Inspection on 31/08/06 for Saxondale

This inspection was carried out on 31st August 2006.

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 23/11/05

Saxondale 12/05/05

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 Mrs Jayne White Key Unannounced Inspection 09:00 31st August 2006 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.V308697.R02.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. Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 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 731409 01226 713409 saxondale@bondcare.co.uk None 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.V308697.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One service user may be aged 55 to 65. 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. 23rd November 2005 Date of last inspection Brief Description of the Service: Saxondale is registered as a care home providing personal and nursing care and accommodation for 36 residents with dementia or a mental disorder. Accommodation is over two floors and a passenger lift and stairs serve these. The home is registered for 32 single and 2 double rooms. A range of communal areas are provided including four lounge areas and a dining room. A commercial type kitchen and laundry serve the home. Sufficient bathing facilities are provided. 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. Information about the home, including the CSCI inspection report is available in the entrance hall to the home. The pre-inspection questionnaire dated 18.08.06 identified the range of fees as £344 for residents requiring personal care, £405 for residents requiring medium band nursing care and £449.25 high band nursing care. Additional charges are made for hairdressing and chiropody. Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced visit took place over ten and a quarter hours from 9:00 to 19:15. As part of the inspection process a postal questionnaire was sent to nine relatives/advocates of residents, ten GPs and twelve health and social care professionals. Questionnaires that were returned included seven by relatives/advocates, three by health and social care professionals and one by a GP. On the day, opportunity was taken to make a partial inspection of the premises, inspect a sample of records, observe care practices and talk to residents, relative, staff and the manager. Nine of the staff on duty were spoken with about aspects of their knowledge, skills and experiences of working at the home, together with five relatives about their views on the quality of care received by their relatives. Also taken into account was other information received by CSCI about the service since the last inspection. In addition the CSCI have reviewed their guidance on requirements, therefore, some requirements have been removed if they had no direct evidence of service user outcome, or reworded. The inspector wishes to thank the residents, staff and manager for their time and co-operation throughout the inspection process. What the service does well: The manager was experienced, qualified and competent to run the home. Relatives general comments about the home included “I moved my father from another home. He is more settled and content here and I am happier with the care he is receiving”, “happy with the care provided”, “highly delighted”, “no problems”, “quite happy with the home”. Residents were provided with access to health care services to promote and maintain their health care needs and were treated with respect and dignity. Observation of the care provided to residents demonstrated residents were helped to exercise choice and control over their lives as far as was possible, taking into account the differing capacities of residents and the lifestyle within the home met their preferences, interests and needs. Residents were encouraged and assisted to maintain contact with their family, friends and the local community as they wished. Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 Page 6 On the whole relatives were aware of how to complain and thought that their complaints would be listened to and dealt with. Staff had a good understanding of the procedures to be followed should they suspect any abuse at the home and said they had, had training in the protection of vulnerable adults. The building and its environment were clean and on the whole well-maintained. Relatives comments about the environment included “rooms spotless”, “cleaned regularly” and “ there’s no stench of urine”. There were sufficient staff with an appropriate mix of skills on duty to meet the needs of residents. Relatives comments about the staff included “they’re willing”, “lovely”, “absolutely fabulous”, “friendly”, “caring”, “always somebody available – high profile – can find someone easily”, “helpful”, “in tune with dealing with dementia – they’re motivated and understand their needs”, “marvellous” and “I admire them”. Staff were trained to equip them with the knowledge and skills for their roles within the home to enable them to care for residents. Systems were in place to safeguard residents’ financial interests. What has improved since the last inspection? What they could do better: Improve the storage and recording of some medication to ensure all medication is recorded and stored appropriately. Remove publicly displayed lists that contain private information about residents so that the residents’ right to privacy is maintained and review the types of aprons provided at meal times to improve the dignity of residents. Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 Page 7 Liquidised meals could be served in a more attractive and appealing way and appropriate cutlery needs to be provided for residents to use, unless there is a documented reason why. Although there was a training programme for staff in place, the home have yet to meet the minimum ratio of fifty per cent of care staff trained to NVQ Level 2 in Care or equivalent. Improvements were required with some of the records kept by the home to safeguard residents’ rights and best interests. Omissions and lack of details were noted in the home’s records for example, assessments, care plans and recruitment. The quality assurance and monitoring system needed to include the views of stakeholders of the service and their opinion of the quality of the service provided. Increased monitoring of moving and handling techniques is required to safeguard residents from injury through inappropriate techniques being used. Action needs to be taken where staff continue not to adhere to appropriate moving and handling techniques. 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.V308697.R02.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 Saxondale DS0000038017.V308697.R02.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): The outcome for standard 3 was inspected. The home did not provide an intermediate care service (standard 6). Residents moving into the home had, had their needs assessed although the home’s own assessment lacked detail and/or was not fully completed. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The files of three residents were inspected. There were aspects of the admission assessment completed by the home for all of the residents that were either not completed and/or lacked detail. Discussion with one relative about their relatives admission to the home identified their relative was assessed by both a care manager and the manager of this home at their previous care home. Saxondale was the families first choice after the reassessment. Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 Page 10 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): The outcomes for standards 7, 8, 9 & 10 were inspected. Residents’ had an individual plan of care, however, the care provided did not always reflect the care documented in the care plan. Residents were provided with access to health care services to promote and maintain their health care needs. The storage and recording of some medication required attention to ensure all medication was recorded and stored appropriately. Residents were treated with respect and dignity, but information about them was publicly displayed compromising their right to privacy. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Four residents’ plans of care were inspected on a sample basis. The residents’ files demonstrated the plan of care was reviewed. The plans contained some Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 Page 11 good profile information, however, the action taken in regard to one resident’s nutritional needs did not correlate with the plan of care, likewise with the falls risk assessment in that two resident’s were being moved without footplates and that this had been assessed for risk was not documented in the file. There were also discrepancies between the documentation of accidents/incidents in the accident and daily record. One relative described that timely intervention was not sought to address the hearing needs of their relative, which resulted in them having to complain to the manager to resolve the problem. Also a number of residents were noted not to be wearing footwear. This does not promote support for the foot when mobilising, does not protect the residents’ feet from injury and poses a risk to slipping on some flooring. The reasons why residents are not wearing footwear was not documented in the care plan including the action to be taken to reduce any risks posed by not doing so. The manager and staff did say a number did not wear them because family either did not provide footwear or provided inappropriate footwear. Residents were provided with access to health care services to promote and maintain their health care needs. Comments by relatives about the care their relative received included “they do everything they can to keep them clean and fed”, “always clean and tidy – clean clothes every day” and “ their health care needs are attended to”. A qualified nurse administered medication to all residents. Records were kept of medication being received into the home. The nurse 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 were medication administration records for residents, which apart from controlled medication were in the main completed appropriately. This included a list of staff administering medication, which allowed their signatures to be identified. In one instance, the medication administration record did not correlate with medication that was remaining. This was referred to the nurse on duty to check and amend if necessary. Medication carried forward from one month to another was not recorded, which did not enable checks of medication received and administered to be carried out. Medication requiring refrigeration was appropriately stored. All other medication was not safely stored as some was stored in a box on the treatment room floor and a controlled drug was not stored in a controlled drugs cabinet or recorded in the bound register. The manager said she was planning for senior cares to be recruited at a later date to administer medicines for residents needing personal care. To plan for this some care staff had, had safe handling of medicines training and were having supervised training in the home by the nurses for six months. Staff said they were looking forward to this and would use the BNF and information slips in medication packages to identify what medication was for and for the side effects. On the whole relatives stated that they felt their relatives were well cared for, staff treated them with respect. One relative said they felt their relative had no Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 Page 12 dignity and was treated like a child. Discussions with staff identified they were aware of the need to treat residents with respect and to consider dignity when delivering personal care. Staff were observed approaching residents in a respectful manner, respecting individual preferences and using diversion strategies when necessary. Good relationships between staff and residents were evident. A list of residents’ dietary needs was displayed in the dining room providing an opportunity for this to be read by relatives, which did not maintain the confidentiality of residents’ information. In addition, at meal times residents were provided with disposable plastic aprons to protect their clothing from spillages. A domestic or household type of apron would improve the dignity of residents who used them and the manager was asked to review the types of aprons provided. Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 Page 13 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): The outcomes for standards 12, 13, 14 & 15 were inspected. Observation of the care provided to residents demonstrated residents were helped to exercise choice and control over their lives as far as was possible, taking into account the differing capacities of residents and the lifestyle within the home met their preferences, interests and needs. Residents were encouraged and assisted to maintain contact with their family, friends and the local community as they wished. On the whole residents received a varied diet suited to their needs, but improvements were needed to make the liquidised meals more attractive and appealing and to provide appropriate cutlery for residents to use, unless there is a documented reason not to do so. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The pre-inspection questionnaire identified recreational activities at the home included board games, musical exercise, bingo, gardening, cake decorating, quizzes, arts and crafts and small trips to the park. An activity co-ordinator Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 Page 14 was employed for four days a week 10:00 – 15:00 and they kept an individual record of the social activities undertaken by each resident. Discussions with the activity co-ordinator identified apart from utilising the garden in the warm weather the residents unless taken out by families didn’t leave the home and given their dementia the activity co-ordinator would not feel confident doing so. It was discussed that going out supervising one resident might be beneficial. During the day the majority of residents were observed to spend the time in the lounges. TVs were on the lounges. Residents were observed reading, playing dominoes and hoola hoop with the activity co-ordinator and walking around the environment as they wished. Relatives comments about the activities provided and stimulation for residents included “staff do try and encourage residents but some residents are not interested”, “there are social functions where family are invited” and “ the activity co-ordinator is good with the residents”. The pre-inspection questionnaire identified meal times were 7:30 and onwards for breakfast, 12:00 – 14:00 for dinner, 16:00 – 18:00 for tea and 21:00 and onwards for supper. There was a four week menu with a choice available at each meal apart from the main meal at dinner. The manager said a choice at this meal had been tried but given the differing degrees of dementia of the residents had not been successful. Likes and dislikes were accommodated. The dining room was clean. Lunch was observed being served in the dining room in two sittings. The menu for the meal was not displayed. Meals were served in an unhurried way, giving residents time to eat and staff regularly prompting residents who were not eating. It was noted that the cutlery used by the majority of residents to eat their meal was a spoon, likewise for residents that were given assistance with their meal. The reason for this was not identified or documented in the care plan, therefore routinely providing a spoon to eat meals may be compromising the residents’ dignity. Staff assisted residents to eat in a discreet and sensitive way. The liquidised meals that were served for residents looked unattractive as the food was all liquidised together. Residents comments about their meals included “lunch was nice”, “food tremendous” and “I enjoyed my lunch”. Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 Page 15 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): The outcomes for 16 & 18 were inspected. On the whole relatives were aware of how to complain and thought that their complaints would be listened to and dealt with. Staff had a good understanding of the procedures to be followed should they suspect any abuse at the home and said they had, had training in the protection of vulnerable adults. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The majority of relatives spoken with stated they had no reason to complain. One relative who did complain to another agency had their complaint referred to the home and adult protection. The home investigated the complaint and appropriate action was taken. A complaints log was held and contained this complaint and adult protection referral. A complaint was taken during the inspection and referred to the provider to investigate. Three of the four questionnaires returned by relatives and/or advocates indicated they knew how to make a complaint but had never had cause to do so. The complaints procedure is displayed in the entrance hall to the home. Staff spoken with said they had attended abuse awareness training and they knew where to access policies and procedures relating to the recognising and reporting of abuse. Staff could describe the action they would take if they Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 Page 16 suspected abuse and could define the types of abuse they would report. Discussions with the manager identified she had not obtained the local multiagency adult protection procedures. She was advised to obtain these. On the whole relatives spoken with felt confident their relatives were safe saying, “they’ve never seen anything untoward” and “staff never show any unkindness”. Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 19 & 26 were inspected. The building and its environment were clean and on the whole well-maintained. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Relatives that were spoken with said they thought the home was comfortable and were pleased with the living environment. Their comments included “rooms spotless”, “cleaned regularly” and “ there’s no stench of urine”. There were four lounges and a large dining room for residents to use. The residents had access to safe and comfortable indoor and outdoor communal facilities. The home was clean and tidy, which promoted a comfortable and homely environment. The home was decorated in a comfortable and welcoming manner, including homely touches of pictures and ornaments. Furnishings and furniture were of a good standard. The residents’ bedrooms looked homely, as residents had been able to bring items of their own furniture and possessions Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 Page 18 with them. Inspection of the building identified a bed base that was torn and exposed. The manager was asked to audit all bases and replace them where necessary within the programme of refurbishment. Replacement of the carpet in the medication room was also asked to be included as it was sticky when walked on. The clothes residents were wearing and those put away in wardrobes and drawers were clean. The clothing in residents’ rooms was inspected to check they were the residents own and they were, on the whole. Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): The outcomes for standards 27, 28, 29 & 30 were inspected. Sufficient staff with an appropriate mix of skills was on duty to meet the needs of residents. The recruitment files did not demonstrate the recruitment process was sufficiently comprehensive in order to ensure the protection of residents. Staff were trained to equip them with the knowledge and skills for their roles within the home and to enable them to care for residents, however, the home have yet to meet the minimum ratio of fifty per cent of care staff trained to NVQ Level 2 in Care or equivalent and monitoring of moving and handling techniques is required. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The rota demonstrated staffing levels were being adhered to and 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 majority of relatives spoken with spoke highly of the staff team and comments about staff included “they’re willing”, “lovely”, “absolutely fabulous”, “friendly”, “caring”, “always somebody available – high profile – can find someone easily”, “helpful”, “in tune with dealing with dementia – they’re motivated and Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 Page 20 understand their needs”, “marvellous” and “I admire them”. Good relationships between staff and residents were observed and staff were observed responding to assistance as required in a responsive manner. Sufficient ancillary staff were employed to ensure standards relating to food, meals and nutrition were met and the home was maintained in a clean and hygienic state. Three staff files were inspected. They included relevant recruitment information including an application form, two written references, criminal records disclosure and where applicable a POVA first check. The files did not demonstrate a full employment history and there was no written evidence that gaps in employment had been explored. In addition the files included records of induction training and disciplinary actions, where applicable. Discussions with staff and a training and development file for each member of staff identified a training programme was in place to enable them to meet the assessed and changing needs of residents. The pre-inspection questionnaire identified details of staff training in the last 12 months included positive dementia care, catheter care, fire moving and handling and safe handling of medication. Future planned training included induction, fire, health and safety, first aid, food hygiene, moving and handling, infection control, abuse and neglect, dementia, pain control and nutrition. Discussions with staff and three staffs’ training records identified that they had received training in safe handling of medication, catheter care, fire, moving and handling, first aid, induction and dementia. The pre-inspection questionnaire identified 22.2 of care staff held NVQ Level 2 in Care or above and 11 staff hold a first aid certificate. Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 Page 21 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): The outcomes for 31, 33, 35 & 38 were inspected. The manager was experienced, qualified and competent to run the home. There were quality assurance and monitoring systems in place, however, these needed to include the views of stakeholders of the service and their opinion of the quality of the service provided. Systems were in place to safeguard residents’ financial interests. On the whole the safety and welfare of residents’ were promoted and safeguarded, however, inappropriate moving and handling techniques were observed, which may place the resident at risk from injury. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 Page 22 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 with dementia. Discussions with the majority of relatives and staff demonstrated the manager promoted an atmosphere of openness and respect where they felt their opinions mattered and the best interests of the resident were promoted. Quality assurance systems formalised this process with a quality audit completed by the company in place, in addition to regulation 26 visits, however, the quality assurance process did not include consultation stakeholders of the service to ascertain their views on the quality of the service provided. Staff comments about the management of the home and the staff team were positive and included “what I like is the manager is interested”, “all staff are helpful”, “we all get on with each other” and “if you step out of line you’re told off but then it’s the end of the story”. Relative comments about the management and staff included “they’re helpful” and “they’re in tune with dealing with dementia – they’re motivated and understand their needs”. A procedure for the handling of resident’s money was in place with residents’ monies held in individual wallets and held securely. Where the home did not hold the monies for residents, advocates were sent a bill for any monies the home had used to attend to their care. Written records of transactions were kept including two signatures for each transaction. One resident’s accounts were reconciled with the money held in the wallet. Records stated that regular fire drills had taken place and that staff had received fire training and fire equipment had been checked. Staff spoken with 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, for example under the arm and without footplates on wheelchairs. A system had been implemented for the monitoring and recording of hot water temperatures on baths and showers. The discharge temperature of the hot water could not be inspected as a plumber had turned the water off to apply pre-set valves of a type unaffected by changes in water pressure, which have fail safe devices to provide water close to forty three degrees centigrade. The manager had liaised with the health and safety executive previously and until all the valves have been fitted where water is discharged in excess of forty three degrees centigrade tap tops are being removed to reduce the risk of scalding to residents. Accidents were recorded, however, there were discrepancies between the documentation of accidents/incidents in the accident report and daily record. Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 Page 23 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 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 3 X 2 X 3 X X 2 Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 Page 24 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 OP3 Regulation 14 Requirement All sections of the admission assessment must be fully completed and include sufficient detail to inform a plan of care for daily living. Care provided must relate to the documented plan of care. The information about accidents/incidents must be factually recorded and be consistent with what has happened and been found and by whom. The plan of care must identify the action to be taken in regard to the provision of care when residents do not wear footwear. Risk assessments must be included in care plans of residents being moved in wheelchairs without the use of footplates. Previous timescale of 24/01/06 not met. All medication must be safely stored. Medication carried forward from one month to another must be recorded. DS0000038017.V308697.R02.S.doc Timescale for action 31/10/06 2. 3. OP7 OP7 OP38 15 15 & 17 31/10/06 31/10/06 4. OP7 13 & 15 31/10/06 5. OP7 OP38 13 31/10/06 6. 7. OP9 OP9 13 13 31/10/06 31/10/06 Saxondale Version 5.2 Page 25 8. OP9 13 9. 10. OP10 OP15 12 16 11. 12. OP15 OP19 12 & 16 16 13. OP29 19, Sch 2 14. OP33 24 15. OP38 13 Controlled drugs must be stored appropriately and their receipt and administration be recorded in a bound register. Lists containing personal information of a resident must not be publicly displayed. The reason for residents to use a spoon to eat their meal must be documented in the care plan or appropriate cutlery provided. When food is liquidised each item of food must be liquidised separately. All bed bases must be audited and where they are identified as needing replacement be placed on the programme for refurbishment. Staff files must demonstrate a full employment history, together with a satisfactory written explanation of any gaps in employment. The quality assurance system must provide for consultation with representatives of the residents. Residents must not be moved in wheelchairs without footplates, unless there is a documented reason not to do so or using an underarm move. 31/10/06 31/10/06 31/10/06 31/10/06 31/03/07 31/10/06 31/03/07 31/10/06 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 OP7 OP38 Saxondale Good Practice Recommendations That the person recording information about an accident and/or incident is the person who witnessed it. DS0000038017.V308697.R02.S.doc Version 5.2 Page 26 2. 3. 4. 5. OP10 OP12 OP19 OP28 The manager should review the types of aprons provided at meal times. That residents are given opportunity for suitable activity and stimulation outside the home. The medication room carpet must be replaced. 50 of all care staff should have NVQ level 2 or equivalent by 2005. Saxondale DS0000038017.V308697.R02.S.doc Version 5.2 Page 27 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 © 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 DS0000038017.V308697.R02.S.doc Version 5.2 Page 28 - 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. 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