Inspection on 08/08/07 for Saxondale

This inspection was carried out on 8th August 2007.

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 31/08/06

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 8th August 2007 07:45 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.V337418.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. Saxondale DS0000038017.V337418.R01.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 207705 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.V337418.R01.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. 31st August 2006 Date of last inspection Brief Description of the Service: Saxondale is a care home providing nursing or personal care and accommodation for 36 older people with dementia or a mental disorder. Bestquest Limited owns the home. The home is situated off Huddersfield Road, Barnsley and is less than a mile from Barnsley town centre. It is close to a bus route and within a ten-minute walk of shops including grocers, hairdressers, chemist, post office and newsagents. The home is a two-storey building. There is a passenger lift. The home has 32 single and 2 double rooms. Communal space includes four lounge areas and a dining room. There is a commercial kitchen and laundry. Sufficient bathing facilities are provided. Information about the home, including the service user guide is available in the entrance hall. This includes the most current CSCI report about the service. The manager said the fee was £363.50. The National Health Service nursing care contribution is in addition to these fees and ranges from £87.00 to £139.00 dependant on the level of National Health Service assessed need. Additional charges are made for hairdressing and chiropody. Saxondale DS0000038017.V337418.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector visited between the hours of 7:45 and 17:45 without giving any notice. Before the inspection, surveys were sent to a range of people, asking them about the home. Nine came back from representatives of people who lived at the home and four from health and social care professionals. The inspection process included inspecting parts of the building, reading some records and observing care practices. It also included discussions with seven people living at the home, two relatives, seven members of staff and the manager. Also taken into account was other information received by CSCI about the service since the last inspection. The inspector wishes to thank the people living at the home, their representatives, staff and manager for their time and co-operation throughout the inspection process. What the service does well: Representatives and health and social care professionals generally expressed satisfaction with the service. The home had a warm, friendly and welcoming atmosphere. People who lived at the home were relaxed and happy. On the whole, the admission process provided representatives with information they needed about the home. They were invited to visit the home before admission, to assess the quality, facilities and suitability. People were provided with access to health care services to promote and maintain their health care needs. They received personal care that was based on their individual needs. There was a complaints procedure that people had access to. People were protected from abuse and had their rights protected. The environment was comfortable with pleasant lounge areas. There was an experienced and stable staff team, with a good mix of carers and ancillary staff. On the whole, there were sufficient staff to support people and for the smooth running of the service. Representatives comments about the staff included “staff are friendly, approachable and courteous”, “there’s a core Saxondale DS0000038017.V337418.R01.S.doc Version 5.2 Page 6 team of regular staff who know residents and the care home’s routine”, “I see the differing stages and types of dementia in the home and how staff and care workers manage it with kindness and patience”, “on my occasional visits I find staff’s response to each person is very good”, “the staff are always welcoming and make us feel that first and foremost our mother is still our mother” and “they are friendly”. What has improved since the last inspection? What they could do better: More detailed information in the assessments would ensure that all people’s individual needs were identified and included in their plan of care. Ensure the record of an accident in the accident report and daily report reflects the same information. This ensures the information accurately reflects what has happened and is not open to questioning. Each person’s personal interests need to be identified and recorded. This will enable a range of group and individual activities to be planned. This will ensure people are provided with activities that meet their individual needs. Detail in the plan of care, how staff and people will communicate when English is not the person’s first language. Ensure that personal information about people is kept secure, to maintain their confidentiality. Provide domestic type aprons at meal times to improve the dignity of people using them. Provide a cover for people when they are moved in the hoist, so that their underclothes are not exposed. Review the whole meal experience including the environment, variety of food, choice of meals and meal presentation. This should include consideration of the relatives’ comments “substitute sliced white bread for wholemeal or offer choice” and “greater use of oily fish such as sardines or pilchards”. This may make the meal time a more enjoyable experience for people. Saxondale DS0000038017.V337418.R01.S.doc Version 5.2 Page 7 Display the complaints procedure in a more prominent position. This will ensure all people are aware of it and know how to complain if necessary. Implement a policy/procedure for bullying and racial harassment. This should ensure appropriate and consistent action is taken should this occur. Take action to erase the mild offensive odour that is present in the home to make it a more pleasant living environment. Keep a tidy garden so that the home does not look neglected and is always suitable for people to use. Include a written explanation of any gaps in staff’s employment history. This will demonstrate the recruitment process is sufficient to safeguard people from the risk of abuse. For staff to demonstrate competence in moving and handling by putting into practice the training they have received. This will ensure people are moved safely and prevent people and staff being placed at risk of injury. The quality assurance process needs to be more comprehensive by including the views of representatives. This will ensure the home is run in the best interests of the people who live there. Also, for the owner to identify in their monthly report, the views of representatives on the quality of the service provided. 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. The summary of this inspection report can be made available in other formats on request. Saxondale DS0000038017.V337418.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 Saxondale DS0000038017.V337418.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. 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. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. On the whole, representatives had the information they needed to choose a home, which would meet the needs of the person they were representing. People had their needs assessed, so that the service would be able to determine whether they could meet their needs, but these could be improved. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) said people were encouraged to view the home. When viewing the home they were encouraged to ask people, visitors and staff, questions about the home. The AQAA also said a brochure and a service users guide was provided. It said all people Saxondale DS0000038017.V337418.R01.S.doc Version 5.2 Page 10 referred to the home were assessed prior to their admission to ensure their needs could be met. The nurse on duty confirmed this information. The files of two people were inspected. Each contained an admission assessment but needed more details. Information from representatives would ensure that the home had a better understanding of the person’s needs and wishes. The manager identified in the AQAA that assessment information could be improved. Surveys returned by representatives identified the majority received sufficient information about the care home. This enabled them to make decisions, on behalf of the person requiring care. Saxondale DS0000038017.V337418.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. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 7, 8, 9 & 10 were inspected. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Overall, the health and personal care that people received was based on their individual needs, which were identified in the plan of care. In general, the principles of respect, dignity and privacy were put into practice. EVIDENCE: Five individual care plans were inspected on a sample basis. These were reviewed regularly. Overall, the plans contained good information. They set out in detail the action that was required by staff to ensure that all aspects of people’s health and personal care needs were met. However, the accident record and daily report still contained conflicting information when an accident occurred. This means the information does not accurately reflect what has happened and can be challenged. A representative said “there have been a Saxondale DS0000038017.V337418.R01.S.doc Version 5.2 Page 12 couple of occasions when my relative has fallen or had a bang to the head when medical treatment has not been given quickly enough in my opinion”. The care plans had not been completed with the involvement of the person’s representative. This meant representatives had not been given the opportunity to provide information about the person and agree with staff the help that they needed. This is particularly important for identifying social activities that are suitable for the person and how often this would be provided. For example, going outdoors. The plans highlighted weaknesses in respect of communication with people where their first language was not English. This means there were times when the person and staff did not understand each other. This can lead to isolation and frustration for the person and a feeling of frustration and inadequacy by care staff. Records of healthcare visits were maintained confirming GP’s, chiropodists and other healthcare professionals were visiting people. Surveys from representatives said the person whom they represented always or usually had their needs met. Their comments included “frequent toilet/pad changing routine”, “they take good care of my relative and his special needs relating to his illness”, “I would like to say that I am pleased that my father is well presented each time I have visited”, “we are always kept up to date now. We insisted on it because sometimes it didn’t happen”, “the care service meets my mother’s needs. Her care is our priority and we are more than satisfied”, “the care and help is good” and “the care home provides excellent levels of care”. Overall surveys from health and social care professionals identified the care service sought advice and acted upon it to manage and improve individual’s health care needs. They as well identified that individual’s health care needs were always or usually met by the service. Additionally they identified the service always or usually responded to the different needs of individuals. Their comments included “the service cares well for residents with difficult problems”, “to the best of my knowledge the residents needs are being met appropriately”, “the service tries to address the needs of different residents through involvement and dignity where possible” and “staff work extremely well to care for residents. I have observed empathy and understanding of individual/person needs”. All medication was looked after by the home because of the person’s diagnosis of dementia. Trained nurses gave out the medication. Medication storage, including controlled drugs was satisfactory. Overall, the date, quantity of medication received from the pharmacy and the signature of the person making the entry was recorded on the medication administration record (MAR). Medication carried over from the previous month was not recorded on the Saxondale DS0000038017.V337418.R01.S.doc Version 5.2 Page 13 current MAR. This meant an exact identification of current stock could not be made without looking through all records since the last receipt of that particular medication. Generally, representatives felt the people whom they represented were well cared for and that staff treated them with respect. There was one negative comment that was “occasionally younger members of staff make the mistake of speaking to residents as though they are naughty children. This is disrespectful and can be offensive”. Discussions with staff identified they were aware of the need to treat people with respect. The staff were also aware of the need to consider dignity when delivering personal care. There was clear and respectful communication between people and staff, for example, at mealtimes and appropriate assistance was given. However, people’s dignity could be improved by using a domestic type of apron, rather than disposable plastic aprons to protect people’s clothing from spillages. The manager confirmed she had investigated this, but was unable to find suitable alternatives. Advice on how this may be achieved was discussed. When a person was assisted to move using a hoist, their dignity was compromised because their underclothes were exposed. In the entrance a ‘bed state’ that contained personal information of people was next to the visitor’s signing in book. This did not maintain the confidentiality of people who lived there. Surveys from health and social care professionals said the care service always or usually respected individual’s privacy and dignity. Saxondale DS0000038017.V337418.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. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 12, 13, 14 & 15 were inspected. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were assisted to make some choices and decisions in their daily life and social activities, but this could be improved. EVIDENCE: The AQAA stated that this service considered that their individual activity plans were something they did well. This was observed on only one of the three files inspected. The plan identified what the person liked to do, but the goals identified did not reflect this and were not individual to the person. The goals reflected the programme of activities arranged by the home that was not appropriate for the person. An activity co-ordinator was employed for four days a week for five hours. Discussions with staff confirmed a record of the social activities undertaken by each person was kept, but this was not available for inspection. There was no information in the daily records to verify that people’s social needs were met. Discussions with the staff identified that apart from utilising the garden in the warm weather, people who lived there didn’t leave Saxondale DS0000038017.V337418.R01.S.doc Version 5.2 Page 15 the home unless families took them out. During the day the majority of people were observed to spend the time in the lounges, with the TVs on or music playing. There were some people who were able and did walk around the home as they wished. One relative commented, “We would like there to be more activities suited to the needs of residents. Only a few are able to participate in activities such as bingo and sing-along. At the same time we realise this would be difficult to achieve”. The dining room was not a welcoming environment to go and enjoy your meal. It was clean, but lacked a homely, comfortable feel. The AQAA identified the home had the silver award for catering. It identified meal presentation was something they could do better. Representatives’ comments about what the service could improve included “substitute sliced white bread for wholemeal or offer choice” and “greater use of oily fish such as sardines or pilchards”. In comparison one said, “the food is good and plentiful” as something the home did well. The cook said white and brown bread was available, but white bread was usually used at breakfast and brown at tea time, unless it was indicated the person would enjoy brown bread all of the time. The manager confirmed brown bread was ordered. At meal times people were not observed to be asked their preference of white or brown bread or shown the choice. The menus identified fish was served twice a week, but this did not include sardines or pilchards. There was a four week menu that identified a choice was available at each meal apart from the main meal at dinner. This was not observed being offered. Breakfast was cereal and bread and jam or bread and marmalade. It did not offer the choice of a cooked alternative as identified on the menu. Tea was sandwiches. The warm alternative on the menu was not offered. However, it was noted that where a person disliked the food, for example baked beans they were given an alternative. All the bread used was white bread and was served on white plates. This did not make the meal attractive and appetising to eat. Meals were served in an unhurried way, giving people time to eat and staff regularly prompted people who were not eating. Staff were seen assisting people to eat in a discreet and sensitive way. Saxondale DS0000038017.V337418.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. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 16 & 18 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There was a complaints procedure that people had access to, but this could be more prominently displayed. People living at the home were protected from abuse and had their rights protected. EVIDENCE: The complaints procedure displayed in the entrance hall ensured that people were aware of how to make a complaint and who would deal with them. One representative in their survey commented, “perhaps a notice about complaints should be displayed prominently”, which indicated where the complaints procedure is displayed is not prominent enough. Generally, surveys returned by representatives confirmed they knew how to make a complaint. They indicated where they had raised a concern the home had always or usually responded appropriately. They said they had “no cause to raise any concern” and “we see matron with any complaint”. Surveys from health and social care professionals said the care service always and sometimes responded appropriately if they had raised any concerns. Saxondale DS0000038017.V337418.R01.S.doc Version 5.2 Page 17 There was an adult protection policy and procedure that promoted the protection of people from harm or abuse. The AQAA confirmed there were some policies/procedures/codes of practice in place to protect people from abuse. These did not include bullying and racial harassment that may occur between people living at the home or staff, by staff and by people living at the home on staff. This could mean that appropriate and consistent action may not be taken should this occur. Staff could describe how they would protect people from abuse. Saxondale DS0000038017.V337418.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. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for 19 & 26 were inspected. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. On the whole, the environment was comfortable with pleasant lounge areas, but a mild offensive odour was present. EVIDENCE: The lounges were well decorated and maintained in a comfortable and welcoming manner. They offered sufficient space for the number of people that used them. The dining area was clean, but did not have the same homely feel, as it was sparse and functional. The corridor areas looked ready for redecoration and this had commenced. One relative commented, “The home could be improved by the interior being a more brighter mode”. One health Saxondale DS0000038017.V337418.R01.S.doc Version 5.2 Page 19 and social care professional commented, “the environment that the staff and patients have to endure is dingy and poorly decorated”. Furniture and fittings on the whole were of a good standard. Access around the home was good. People were able to personalise their rooms with pictures, photographs, ornaments and furniture. A handyman was employed at the home and a routine programme of maintenance was in place, but this was not documented. This meant future planning was verbally agreed and could easily be missed or delayed without a written plan. The garden area was overgrown and would be enhanced by being tidied up, as it gives the impression of being neglected. In its current state it is not suitable for people to use. This is a pity given the recent nice weather. Some representatives expressed concern that people living at the home were confined to the indoors. The manager said the recent torrential rain and localised flooding, coupled with the garden being sunken and walled had prevented work being carried out as normal. The home looked clean, however, a mild offensive odour was present throughout the day. This was not pleasant and if eliminated would make for a more pleasing living environment. One relative confirmed this was usually present and was their only criticism with the home. They said they had spoken with matron about it. Laundry facilities were sited away from food preparation areas and areas used by people who lived there. This ensured the laundry process did not impose on the life of people living at the home and that good infection control measures were in place. One relative said, “cleanliness of bed linen/towels etc” is excellent. Saxondale DS0000038017.V337418.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. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 27, 28, 29 & 30 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There was an experienced and stable staff team, with a good mix of carers and ancillary staff. On the whole, there were sufficient staff to support people and for the smooth running of the service. Staff recruitment could improve. Staff had received training, so that on the whole they were competent to meet peoples’ needs. EVIDENCE: Generally, all representatives spoke positively about the care people whom they were representing received. Their comments about staff included “staff are friendly, approachable and courteous”, “there’s a core team of regular staff who know residents and the care home’s routine”, “I see the differing stages and types of dementia in the home and how staff and care workers manage it with kindness and patience”, “on my occasional visits I find staff’s response to each person is very good”, “the staff are always welcoming and make us feel that first and foremost our mother is still our mother” and “they are friendly”. The staff rota demonstrated that there was a good skill mix of staff to meet the assessed needs of people. There was one negative comment by a Saxondale DS0000038017.V337418.R01.S.doc Version 5.2 Page 21 representative, which was “I think sometimes there does not seem to be many staff around if I need to ask any questions about my relative’s care”. The manager provided information that identified approximately 32 of care staff held NVQ Level 2 in Care. She said approximately 26 had completed NVQ Level 3 in Care, but were awaiting their certificates. Additionally, approximately 26 were to commence either NVQ Level 2 or 3 in September. Staff stated they had opportunities for training and this had included emergency first aid, dementia, infection control, health and safety and moving and handling. Training files were kept. Certificates were in place that confirmed training had taken place and what the content of the training was. Observation of staff practice, however, identified the training they had received was not put into practice when moving and handling people. Issues noted included not applying brakes on the wheelchair before moving the person. On one occasion a person was attempted to be moved by gripping their clothing. When staff realised they were being observed a moving and handling belt was obtained and used. Poor practice is unsafe and can lead to injury of both the person being moved and the member of staff. Three of the four surveys from health and social care professionals said staff always or usually had the right skills and experience to support individual’s social and health care needs. One said they didn’t feel able to comment. They felt it was not their responsibility to ensure this, but trusted they did have the right skills and experience. Another commented, “Staff are well meaning and caring”. 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 consistently demonstrate a full employment history and there was no written evidence that gaps in employment had been explored. This did not demonstrate the recruitment process was sufficient to safeguard people from abuse. Saxondale DS0000038017.V337418.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. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 31, 33, 35 & 38 were inspected. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Saxondale was well managed, but improvements were needed with quality assurance and supervision of staff. This should improve the health, safety and welfare of people living at the home and staff. The quality assurance process needs to be more comprehensive to ensure the home is run in the best interests of the people who live there. Saxondale DS0000038017.V337418.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager had many years experience within the caring profession. This enabled her to contribute to the care of people and communicate a clear sense of leadership to staff. Representatives, staff and health and social care professionals on the whole expressed satisfaction with the service. Their comments included “they are very caring and kind to myself, as it is not a happy thing to watch your loved one with dementia” and “the manager and various other staff appear to take a service user led perspective wherever possible”. The manager had a good knowledge of the needs of people and she was committed to providing a good quality of service. There was a relaxed and friendly atmosphere within the home. Staff spoken with stated that they enjoyed working there. The last quality audit had not been completed. The quality assurance process did not actively seek the views of representatives, for example, through formal questionnaires. This would give the representatives the opportunity to give their opinion on the quality of the service. It would also enable the service to take their views into account when deciding the services to offer people who live there and how they are to be provided. An example of this might be access to the outdoors. Regulation 26 visits were undertaken, but did not provide comprehensive information, as the format was a tick box system with a comment box. It did not identify the outcome of discussions with representatives. This did not demonstrate they had considered representatives’ opinions of the quality of the service provided and taken action to improve the service as may be necessary. The service had identified in their AQAA that evaluating and improving the quality assurance process were their plans for improvement in the next twelve months. The financial transactions made on behalf of two people that lived there were inspected. This included the date monies were deposited and returned, the purpose for which the money was used, a receipting mechanism and two signatures that confirmed the transaction. When the building was inspected fire exits were free from obstruction. The fire risk assessment was up to date. Hazardous substances were securely stored. The AQAA confirmed electrical circuits, portable electrical equipment, the lift, fire detection and fighting equipment, emergency call equipment and heating system had been serviced or tested as recommended by the manufacturer. Inspection of the servicing of hoists and contracts for soiled waste disposal was made and was satisfactory. Notifiable incidents were being reported to the CSCI. Saxondale DS0000038017.V337418.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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Saxondale DS0000038017.V337418.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 OP3 Regulation 14 Requirement All sections of the admission assessment must be fully completed and include sufficient detail. This will ensure there is sufficient information to formulate the plan of care for daily living. Previous timescale of 31/10/06 not met. The records of accidents/incidents must not contain conflicting information as this does not accurately reflect what happened when and can be challenged. Document the arrangements to engage people in their social interests within the plan of care, in conjunction with their representative. This focuses the attention on each person’s needs as well as informing the programme of activities to be arranged. Lists containing personal information must not be publicly displayed. Previous timescale of 31/10/06 not met. DS0000038017.V337418.R01.S.doc Timescale for action 31/10/07 2 OP7 15 & 17 31/10/07 3 OP7 OP12 OP14 15 (1) 16 (2) (m) & (n) 31/10/07 4 OP10 12 09/08/07 Saxondale Version 5.2 Page 26 5 OP10 12 (4) (a) 6 OP15 OP19 12 (3) 7 OP19 23 (2) (o) 8 OP26 16 (2) (k) 9 OP28 OP30 OP31 OP38 13 (5) 10 OP29 19, Sch 2 11 OP33OP31 24 Underclothes must not be exposed when people are moved using the hoist as this compromises their dignity. The meal time experience must be reviewed and include: • The environment • Choices, including white and brown bread and the provision of pilchards and sardines on the menu • Meal presentation This should enable a more enjoyable experience at meal times for people. The garden area must be tidied so the area does not look neglected and is suitable for people to use. The mild offensive odour in the home must be erased, so the home is a more pleasant environment for people to live. Staff when moving and handling people must: • Apply brakes on wheelchairs • Use appropriate moving and handling equipment This should ensure people are moved safely. Staff files must demonstrate a full employment history, together with a satisfactory written explanation of any gaps in employment. This should demonstrate the recruitment process is sufficiently thorough to safeguard people from the risk of abuse. Previous timescale of 31/10/06 not met. The quality assurance system must provide for consultation with representatives. This would enable the home to know their opinion of the quality of care provided and make DS0000038017.V337418.R01.S.doc 09/08/07 31/12/07 14/08/07 08/09/07 09/08/07 31/10/07 31/03/08 Saxondale Version 5.2 Page 27 12 OP33 26 (4) (a) improvements where necessary. Previous timescale of 31/03/07 not met. The person carrying out the monthly visit must include the views of representatives as part of that process. This will enable them to consider the quality of service provided from their perspective and make improvements where necessary. 31/10/07 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 OP9 Good Practice Recommendations Medication carried forward from one month to another should be recorded on the current medication administration record. This should enable an efficient and correct record of current stock and efficient auditing of medication. The manager should review the types of aprons provided at meal times, to enhance improve peoples’ dignity. That opportunity for suitable activity and stimulation outdoors is considered when formulating the social care plan for people. This means peoples’ individual needs will be met and not give the perception that ‘once admitted you don’t go out’. Display the complaints procedure in a more prominent position. This will ensure all people are aware of it and therefore how to complain if necessary. Implement a policy/procedure for bullying and racial harassment that may occur between people living at the home or staff, by staff and by people on staff. This should ensure appropriate and consistent action is taken should this occur. 2 3 OP10 OP12 4 5 OP16 OP18 Saxondale DS0000038017.V337418.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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