CARE HOMES FOR OLDER PEOPLE
Saxondale Clarke Street Barnsley South Yorkshire S75 2TS Lead Inspector
Mr Steven Vessey Unannounced Inspection 23rd November 2005 10:45 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 Saxondale DS0000038017.V263957.R01.S.doc Version 5.0 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. Saxondale DS0000038017.V263957.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Saxondale Address Clarke Street Barnsley South Yorkshire S75 2TS 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) 01226 207705 01226 207705 saxondale@bondcare.co.uk Bestquest Limited Mrs Mary Ackroyd Care Home 36 Category(ies) of Dementia - over 65 years of age (36), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (36) Saxondale DS0000038017.V263957.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 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. One service user may be aged 55 to 65. 2. Date of last inspection 12th May 2005 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 DS0000038017.V263957.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six and a quarter hours from 10:45 am to 2:30 pm on 23rd November 2005 and 10:20 am to 12:25 pm on 24th November 2005. 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, four residents and relatives in some detail. What the service does well: What has improved since the last inspection?
The management of medication had improved, as records relating to the disposal of medication were available. Residents’ financial records were fully completed and showed that residents’ money was used appropriately. Water temperatures on baths and showers had been checked and recorded at around 43 degrees centigrade. Accident records had been fully completed and tripping hazards had been removed from residents’ bedrooms. Saxondale DS0000038017.V263957.R01.S.doc Version 5.0 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 DS0000038017.V263957.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Saxondale DS0000038017.V263957.R01.S.doc Version 5.0 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 the following standard(s): 3, standard 6 is not applicable at the home. Resident’s records included a detailed assessment of their needs. EVIDENCE: Three care plans included detailed assessments of the residents needs. Saxondale DS0000038017.V263957.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 and 10. Residents had a detailed up to date plan of care reflecting their identified assessed needs. Resident’s health care needs were in the main met, however this would be improved if all care plans included information relating to residents wishes regarding their care following death and risk assessments were included in care plans for residents being moved in wheelchairs without the use of footplates. Medication was managed safely and stored securely. Residents were treated with respect and had adequate privacy. EVIDENCE: Three care plans included detailed information as to the actions that needed to be taken by staff to meet the needs of residents and reflected information contained in their full needs assessments. The health care needs of residents were in the main met as the care plans included risk assessments relating to falls, pressure sores and moving and handling. However two care plans did not include information relating to
Saxondale DS0000038017.V263957.R01.S.doc Version 5.0 Page 10 residents wishes regarding their care following death and risk assessments were not included in care plans for residents who were unable to use footplates when being moved in a wheelchair. The deputy manager stated that the residents who required a risk assessment relating to wheelchair footplates had been identified and a risk assessment was to be formulated in the near future. Records were kept of medication being received into and leaving the home, the manager stated that the community pharmacist was accepting medication returns and had stated that he had the appropriate licence to enable him to do this. There was medication administration records for residents, which were in the main completed appropriately, these included a list of staff administering medication, which allowed their signatures to be identified. A qualified nurse administered medication to all 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. Residents and relatives stated that residents were well cared for, staff treat them with respect and they were able to spend time in their room if they wish. Care staff were able to describe how they promoted privacy and dignity when providing care for residents and stated that information relating to this was included in their induction training. Nursing staff described how they monitored care delivery to ensure the privacy and dignity of residents was maintained. Saxondale DS0000038017.V263957.R01.S.doc Version 5.0 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 the following standard(s): 15 Residents received a choice of food, which was of good quality. EVIDENCE: Lunch was observed being served in the dining room in two sittings. 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 comments on meals included “lunch was nice” and “I enjoyed my lunch”. Staff assisted residents to eat in a discreet and sensitive way, sitting at the table and interacting with residents, maintaining their dignity. Saxondale DS0000038017.V263957.R01.S.doc Version 5.0 Page 12 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 and 18 Relatives were aware how to complain and thought that their complaints would be listened to and dealt with. Residents were protected by the policies and procedures in place relating to the recognising and reporting of abuse and abuse awareness training attended by staff. EVIDENCE: Relatives spoken to stated that they were aware of how to complain but also stated that they had no reason to complain. A complaints log was held but no recent complaints had been recorded. Relatives stated that they thought residents were safe; staff spoken to stated that they had attended abuse awareness training and that this was included in their induction training, they were aware of the policies and procedures in place relating to the recognising and reporting of abuse. Saxondale DS0000038017.V263957.R01.S.doc Version 5.0 Page 13 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, 21 and 24 The home was in the main well decorated and maintained, however some areas of the home were showing signs of wear and tear. The living environment for residents would be improved if the smoking lounge and bathrooms were redecorated. Resident’s rooms were clean, comfortable and personalised. EVIDENCE: In the main the environment was well maintained, some bedrooms had been redecorated and had replacement carpets and a new height adjustable bed and pressure care mattress had been purchased. However some areas of the building were showing signs of wear and tear, the wallpaper in the smoking lounge was damaged and there was damage to the walls in the bathrooms and shower room, including stains above the radiators. Saxondale DS0000038017.V263957.R01.S.doc Version 5.0 Page 14 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 and 30. Sufficient staff with an appropriate mix of skills was on duty to meet the needs of residents. Less than 50 of care staff were qualified at NVQ level 2, however staff are undertaking the NVQ level 2 qualification. A robust recruitment procedure was in place, however residents were not fully protected, as CRB disclosures for two staff recently employed had not been received back by the home, however the manager stated that these staff were being supervised. Staff had received induction training and were offered further training opportunities. EVIDENCE: The rota showed that there was adequate numbers of staff with an appropriate mix of skills to meet the needs of the residents; relatives and staff confirmed this. The manager stated that four care staff had completed training at NVQ level 2 in care and six care staff were currently undertaking the training. She stated that another four would be commencing the training in January 2006 and some care staff would be commencing training at NVQ level 3 in care. The manager stated that two care staff had recently been employed and had commenced work; she stated that a CRB disclosure had been applied for but had not yet been returned and that due to this the staff members were being
Saxondale DS0000038017.V263957.R01.S.doc Version 5.0 Page 15 supervised. Staff files included other relevant recruitment information including two written references and included records of induction training. Staff stated that they were offered other training opportunities. Saxondale DS0000038017.V263957.R01.S.doc Version 5.0 Page 16 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, 35 and 38. The manager was experienced, qualified and competent to run the home. Residents’ financial interests were safeguarded. Residents and relatives felt that the home was safe, however the hot water on hand washbasins presented a risk of scalding and a fire extinguisher had not been serviced. EVIDENCE: The manager had appropriate nursing and management qualifications, had worked at the home for a number of years and had extensive experience of working with older people. 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. Two residents accounts were reconciled with the money held in the wallet.
Saxondale DS0000038017.V263957.R01.S.doc Version 5.0 Page 17 Records stated that regular fire drills had taken place and that staff had received fire training and fire equipment had been checked, however the last service date recorded on the fire extinguisher in the boiler house was December 2003. Staff spoken to confirmed they had received moving and handling training and stated that they were provided with the appropriate equipment to move residents safely, however several members of staff were observed moving residents using unsafe methods. A system had been implemented for the monitoring and recording of hot water temperatures on baths and showers and the recorded temperatures were around 43 degrees centigrade. The discharge temperature of the hot water on the hand washbasin in a bathroom was recorded at 55 degrees centigrade; the hot water temperature was also in excess of 43 degrees centigrade and hand washbasins in residents’ bedrooms. The handyman stated that the temperature of the hot water could be reduced if the thermostat on the water storage heaters was turned down, this then showed that the hot water was being stored at a temperature of around 50 degrees centigrade, potentially increasing the risk of legionella. The Health and Safety Executive have been made aware of the risks relating to hot water temperatures and legionella. Accident records were fully completed. Saxondale DS0000038017.V263957.R01.S.doc Version 5.0 Page 18 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X 3 X X 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 3 X X X 3 X X 2 Saxondale DS0000038017.V263957.R01.S.doc Version 5.0 Page 19 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 OP8 Regulation 13 Requirement Information relating to residents wishes for care following their death must be recorded in all care plans. Risk assessments must be included in care plans of residents being moved in wheelchairs without the use of footplates. The smoking lounge must be redecorated. The bathrooms must be redecorated. Staff must not be employed without a CRB disclosure and POVA check. (Previous timescale of 12/06/05 not met). The temperature of the water at hot water outlets accessible to residents must be reduced to around 43 degrees centigrade. Systems must be in place to control the risk of legionella. (Linked to requirement 4). All fire extinguishers must be serviced regularly. Timescale for action 24/02/06 2. OP8 13 24/01/06 3. 4. 5. OP19 OP21 OP29 23 23 19, Sch 2 24/03/06 24/03/06 24/12/05 6. OP38 23 24/12/05 7. 8. OP38 OP38 23 23 24/01/06 24/12/05 Saxondale DS0000038017.V263957.R01.S.doc Version 5.0 Page 20 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 OP28 OP38 Good Practice Recommendations 50 of all care staff should have NVQ level 2 or equivalent by 2005. A system should be in place for checking and recording hot water temperatures throughout the building. Saxondale DS0000038017.V263957.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Sheffield Area Office 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
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