CARE HOMES FOR OLDER PEOPLE
Smalley Hall Residential Home Main Road Smalley Derbyshire DE7 6DS Lead Inspector
Claire Williams Unannounced Inspection 4th October 2005 01:33 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 Smalley Hall Residential Home DS0000020215.V256450.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. Smalley Hall Residential Home DS0000020215.V256450.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Smalley Hall Residential Home Address Main Road Smalley Derbyshire DE7 6DS 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) (01332) 882848 (01332) 882351 Ashmere Care Group Mr Gerald Poxton, Mrs Sandra R Poxton, Mrs Ann Theresa Poxton, Dr Michael G Poxton, Mr David A Poxton Mrs Rosamund Morley Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Smalley Hall Residential Home DS0000020215.V256450.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 13th June 2005 Brief Description of the Service: Smalley Hall is a large building, that was extended and re-furbished in 1988/89. The home is in attractive surroundings on the outskirts of the village of Smalley. the home is registered to provide personal care and accommodation for older people. 27 places are provided with 23 single bedrooms and 2 double bedrooms. The home is on 2 floors with a passenger lift provided. There is a large lounge area and a connecting dining area with a smaller sitting room. A spacious conservatory overlooks the patio. Car parking space is provided. Smalley Hall Residential Home DS0000020215.V256450.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 1.33pm. The visit lasted 4 hours. The inspector checked the previous requirements and recommendations made in the previous inspection report, and checked the key areas that were required to be assessed in a 12-month period. She examined care files and associated documents, medication, and training was discussed. Time was spent observing service user and staff interaction, and the inspector spoke with 8 residents, and 2 relatives. The Registered Manager and senior care assisted the inspector with the inspection. For the purpose of this report the people who live in this home will be refereed to as ‘Residents’. What the service does well: What has improved since the last inspection?
Smalley Hall Residential Home DS0000020215.V256450.R01.S.doc Version 5.0 Page 6 The Registered Manager has been able to arrange essential training for the staff team and is currently ensuring that all of the staff has received all of the required training for their role. The staff team now ensure that they record the follow up action in individuals care plans following a problem or significant event, which may have affected a resident. The Registered Manager and the Registered Provider have devised a redecorating plan and are currently decorating several areas of the home. 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. Smalley Hall Residential Home DS0000020215.V256450.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 Smalley Hall Residential Home DS0000020215.V256450.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): These standards were not assessed on this occasion. EVIDENCE: Smalley Hall Residential Home DS0000020215.V256450.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, 10 and 11 Resident’s health care needs were assessed and planned for and the residents felt that they are treated with respect and dignity. The medication practices need to be improved to safeguard residents. EVIDENCE: All of the files examined by the inspector contained a care plan that covered an individual’s health, personal, and social care needs. These were written in sufficient detail to inform the staff team on how to meet the individual’s needs. The files contained risk assessments in relation to Moving and handling, tissue viability and falls, all of which have been reviewed regularly. There was evidence in all of the files to confirm they had been reviewed on a monthly basis in consultation with the individual who had signed the plan in agreement. There was information contained in majority of the files concerning individual’s last wishes and arrangements. The staff team complete daily case notes on each individual recording their general well- being, and now ensure that all follow up action is recorded following a resident having a problem. Residents commented to the inspector that the staff team were “excellent”, “caring” and always treated them with dignity and respect. The relatives who spoke with the inspector also stated, “the care is good and there is a nice
Smalley Hall Residential Home DS0000020215.V256450.R01.S.doc Version 5.0 Page 10 atmosphere in the home”, “the staff are always around to help” and generally commented on how their relative was “well looked after and all their needs met”. The inspector checked the Medication Administration Records (Mar charts) for all of the residents. In response to the previous inspection report improvements have been made in the recording of the medication administered to residents. However the inspector did identify some inconsistencies these included; gaps in the Mar charts, without any explanation, the actually dosage administered when the medication is a variable dose not being recorded on all occasions, handwritten instructions not always being checked and signed by two people. Therefore the requirements made previously will be repeated in this report. The temperature of the medication fridge was recorded and monitored daily. The senior staff team are responsible for administering the medication, and have completed a distant learning course in ‘safe handling of medicines’. It was recommended by the inspector that the Registered Manager complete an assessment of medication competence on all seniors in order to ensure that their practices are in accordance with the homes policies and the training undertaken. The Registered Manager is currently working on a homely remedies policy with fellow managers from the company. Smalley Hall Residential Home DS0000020215.V256450.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): 12, 13 and 14 Service users have the opportunity to access recreational activities of their choice, and are encouraged to maintain contact with their family and friends EVIDENCE: Residents informed the inspector of the recent outings they have been supported to attend these included trips out to Matlock Bath, Carsington Water for a picnic, and various outings for food. The residents have been supported to be involved in the gardening at the home, and have won a garden competition, which they felt very proud about. The Registered Manager has already consulted the residents about arrangements for Christmas and a party has already been planned with carol singers. Residents confirmed that the staff team encourage and assist them to maintain contact with their relatives or representatives. Relatives spoken to commented on how supportive and informative the staff and the Registered Manager were. Relatives also commented on the “high standard of care” provided by the staff team, and how “friendly and caring” the staff team were. Discussions with residents confirmed that they are encouraged to exercise their personal choice and autonomy in the home. Residents choose how they wish to spend their day, and stated that routines are “flexible” and “easy” within the home. Smalley Hall Residential Home DS0000020215.V256450.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, 17 and 18 The home has an effective complaints and adult protection procedures, in order to safeguard residents. Resident’s legal rights are protected. EVIDENCE: The home has a complaints procedure in place, and the staff team record all concerns and complaints made by residents or their representatives, and encourage individuals to air their views. The home has received four complaints since the previous inspection, and these have been dealt with satisfactory. Resident’s legal rights are protected within the home, and they are encouraged to exercise their political views through the provision of postal votes. The home has a copy of the Department of health Protection of Vulnerable Adults Guidance and a copy of the Derbyshire Vulnerable adult’s procedures. All of the staff team apart from two have now attended internal training in Abuse. This training incorporates the Derbyshire Vulnerable Adults procedures, and information on the homes whistle blowing procedures. The Registered Manager attended the Local authority vulnerable adults training course in June 2005. Smalley Hall Residential Home DS0000020215.V256450.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 The home is furnished and maintained to a satisfactory standard and offers homely and spacious facilities for residents to enjoy. EVIDENCE: The Registered Provider and the Registered Manager have implemented a redecoration and development plan. Several areas of the home have already been redecorated and upgraded and the dining room and lounge have recently been completed. When all of the redecoration has been completed work will then commence on the radiator guards and then the carpets will be replaced. Two requirements were made in relation to this work, and the timescales have not yet elapsed therefore the requirements have been carried forward to this report. Both the residents and the relatives commented on how the home is always clean and smells nice, and is well maintained. Smalley Hall Residential Home DS0000020215.V256450.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 and 30 The deployment of the staff team was sufficient to meet the assessed needs of residents on this visit. The staff team have access to training opportunities in order to fulfil their role. EVIDENCE: A copy of the rota for the previous week was obtained. The rota indicated that a senior staff member and two care staff are on duty at all times. The staff team cover any sickness and holidays ensuring all shifts are covered. The residents confirmed that staff are always around and attentive to their needs. The inspector requested the statistics for the amount of staff trained within the home. The Registered Manager confirmed that there are 5 staff members who have completed a National Vocational Qualification (NVQ) training at level 2, and 3 staff members due to commence at this level at the next intake. There are 5 staff members undertaking NVQ level 3. The home therefore is on target to meet the government’s requirement of having at least 50 of the staff team trained to a minimum of NVQ level 2 by December 2005. The Registered Manager is in the process of developing a training matrix recording all of the training achieved, and the training that is outstanding for the staff team. As this has not yet been achieved the previous requirement will be repeated in this report with a new timescale. Smalley Hall Residential Home DS0000020215.V256450.R01.S.doc Version 5.0 Page 15 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): 33, 35 and 38 Resident’s views are listened to, and their financial interests safeguarded. Progress has been made in the completion of mandatory training, which will ensure that resident’s health and safety is maintained. EVIDENCE: The Registered Manager facilitates regular resident meetings in order to discuss the quality of the services and provisions provided. Within this meeting discussions are held about any improvements to the services and plans for future events. The residents felt that they are adequately consulted concerning the running of the home. The Registered Manager has not yet developed a quality assurance survey, which can be sent to residents and their representatives to obtain feedback about the home. The Registered Manager informed the inspector that nearly all of the staff team have now completed the required mandatory training. The remainder of the staff who have not undertaken this training are on planned courses for the future. The night staff receive fire training twice a year.
Smalley Hall Residential Home DS0000020215.V256450.R01.S.doc Version 5.0 Page 16 The inspector checked the financial records and the money held in safekeeping for 5 residents. All of the resident’s money was stored separately in individual purses. All money held cross-referenced to the balance recorded on the transaction sheets. Receipts are obtained for purchases made on behalf of the residents, and two staff members countersign the majority of the transactions made. Smalley Hall Residential Home DS0000020215.V256450.R01.S.doc Version 5.0 Page 17 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X X X X X X X STAFFING Standard No Score 27 3 28 3 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 3 Smalley Hall Residential Home DS0000020215.V256450.R01.S.doc Version 5.0 Page 18 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 OP9 Regulation 13 (2) Requirement The Registered Persons must ensure there are no gaps in the Medication Administration Records. Staff must initial each record or use the appropriate code. (Requirement repeated from previous inspection report) The Registered Persons must ensure that where an optional medication dose was stated, staff must record what dose had been administered. (Requirement repeated from previous inspection report The Registered Persons must develop and implement a policy on administering and recording of homely remedies. (Requirement repeated from previous inspection report The Registered Persons must ensure that all handwritten medication instructions are checked and signed by two staff members. The Registered Persons must complete the programme to replace the bathroom floor and corridor carpets. (Requirement
DS0000020215.V256450.R01.S.doc Timescale for action 01/12/05 2 OP9 13 (2) 01/12/05 3 OP9 13 (2) 01/01/06 4 OP9 13 (2) 01/12/05 5 OP19 23 (2) 30/12/05 Smalley Hall Residential Home Version 5.0 Page 19 6 OP19 23 (2) (d) 7 OP30 18 8 OP33 12 (3) carried forward) The Registered Persons must ensure that all areas that require redecoration must be completed. Requirement carried forward) The Registered Persons must develop an overall training and development plan to include individual and collective training needs of the staff. (Requirement repeated from previous inspection report) The Registered Persons must devise and distribute quality assurance questionnaires in order to obtain feedback from the residents and their relatives 30/12/05 01/01/06 01/01/06 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 OP9 Good Practice Recommendations The Registered Manager should devise and complete an assessment of medication competence on all staff that administers medication. Smalley Hall Residential Home DS0000020215.V256450.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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