Inspection on 12/05/05 for Saxondale

This inspection was carried out on 12th May 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

Saxondale 08/08/07

Saxondale 31/08/06

Saxondale 23/11/05

Saxondale 02/11/04

Saxondale 27/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Saxondale Clarke Street Barnsley South Yorkshire S75 2TS Lead Inspector Steve Vessey Unannounced 12 May 2005 09:50 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. Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Saxondale Address Clarke Street Barnsley South Yorkshire S75 2TS 01226 207705 01226 386600 None Bestquest Limited 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) Mrs Mary Ackroyd N Care Home with Nursing 36 Category(ies) of DE(E) Dementia - over 65 - 36 registration, with number MD(E) Mental Disorder -over 65 - 36 of places Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user may be aged 55 to 65. 2. Appropriate staffing levels must be maintained. The care staff, qualified nursing staffing levels and the manager supernumerary time must be maintained as agreed with the previous registering authority. The staffing requirement is highlighted on the Section 25(3) Registered Homes Act 1984 Notice dated 20th February 2001. Date of last inspection 2 November 2004 Brief Description of the Service: Saxondale home provides personal and nursing care for service users with dementia or a mental disorder. The home is situated off Huddersfield Road and is less than a mile from Barnsley. The home is close to a bus route and within a ten-minute walk of shops including grocers, hairdressers, chemist, post office and newsagents. Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over approximately six and a half hours from 9:50 to 16:30. The inspection process included a partial tour of the premises, inspection of a sample of records and policies, discussions with staff, residents and relatives and observation of staff carrying out their duties. The majority of residents and staff were seen during the inspection and the inspector had the opportunity to speak to eight staff, ten residents and relatives in some detail. What the service does well: What has improved since the last inspection? The manager has received her level 4 NVQ management qualification certificate. Some refurbishment and redecoration had taken place within the home, including the redecoration and re carpeting of some bedrooms and the replacement of the floor covering in some bathroom and toilet areas. Some new lounge furniture and a new carpet have been ordered for communal areas. New electrical equipment, for example televisions and DVD players had been provided in some of the communal lounges. The home had complied with the majority of the requirements and recommendations made following the last inspection. Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 6 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. Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 7 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 Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 8 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) 3, standard 6 was not applicable at the home Resident’s records included a detailed assessment of their needs. EVIDENCE: Three care plans included assessments carried out by staff at the home, and information from the placing authority. A relative stated that they had been asked for information prior to the resident’s admission. Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 9 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 and 9 Residents had a detailed up to date plan of care reflecting their identified assessed needs. Resident’s health care needs were met. Medication was in the main managed safely, however there were some gaps in medication records. EVIDENCE: Three care plans had detailed information including the action to be taken by staff to meet the needs of the residents. Care plans were up to date and regularly reviewed. One relative stated that she was aware of what was in the residents care plan and that she was happy with the care received. Relatives had signed some risk assessments. A student nurse who had recently commenced a placement at the home stated that her first impressions of the home were good. Risk assessments were in place relating to development of pressure sores, falls and nutrition, meeting the health care needs of residents, there was also information recorded detailing how resident’s medication and finances were managed. Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 10 Records were kept of medication being received into the home, the medication received for a resident admitted from hospital was not recorded on the medication administration records. The Deputy Manager stated that medication leaving the home was recorded in a book, however this could not be found. There was a medication administration record for residents, however there were some gaps on the medication administration record, which should have been completed by the member of staff at the time of administration, not fully maintaining the health safety and welfare of residents. A qualified nurse administers medication to residents, when observed administering medication the nurse was sensitive to the needs of the residents. All medication was stored appropriately and securely, maintaining the health safety and welfare of residents. Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 11 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, 14 and 15 Residents are given choice in many aspects of their lives, allowing them to maintain their independence. Residents were happy with the activities and outings on offer. Relatives and friends were encouraged to visit. Residents and relatives are offered information about advocacy services. Residents receive a choice of food, which is of good quality. EVIDENCE: Residents and staff stated that residents could choose when they get up and go to bed and could spend time in their room when they want to. Staff stated that if residents did not like the food on the menu they could have an alternative, maintaining choice and independence. Staff stated that they have time to spend with residents and that residents are encouraged to participate in activities such as, bingo, skittles, dominoes and cards. Residents also receive support from other people visiting the home, e.g. hairdresser, optician, chiropodist, and representatives from the local church, maintaining contact with the local community. Resident’s choice and comfort is maximised by their rooms being personalised, a relative who stated that they had brought in furniture and ornaments to personalise the room confirmed this. Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 12 There was information relating to advocacy services available, which residents can use to help them exercise choice and control over their lives. Lunch was observed being served in the dining room in two sittings. The inspector had lunch; the main course was served hot and was of good quality. Meals were served in an unhurried way, giving residents time to eat; staff regularly prompted residents who were not eating. Residents were asked if they would like a pudding. Residents comments on meals included “lunch was very nice” and “we can’t grumble at the meals”. Staff assisting residents to eat did so in a discreet and sensitive way, sitting at the table and interacting with residents. Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 13 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 and 18 Relatives were aware how to complain and thought that their complaints would be listened to and dealt with. Policies and procedures were in place and abuse awareness training had taken place to protect residents from abuse. EVIDENCE: There was a complaints log available which included the required information; no complaints had been logged recently. A relative stated that if she had a complaint she would speak to staff, she stated that she thought that staff would listen and that they would try to resolve the issue. Residents were protected by staff awareness of local abuse and whistleblowing policies and procedures and staff having attended adult protection training. Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 14 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, 24, and 26 The home was in the main well decorated and maintained. Resident’s rooms were clean comfortable and personalised, one room had a potential tripping hazard. The home was in the main clean, pleasant and hygienic. EVIDENCE: Areas of the home checked were clean, odour free and decorated to a reasonable standard, resulting in a mainly safe and well-maintained environment. Residents and relatives spoken to stated that the home was always very clean and that they were happy and comfortable in their rooms, bedding checked was clean ensuring the comfort of residents. There was an electric cable to a lamp trailing across the floor of a resident’s room, presenting a tripping hazard. A student nurse on a placement at the home stated that the home was nice. A relative stated that in the main the laundry service residents received was good. Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 15 Staff stated that there was sufficient equipment in the laundry to enable them to offer an effective service to residents and that if equipment needed maintenance this was carried out very quickly, for example one of the dryers had stopped working on the morning of the inspection and had been repaired the same afternoon. The manager stated that plans for some refurbishment of the home were in place, this included some bedrooms to be redecorated, some new lounge furniture and some carpets to be replaced. The flooring in some toilet and bathroom areas was in the process of being replaced. Residents, relatives and staff all stated that the home was kept clean. Staff spoken to stated that they had received infection control training and that they were supplied with the appropriate personal protective equipment to reduce the risk of infection. Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 16 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, and 30. Sufficient staff with an appropriate mix of skills was on duty to meet the needs of residents. There are no care staff qualified at NVQ level 2, however some staff are undertaking the NVQ level 2 qualification. Residents were not fully protected, despite a robust recruitment procedure being in place, as CRB disclosures for two staff recently employed could not be found. Staff had received induction training and had further training opportunities. EVIDENCE: The Deputy Manager was on duty as the nurse in charge, there were also five care assistants, the administrator, one domestic/laundry staff, a cook, a kitchen assistant and the Manager on duty. The home provides placements for student nurses and two students were also on duty. Staff and relatives spoken to stated that there was sufficient staff on duty to meet the needs of the residents. The manager stated that twelve staff are working towards NVQ level 2 but as yet no staff are qualified. Two staff spoken to stated that they were undertaking the award. Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 17 Two staff files included an application form, detailing a ten year work history and two references, one of which was from the last employer. The manager stated that she had received CRB disclosures for staff whose files were checked, but was unable to find them on the day of the inspection, The manager contacted the inspector following the inspection and provided the disclosure number for one member of staff but stated that the CRB form for the other member of staff had been returned for more information, therefore residents are not fully protected by recruitment policies and procedures. Staff files included details of induction training and staff stated they had sufficient training opportunities, which included training on dementia care, one of the nursing staff stated that she been offered enough training to fulfil her own requirements for registration with the NMC. Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 18 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) 31, 33, 35 and 38 The manager is experienced, qualified and competent to run the home. There is a quality monitoring system in place. A procedure on the handling of resident’s money was in place, however residents financial interests were not completely safeguarded, as one resident’s money did not reconcile with the financial records kept. Residents and relatives feel that the home is safe, however the testing of water temperatures should be introduced and accident records should be fully completed, to improve the safety of the home. EVIDENCE: The manager had received her certificate to confirming her level 4 NVQ management qualification. Regulation 26 visits take place and the reports are forward to the Commission for Social Care Inspection. Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 19 Relatives stated that they were asked how they feel about the home but that they had not been asked to complete a questionnaire. Staff stated that the manager and other senior staff are approachable and will listen and address any issues raised. A procedure for the handling of resident’s money was in place, money was held in individual wallets and held securely. Written records of transactions were kept, these included two signatures for each transaction. Three residents accounts were checked, two were reconciled with the money held in the wallet. The third showed that there was less money in the wallet than on record sheet. The manager stated that there had been problems with the staff wages at another home within the company and that the owner had contacted her and asked if there was any money at the home to enable them to pay the staff wages. The manager stated that as there was no petty cash on site she decided to use the resident’s money until some petty cash could be obtained. The money was replaced on the day of the inspection. Records were in place stating fire equipment had been checked, regular fire drills take place and that staff had received fire training this was confirmed by staff. The nurse in charge stated she had taken charge of a fire drill promoting the safety of residents and staff. Staff confirmed that they had received moving and handling training and stated that they were provided with the appropriate equipment to move residents safely. Gas appliances had been serviced, electrical testing had been carried out and the servicing of baths and hoists had been carried out. The manager stated that a risk assessment in relation to first aid provision was included in the generic risk assessment and the first aid policy had been amended to in line with this. The manager stated that the water temperatures had not been checked and recorded recently, but that this was to recommence in the near future. Accident records were not fully completed, on one accident record there was no time or location of the accident recorded. Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 20 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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x 2 x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x 1 x 2 2 Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 21 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 9 Regulation 13 Requirement Timescale for action 12/06/05 2. 3. 4. 5. 6. 24 29 35 35 37 16 19, Schedule 2 16 16 12 Records for the receipt administration and disposal of medication must be complete and available. A check of residents rooms must 12/06/05 take place to ensure there are no hazards affecting their safety. Staff must not be employed 12/06/05 without a CRB disclosure. Written records of all transactions on behalf of residents must be kept. Residents personal money must solely be used for the individual resident. Records must be kept as required by the Care Home Regulations and National Minimum Standards (Previous timescale of 01/02/05 not met). A system must be in place for checking and recording water temperatures. Accident records must be fully completed. 12/06/05 12/06/05 12/07/05 7. 8. 38 38 23 23 12/08/05 12/08/05 Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 22 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 28 Good Practice Recommendations 50 of all care staff should have NVQ level 2 or equivalent by 2005. Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Saxondale J51 S38017 Saxondale V226831 12.05.05 UI Stage 4.doc Version 1.30 Page 24 - 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!