessing respite services are weighed on admission and preferably before discharge. 01/07/06 Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 28 11 OP8 12(1)(a) 13(4) 12 OP8 12(1)(a) 13 OP8 12(1)(a) 14 OP9 13(2) The registered provider and manager must refer the two residents identified during the inspection to the dietician for advice on loosing weight. The registered provider and manager must ensure that residents’ with diabetes are screened regularly by a specialist optician. The registered provider and manager must ensure that records are maintained for each resident to demonstrate that they have received regular chiropody. The registered person and manager must ensure that all prescribed preparations for example food supplements and creams are signed for when given. Timescale of 09/01/06 not fully met. 01/07/06 01/09/06 01/08/06 01/07/06 15 OP9 13(2) 16 OP9 13(2) The registered person and manager must ensure that the staff example initial list in respect of staff who administer medication is updated. The registered person and manager must ensure that all medication records contain the correct information this to include for example; allergies and the doctors name. Timescale of 25/01/06 not met. 07/07/06 21/07/07 Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 29 17 OP9 13(2) 18 OP9 13(2) The registered person and manager must ensure that the ‘medication error’ section in the homes’ medication policy is expanded to detail the instruction that any medication errors have to be reported to the CSCI in accordance with Regulation 37. The registered person and manager must carry out an investigation to determine why (GP’s) tablets remaining do not tally with what should be left. 21/07/07 07/07/06 19 OP12 12(1b) (4)b) 16(2m)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. Timescale of 01/09/05 and 01/02/06 not fully met. Progress however, is being made. 01/08/06 20 OP11 12(2) 12(4)(b) The registered person and manager must ensure that the last wishes of each resident is determined and recorded on their personal file/care plan. This particularly important concerning any religious or cultural needs that have to be met before or after death an example of which; Catholic faith and last rites. 10/07/06 Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 30 21 OP12 16(2)(m) (n) The registered person must ensure that the activity participation tick chart in respect of each resident is diligently and consistently completed. Timescale of 01/08/05 and 01/02/06 not fully met. 21/07/06 22 OP15 12(1)(a) 17(2) 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). Timescale of 10/08/05 and 01/02/06 not fully met. 15/07/06 23 OP15 17(2)Schd The registered person and 4-13 manager must ensure that each residents’ daily food consumption charts are consistently completed. 12(4)(b) 16(2)(i) The registered person and manager must further explore the dietary needs/ dietary preferences of each resident. This to include specific needs of residents from African Caribbean origins. The registered person and manager must ensure that complaints leaflets produced in a format applicable to the needs of the residents’ examples being; written/pictorial are on display and are available within the home. 01/07/06 24 OP15 05/07/06 25 OP16 22(1)(2) 01/08/06 Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 31 26 OP16 22(3)(4) The registered person must ensure that; A written account of how any complaints/ concerns have been dealt with which must be retained in the complaints log. Written feedback of investigation outcomes/action taken, to all complainants must be given. 15/07/06 27 OP18 13(6) The registered person and manager must ensure; That all staff receive abuse awareness training ( who have not already). That the homes policies and procedures aimed to protect vulnerable people are reviewed. Timescale of 01/03/06 not fully met. 01/08/06 28 OP18 13(6) The registered person and manager must be informed of the outcome of the investigation about the concerning allegation reported in March 2006. A serious concern letter was issued by the CSCI in which this requirement was included. 22/06/06 Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 32 29 OP18 13(6) 30 OP18 13(6) The registered person and manager must ensure that protective documented strategies/ risk reduction measures are put into place to protect vulnerable persons ( as described in the letter issued by the CSCI dated 22/06/06). These must be implemented and retained on site. A serious concern letter was issued by the CSCI in which this requirement was included. The registered person and manager must provide to the CSCI investigation records and the outcome regarding the issue discussed during the inspection. A serious concern letter was issued by the CSCI in which this requirement was included. 23/06/06 01/07/06 31 OP18 13(6) CSA 2000 32 OP18 17(2) Sch 4 (6)(f) The registered person and manager must ensure that a referral is made to the POVA list. A serious concern letter was issued by the CSCI in which this requirement was included. The registered person and manager must ensure that all records concerning any disciplinary are kept within the care home and be made available for inspection. A serious concern letter was issued by the CSCI in which this requirement was included. 26/06/06 01/07/06 Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 33 33 OP19 23(2)(b) The registered person and manager must ensure; That all gardens areas are tidy and maintained this includes clearing weeds and moss from patio areas and borders. The revarnishing /renovating of wooden garden furniture. That the garden then receives sufficient attention through out the year. Records of garden work undertaken must be made complete with dates. 15/07/06 34 OP19 23(2)(d) 35 OP21 23(2)(j) The registered person and manager must add to the homes routine maintenance programme the redecoration of woodwork ( skirting boards/ doorframes in corridors and on landings- other areas identified that need this). Work should be completed by timescale set. The registered person and manager must ensure that an assisted bathing facility is provided on the first floor. Timescale of 01.10.05 and 01/03/06 not met. 01/09/06 01/09/06 Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 34 36 OP24 16(2)(c) The registered person and manager must ensure that an audit against standard 24 is carried out in respect of each bedroom with the resident who occupies it. It must be confirmed that either the resident is satisfied with what is provided in their room or reason items not provided for example risk factors. This process must be repeated each time a bedroom becomes vacant and is re-occupied. The registered person and manager must ensure that all plastic trims and flooring in bathrooms and toilets are intact. Timescale of 01/02/06 not fully met. 21/07/06 37 OP26 13(3) 01/08/06 38 OP26 13(3) 39 OP26 13(3) 40 OP26 13(3) The registered person and 10/07/06 manager must ensure that adequate written instructions are in place for staff to follow if any infection is within the home for example vomiting, MRSA. The registered person and 10/07/06 manager must ensure that laundry procedures / infection control procedures are on display in the laundry. The registered person must 01/07/06 ensure that; Stains on sinks in the laundry are removed. Dirty laundry bags are not left directly on the laundry floor. Only disposable gloves are used in the laundry. Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 35 41 OP30 18(1)(a) 42 OP30 17(2) 43 OP33 24(1) The registered person and manager must ensure that a training plan is on file for each staff member and that this is maintained. The registered person and manager must ensure that a copy of all staff certificates be retained on their file. The registered person and manager must continue with the progress made in respect of quality monitoring systems. Timescale of 01/04/06 not fully met. To be met fully by new timescale set. Must include gaining the views of stakeholders. 01/08/06 01/08/06 01/09/06 44 OP33 26 45 OP35 17(2) Sch 4(10) A monitoring system/audits against all National Minimum Standards/ Care Home Regulations to include non compliance identification and corrective action procedures. The registered person must 10/07/06 ensure that they or a nominated/ appropriate person visits the home at least once a month on an unannounced basis and compiles a report of the findings as per Regulation 26. A copy of this report must be forwarded to the CSCI every month. The registered person and 20/07/06 manager must ensure that furniture/ TV’s are recorded on the individual residents inventory. This must happen straight away for new admissions. Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 36 46 OP35 25(2)(e) 47 OP38 13(2)(c) 18(1)(a) The registered person and manager must request and retain on site a copy of the chiropodists public liability insurance. The registered person and manager must continue to ensure staff receive all mandatory training required. This to include 2 fire drill/ training sessions in any 12 month period. 01/08/06 01/08/06 48 OP38 13(4) 23(2)(c) 49 OP38 13(3)16 (2)(j) The registered person must ensure that any bedrails used in the home are fully checked weekly and a record is made to demonstrate that this has been done. The registered person and manager must ensure that kitchen windows are fitted with fly screens as per EHO report. Timescale of 01/04/06 not met. The registered person and manager must ensure that all ‘short life’ items for example preserves and sauces are date labelled when opened. Timescale of 25/01/06 not fully met. The registered person and manager must forward to the CSCI; A copy of a valid service certificate for the fire alarm system and emergency lighting supply. 07/07/06 01/08/06 50 OP38 13(3)16 (2)(j) 10/07/06 51 OP38 23(4) 10/07/06 Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 37 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 OP27 Good Practice Recommendations The registered person and manager should consider raising night staff hours to provide three staff. Russell Court DS0000041944.V299641.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 DS0000041944.V299641.R01.S.doc Version 5.2 Page 39 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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