Inspection on 10/02/04 for Snydale Care Home

Care Home For Older PeopleSnydale Care HomeNew Road Old Snydale Pontefract West Yorks WF7 6HDAnnounced Inspection10th February 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Snydale Nursing Home Address New Road, Old Snydale, Pontefract, West Yorks, WF7 6HD Email Address Name of registered provider(s)/Company (if applicable) Partners:Mr S Holroyd, Mrs T Holroyd, Mr A Westerman Name of registered manager (if applicable) Mrs Carol Sadler Type of registration Care Home No. of places registered (if applicable) 52 Tel No: 01924 895517 Fax No: 01924 894808Category(ies) of registration, with (number of places) Physical disability over 65 years of age (52) Registration number J010000045 Date First registered 30th October 1987 Was the home registered under the Registered Homes Act 1984 Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 22nd August 2003 YES NO 27/08/03 If Yes Refer to Part CSnydale Care HomePage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 310th February 2004 09:45 am Gillian Walsh Tony Railton Not Applicable Not ApplicableID Code110611 73592Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at the time of inspectionNone Present Not Applicable Mrs T Holroyd (Registered Proprietor) Mrs C Sadler (Registered Manager)Snydale Care HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspection Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration (if applicable) Lay Assessors Summary (where applicable) Providers Response Providers comments Action Plan Providers AgreementSnydale Care HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the NCSC in respect of Snydale Nursing Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Snydale Care HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Snydale Nursing Home is registered as a care home that provides care, including nursing, for up to for up to fifty-two older people. It is located in the small village of Old Snydale, which is between Normanton and Featherstone. The accommodation is set out on two floors with a majority of single bedrooms and six double rooms. The main sitting room and dining facilities are located on the ground floor. There is level access at the main entrance and a hydraulic passenger lift allows easy access to the first floor accommodation. The home provides well furnished and comfortable accommodation. Snydale Nursing Home is situated off the main road and is accessed via a long drive that leads up to the care home. There are off-street parking facilities for visitors. A local bus service passes right by the front entrance at the bottom of the drive every hour.Snydale Care HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This was an announced inspection made on the 10th February 2004. The registration certificate includes 2 conditions. These are that the home can · 1. Accommodate one named person with physical disabilities under 65 years · 2. Accommodate one named person under category Terminally ill (TI(E) Choice of Home (Standards 1-6) 1 of the 5 standards inspected was fully met. The home does not provide intermediate care (standard 6) 4 standards were not met. The registered provider is currently working on the production of a statement of purpose and a service user guide. The availability of these documents has been made a requirement at the last three inspections of the home and for this reason the inspector has required that both documents be produced and copies sent to the National Care Standards Commission by 31st March 2004. Whilst the registered provider has again made agreements in relation to this should this not be achieved by the agreed date of 31 March 2004 formal action will be considered. Statements of terms and conditions are not being issued to new residents on admission. This must be a standard form of contract for the provision of services and facilities by the registered provider to residents and must be included in the service user guide. Pre admission assessments are now taking place prior to any admissions to the home. The documents used are comprehensive and cover all aspects of care. As required under regulation 14(1)(d) the registered person must confirm in writing to the potential resident that the home is able to meet with their assessed needs. The home does take emergency admissions and information is given about the home to the new resident within 48 hours although this is not currently included the service user guide. Health and Personal Care (Standards 7-11) 1of the 3 standards inspected on this occasion were met. 2 were partially met. The inspector was pleased to find that real improvements had been made in the care planning and daily record keeping processes used by the home. To further improve care planning and review, it is recommended that the resident or their supporters be included in this process and their signatures obtained to evidence this inclusion. The home employs the services of all available community health professionals. A recommendation has been carried forward from the previous report that nutritional assessments should be undertaken on admission and reviewed as required. The procedures for the receipt, recording, storage, handling, administration and disposal of medicines were checked and all were found to be correct. Daily Life and Social Activities (Standards 12-15) All of the 3 standards inspected on this occasion were met. The procedures for the receipt, recording, storage, handling, administration and disposal of Snydale Care Home Page 6 medicines were checked and all were found to be correct. Wherever possible residents are encouraged to manage their own finances. All of the residents who spoke with the inspector said that they enjoyed the food supplied by the home very much. Choice is available at each meal and special diets can be catered for. Complaints and Protection (Standards 16-18) Both of the 2 standards inspected on this occasion were met. The homes manager said that all residents are registered on the electoral role and go out to vote where possible, others make use of a postal vote. The homes policy and procedure file now includes a copy of the whistle blowing policy. Although this standard is fully met, the inspector feels staff awareness would be enhanced, if the policy is covered during induction and periodically revisited during supervision. The home uses the Wakefield Metropolitan District Council adult abuse procedure. Environment (Standards 19-26) 3 of the 4 standards inspected on this occasion were met and 1 was partially met. Inspection showed that residents have the specialist equipment they require to maximise their independence and that they all have comfortable, personalised rooms to suit their individual needs. Some bedrooms have been provided with new pine bedroom furniture, new beds and new pressure relieving mattress. These improvements to the home are to be commended. However, to comply fully with minimum standards and in particular standard 24.4 a review should be undertaken of the floor covering of the en-suite toilet floors as a number require some minor remedial work. On the day of the inspection it was noted that all areas of the home are clean and hygienic. Staffing (Standards 27-30) 2 of these 4 standards were fully met with the remaining 2 found to be partially met. Staffing is organised with 2 nurses and 6 care assistants on the morning shift, 1 nurse with 6 care assistants on the afternoon shift and 1 nurse with 4 care assistants on the night shift. The homes manager said that these staffing levels were appropriate for the needs of the residents currently in the home. NVQ training to level 2 is current and ongoing at the home, a recommendation has been carried forward that this training should continue in order to meet with the minimum standard by 2005. Service users are supported and protected by the homes recruitment policies, procedures and practices. Staff training is ongoing at the home with each employee having their own individual training programme. The registered provider told the inspector that the induction programme is currently being reviewed and developed. Management and Administration (Standards 31-38) 6 of these 8 standards were fully met. 1 was partially met and another was not met. The homes manager, Mrs Carol Sadler is due to retire in July 2004 and the responsible individual is considering a restructure in the staffing arrangement following Mrs Sadlers retirement. Mrs Sadler works closely with all the staff at the home and encourages their development through training and support. The home does have a quality assurance and monitoring system which includes seeking the views of service users on the care provided by the home. However, to comply fully with standard 33.4 and 33.7 the views of other stakeholders for example G.Ps, District Nurses or Snydale Care Home Page 7 Social Workers should also be sought regarding the running of the home. The registered person should then collate all the information gathered and publish a report indicating any changes made to the running of the home as a result of service users surveys. A requirement has been made that the registered provider ensures that monthly visits and reports, as required by regulation 26, are completed and, a copy of the report is sent to the National Care Standards Commission. It was established that service users financial interests are safeguarded by the homes financial policies, procedures and practices. Supervision has commenced for all staff and is being organised to be held two monthly. Records were seen to be kept safely and in line with current legislation and it was established that the health safety and welfare of service users and staff are promoted.Snydale Care HomePage 8 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action 1 4(1) Schedule 2 OP1 Provision of a Statement of Purpose. This must 31 October contain the information required in Schedule 2. 2003 Once prepared a copy is to be forwarded to the NCSC. Provision of a Service User Guide. Once prepared a copy is to be forwarded to the National Care Standards Commission and a copy is given to all residents at the home. 31 october 200325(1)OP1Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 OP1 OP8 OP28 All staff should have knowledge of, and have access to copies of the homes statement of purpose and service user guide. Nutritional screening should be undertaken on admission and then periodically as needed. The home should continue with their programme of NVQ training in order to meet the minimum standard by 2005.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Not applicableMet (Yes / No)Snydale Care HomePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 4(1) Schedule 2 OP1 Provision of a Statement of Purpose. This must contain the information required in Schedule 2. Once prepared a copy is to be forwarded to the NCSC. Provision of a Service User Guide. Once prepared a copy is to be forwarded to the National Care Standards Commission and a copy is given to all residents at the home. As part of the service user guide a statement of terms and conditions must be provided to each new resident on admission. The registered person must confirm in writing to the potential resident that the home is able to meet with their assessed needs. The registered provider must ensure monthly reports are produced as required by regulation 26, and send a copy of these reports to the National Care Standards Commission. 31 March 200425(1)OP131 March 200435(1)(c)OP231 March 2004 From next admission to the home and ongoing.414(1)(d)OP4526OP3331 April 2004Snydale Care HomePage 10 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard * Residents or their supporters should be included in the care planning and review process and their signatures obtained to evidence this inclusion. Nutritional assessments should be undertaken on admission and reviewed as required. The home should continue with their programme of training in order to meet the minimum standard of 50 of staff trained to NVQ 11, in care by 2005. Work should continue to develop the induction programme to bring it in line with TOPSS specifications. Following the current managers scheduled retirement, the newly appointed manager should have a relevant professional care qualification and hold, or begin studies to achieve a NVQ level 4 in care management by 2005. A review should be undertaken of the floor coverings in the en-suite toilets as there is some minor remedial work identified. Other stakeholders views on the care provided by the home should be sought and the results of any quality monitoring surveys published. The information gathered as part of the quality assurance monitoring should be collated and a report provided to reflect the views of service users.1OP72OP83OP284OP305OP316 7OP24 OP338OP33* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Snydale Care HomePage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES YES NO YES YES YES NO NO YES NO YES NO YES YES YES NO NO YES NO YES 30 0 0 YES YES YES YES 33 8 10/02/2004 09.45 7Snydale Care HomePage 12 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards for Care homes for older persons have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Snydale Care HomePage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide Range of fees charged From (£) X To (£) XAny charges for extrasYESIf yes, please state what the extras are: 1 Key findings/Evidence Standard met? The provider is currently working on the production of a statement of purpose and a service user guide. The availability of these documents has been made a requirement at the last three inspections of the home and for this reason the inspector has required that both documents be produced and copies sent to the National Care Standards Commission by 31st March 2004. This date was discussed and agreed at the inspection, in the event of this revised timescale not being met then the Commission will consider whether this will be progressed through more formal action.Snydale Care HomePage 14 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 1 Key findings/Evidence Standard met? Statements of terms and conditions are not being issued to new residents on admission. This must be a standard form of contract for the provision of services and facilities by the registered provider to residents and must be included in the service user guide. A requirement has been made in this breach of regulation. Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? Pre admission assessments are now taking place prior to any admissions to the home. The documents used are comprehensive and cover all aspects of care. The homes manager also informed the inspector that admissions are not taken until a copy of the social workers assessment has also been obtained by the home. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 1 Key findings/Evidence Standard met? Following assessment the home makes confirmation with the social worker over the telephone that they are able to meet with the persons assessed needs. As required under regulation 14(1)(d) the registered person must confirm in writing to the potential resident that the home is able to meet with their assessed needs.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 1 Key findings/Evidence Standard met? Prospective residents are invited to visit the home before making a decision to move in, this would normally involve spending a full day at the home. The home does take emergency admissions and information is given about the home to the new resident within 48 hours of their admission. The emergency admissions procedure must be included in the statement of purpose. Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff to deliver short-term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? Intermediate care is not provided at the home. Snydale Care Home Page 15 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? The inspector was pleased to find that real improvements had been made in the care planning and daily record keeping processes used by the home. Care plans were found to be descriptive and informative and daily records were linked into the care needs and interventions described in the care plans. Several assessments are completed both before and after admission from which the initial care plan is formulated. The inspector was pleased to note that these assessments include a body graph which show any sores, bruising, scars or other injury sustained by the resident before admission. All care plans had been reviewed monthly or more frequently if required. To further improve care planning and review, it is recommended that the resident or their supporters be included in this process and their signatures obtained to evidence this inclusion.Snydale Care HomePage 16 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. Number of incidents where service users have been taken to Accident and Emergency during last 12 months Number of service users with pressure sores at time of inspection (from information taken from care notes)X X2 Key findings/Evidence Standard met? The home employs the services of all available community health professionals. McMillan nurses, tissue viability nurses, community psychiatric nurses, GPs and continence advisers all visit the home as required. Dental, optical and audiology services are also available either through visits to the home or attendance at clinics. Nutritional screening is not routinely undertaken on admission although residents weights are recorded. A recommendation has been carried forward from the previous report that nutritional assessments should be undertaken on admission and reviewed as required. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? The procedures for the receipt, recording, storage, handling, administration and disposal of medicines were checked and all were found to be correct. The inspector was pleased to note that shortfalls outlined in the previous report have all been addressed and that a safe system is now in place. Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with and examination by health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? Not assessed on this occasion Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? Not assessed on this occasionSnydale Care HomePage 17 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 0 Key findings/Evidence Standard met? Not assessed on this occasion Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences 3 Key findings/Evidence Standard met? The home does not impose restrictions on visitors and assists residents in maintaining social relationships. Local clergy are invited to the home to provide spiritual support and give communion. Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? Wherever possible residents are encouraged to manage their own finances and one person does so. Information on advocacy services is available on the notice board in the foyer of the home.Snydale Care HomePage 18 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet which is suited to individual, assessed and recorded requirements and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? All of the residents who spoke with the inspector said that they enjoyed the food supplied by the home very much. Choice is available at each meal and special diets can be catered for. Both inspectors were invited to sample lunch and agreed with residents that the standard of food was very high. Meals are taken in the spacious and comfortable dining room.Snydale Care HomePage 19 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple clear and accessible complaints procedure which includes the stages and time-scales for the process and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days Key findings/Evidence Not assessed on this occasion X X X X X X X 0Standard met?Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? The homes manager said that all residents are registered on the electoral role and go out to vote where possible, others make use of a postal vote.Snydale Care HomePage 20 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial, or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 03 Key findings/Evidence Standard met? The responsible individual showed the inspector the homes policy and procedure file which now includes a copy of the whistle blowing policy. Although this standard is fully met, the inspector would recommend that in order to further staffs awareness, the policy is covered during induction and periodically revisited during supervision. The home uses the Wakefield Metropolitan District Council adult abuse procedure.EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? Not assessed on this occasionSnydale Care HomePage 21 Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? Not assessed on this occasion Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? Not assessed on this occasion Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons including a qualified occupational therapist, with specialist knowledge of the client groups catered for and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? Through discussion with the owner and examination of the Environmental Health Reports and aids and maintenance certificates and risk assessments it was established that service users have the specialist equipment they require to maximise their independence.Snydale Care HomePage 22 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO YES NO 41 1 4 1 0 019 23 5 03 Key findings/Evidence Standard met? Through discussion with the owner, service users and inspection of the home it was established that service users own rooms suit their needs.Snydale Care HomePage 23 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy and meets the assessed needs of the service user. 2 Key findings/Evidence Standard met? Through discussion with the owner, service users and inspection of bedrooms it was established that service users live in safe comfortable bedrooms with their own possessions around them. It was also noted that almost all bedrooms have been decorated since the last inspection. Some bedrooms have been provided with new pine bedroom furniture, new beds and new pressure relieving mattress. These improvements to the home are to be commended. However, to comply fully with minimum standards and in particular standard 24.4 a review should be undertaken of the floor covering of the en-suite toilet floors as a number require some minor remedial work. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? Not assessed on this occasion Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? On the day of the inspection it was noted that all areas of the home are clean and hygienic. The care staff and in particular domestic staff are to be commended for their efforts in maintaining such a high standard of cleanliness throughout the home.Snydale Care HomePage 24 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X8 33 X3 Key findings/Evidence Standard met? Copies of duty rosters were seen and showed that staffing is organised with 2 nurses and 6 care assistants on the morning shift, 1 nurse with 6 care assistants on the afternoon shift and 1 nurse with 4 care assistants on the night shift. The homes manager said that these staffing levels were appropriate for the needs of the residents currently in the home.Snydale Care HomePage 25 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 2 6 2 Key findings/Evidence Standard met? NVQ training to level 2 is current and ongoing at the home with 2 staff due to commence NVQ level 3. There are also 2 senior care assistants who have qualified as NVQ assessors and are therefore able to progress the training at the home. A recommendation has been carried forward that this training should continue in order to meet with the minimum standard by 2005. Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? Service users are supported and protected by the homes recruitment policies, procedures and practices. Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme, which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 2 Key findings/Evidence Standard met? Staff training is ongoing at the home with each employee having their own individual training programme. Six members of staff are currently undergoing training so that they can be accredited trainers for manual handling and the homes administrator is to do the course for delivering fire training. Five of the current staff team are first aiders. The induction seen for the most recently appointed member of staff was more of an orientation to the home and its policies rather than a programme of induction leading foundation training. The registered provider told the inspector that the induction programme is currently being reviewed and developed.Snydale Care HomePage 26 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 2 Key findings/Evidence Standard met? The homes registered manager, Mrs Carol Sadler is an experienced Registered General Nurse who has been `matron at Snydale for approximately 15 years. She does not hold a formal management qualification. Mrs Sadler told the inspector that she did not have any real knowledge of the administration side of running the home as this is dealt with by the registered person, Mrs Holroyd, and the homes administrator Mrs Jennings. Mrs Sadler is due to retire in July and the responsible individual is considering a restructure in the staffing arrangement following Mrs Sadlers retirement. Mrs Sadler has demonstrated a long commitment to her role and to the residents of Snydale Nursing Home. The inspectors would like to thank her for her assistance and wish her a long and happy retirement. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The current manager works closely with all the staff at the home and encourages their development through training and support. Staff appear to be happy to approach their manager with any questions or ideas they may have regarding the way care is organised and delivered at the home.Snydale Care HomePage 27 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 1 Key findings/Evidence Standard met? The home does have a quality assurance and monitoring system which includes seeking the views of service users on the care provided by the home. However, to comply fully with standard 33.4 and 33.7 the views of other stakeholders for example G.Ps, District Nurses or Social Workers should also be sought regarding the running of the home. The manager or registered person should then collate all the information gathered and publish a report indicating any changes made to the running of the home as a result of service users surveys. As a manager is employed and the registered providers are not in day to day control of the running of the home, the registered provider must ensure monthly unannounced visits and reports, are produced as required by regulation 26 and send a copy of these reports to the National Care Standards Commission. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? A certificate for appropriate employer liability insurance was seen. Accounts and business plan, demonstrating viability, were not requested at this inspection. Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders 0 0 03 Key findings/Evidence Standard met? Through discussion with the owner and examination of service users financial records it was established that service users financial interests are safeguarded y the homes financial policies, procedures and practices.Snydale Care HomePage 28 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? Supervision has commenced for all staff and is being organised to be held two monthly. All staff have an individual development plan which is used at supervision and links in with the annual appraisal and training programme. Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? Records were seen to be kept safely and in line with current legislation.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable, the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? Through discussion with the owner and examination of the Fire Safety an Environmental Health Officers reports, lift and hoist maintenance certificates it was established that the health safety and welfare of service users and staff are promoted.Snydale Care HomePage 29 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateGillian Walsh Tony Railton Ruth Rainey 26 April 2004Signature Signature SignatureSnydale Care HomePage 30 PART D(where applicable) N/aLAY ASSESSORS SUMMARYLay Assessor Date Public reportsNA NASignatureNAIt should be noted that all NCSC inspection reports are public documents.Snydale Care HomePage 31 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 10th February 2004 of Snydale and any factual inaccuracies: Please limit your comments to one side of A4 if possibleSnydale Care HomePage 32 Action taken by the NCSC in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther:Snydale Care HomePage 33 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I of Snydale confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I of Snydale am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Snydale Care HomePage 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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