Inspection on 11/10/04 for Snydale Care Home

Care Home For Older PeopleSnydale Care HomeNew Road Old Snydale Pontefract West Yorks WF7 6HDAnnounced Inspection11th October 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 Care Home Address New Road, Old Snydale, Pontefract, West Yorks, WF7 6HD Email address Name of registered provider(s)/company (if applicable) 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) Old age, not falling within any other category (52), Physical disability over 65 years of age (52) Registration number J520002012 Date first registered Date of latest registration certificate 31st July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection 10th September 2004 YES NO 30/07/04 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 311th October 2004 10:00 am Gillian Walsh Helen Walker -ID Code110611 73596Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionDiane Rose (Acting Manager) Tracey Holroyd (Registered Proprietor)Snydale Care HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & 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: D.1. D.2. D.3. Compliance with Conditions (if 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 Commission for Social Care Inspection (CSCI), 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 CSCI in respect of Snydale Care 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 CSCI 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 · 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 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 and a large garden at the back of the home provides a pleasant environment for service users to sit out in good weather 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 at Snydale Care Home on 11th October 2004. During the day the inspectors were pleased to hear from several service users how satisfied they are with the care and facilities provided for them at the home. The new manager has recently applied to the Commission for Social Care Inspection to be registered as a home manager and is therefore, for the purpose of the report, referred to as the acting manager. The inspectors would like to thank service users and staff for their time and assistance during the inspection. Choice of Home (Standards 1-6) All of the 3 standards inspected on this occasion were met. Standard 6 (intermediate care) is not provided at the home. A comprehensive statement of purpose has been developed and is available at the home. The service user guide provides clear information about the home. Pre admission assessments take place prior to any admissions to the home. The documents used are comprehensive and cover all aspects of care. Following assessment, a letter is sent to all prospective service users confirming that the home is able to meet with their assessed needs. Health and Personal Care (Standards 7-11) 3 of the 4 standards inspected on this occasion were met, 1 was partially met. A selection of care plans were examined. It was evident that staff at the home have been working hard to improve the assessment and care planning process and some plans were seen to contain good detail of service users needs and personal preferences. Some care plans however lacked detail both within the plan and in the review process. A recommendation has been made that work should continue to develop care plans. The home employs the services of all available community health professionals to assist in the maintenance and promotion of service users health. The inspector was pleased to see that a number of improvements had been made to ensure that the home maintains safe procedures with regard to the receipt, recording, storage, handling administration and disposal of medicines.Snydale Care HomePage 6 Daily Life and Social Activities (Standards 12-15) Both of the standards inspected on this occasion were met. Wherever possible service users are encouraged to manage their own finances and one person does so. Information on advocacy services is available in the home. Service users are encouraged to bring personal possessions into the home. Service users who spoke with the inspectors expressed a great satisfaction with the quality of the meals at the home. Complaints and Protection (Standards 16-18) 2 of these 3 standards were met,1 was partially met. Improvements have been made with regard to the homes processes for dealing with complaints. The registered provider and the acting manager have a positive attitude to complaints and intend to organise training for staff in this area to promote this attitude throughout the home. Discussions with the new acting manager and other staff demonstrated a need for an update in training particularly with regard to adult abuse procedures. A recommendation has been made in this regard. Environment (Standards 19-26) 4 of the 6 standards inspected on this occasion were met, 2 were partially met. Inspection of bathroom and toilet facilities showed that these are available in sufficient number to meet with the needs of service users and improvements to toilet and bathroom areas, including new soap dispensers, have been made since the last inspection. Aids and adaptations are available within the home to meet with the needs of the current service users. The majority of the bedrooms seen during the inspection were nicely furnished and decorated, some benefiting more recently from new decoration and furniture, and the majority had been personalised by the service user. The majority of the home appeared clean, tidy and well maintained, some recommendations have been made in relation to hygiene. Staffing (Standards 27-30) 2 of these 4 standards were met, 1 was partially met and 1 was not met. Staff rosters indicated that staff numbers are maintained in line with the requirements of the staffing notice issued by the previous regulatory authority. A recommendation has been made that NVQ training should continue in order to meet with the minimum standard by 2005. A selection of staff files were examined and were found to contain the documentation required to ensure the protection of service users. Staff training needs are identified and discussed during supervision. Documentation regarding training needs, training undertaken and planned training is available in the home but this needs to pulled together and organised. A requirement has been made with regard to fire safety training for staff. Management and Administration (Standards 31-38) 2 of the 6 standards inspected on this occasion were met, 3 were partially met and 1 was not met. The acting manager is a qualified registered general nurse who has recently completed a BSc in healthcare studies. Snydale Care Home Page 7 The inspectors were pleased that the registered provider has commenced regulation 26 visits to the home and as a result of this has identified processes within the home that are in need of update and improvement. It is recommended that the registered proprietor and acting manager work towards formalising a system of continuous quality monitoring. A requirement and a recommendation have been made with regard to service users finances being dealt with at the home. The inspector were pleased to not that care plans are now stored in locked filing cabinets in line with the requirements of the data protection act. The inspectors did see some certification with regard to health and safety within the home. A recommendation has been made that the acting manager and other relevant staff be made aware of the whereabouts of all documentation relating to the running of the home so that this can be produced at future inspections.Snydale Care HomePage 8 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY 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. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action Action is being taken by the Commission for Social Care Inspection 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 StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (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 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. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action Arrangements must be made for staff at the home to receive suitable training in fire prevention. Drills must be held at suitable intervals to ensure that staff are aware of the procedures to be followed in the case of fire. The registered person must not pay money belonging to any service user into a bank account unless(a) the account is in the name of the service user, or any of the service users to which the money belongs; and (b) the account is not used by the registered person in connection with the carrying on or management of the care home. 31 December 2004123(4)(d)OP30220(1)(a)(b)OP35Snydale 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). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * · Work should continue to develop care plans to ensure that all necessary detail regarding individual care needs and personal preferences, are included to ensure that service users assessed needs are met. Care plan reviews should be documented and signatures of the service user or their relative obtained to demonstrate their agreement with the plan of care.1OP7 ·2OP18Training updates should be organised for staff in relation to adult abuse policies and procedures. · The star key lock in the downstairs bathroom and any other relevant areas should be disabled or removed to ensure that service users cannot accidentally become locked in the room. Foot operated waste bins should be provided in toilet and bathroom areas. The toilet cistern in the upstairs bathroom should be repaired. Bath hoist seats were seen to be quite dirty and should be thoroughly cleaned after use. Staff should ensure that service users toiletries personal are kept clean.3OP21· · ·4OP26·5OP28The home should continue with their programme of training in order to meet the minimum standard of 50 of staff trained to NVQ level 2, in care by 2005. Documentation regarding staff training should be organised into a training matrix so that training needs and updates can be easily identified. The registered proprietor and acting manager should work towards formalising a system of continuous quality monitoring using questionnaires and feedback cards to gain the views of service users, relatives, staff and other stakeholders. An annual report should then be made available within the home and a copy forwarded to the Commission for Social Care Inspection. Page 116OP307OP33Snydale Care Home 8 9 10OP34 OP35 OP38A business and financial plan should be available in the home. Two signatures should be obtained for all transactions relating to service users finances.The acting manager and other relevant staff should be made aware of the whereabouts of all documentation relating to the running of the home so that this can be produced at future inspections. * 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 12 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 YES NO YES NO YES YES YES YES NO YES NO YES NO YES 20 0 0 YES NO YES YES X X 11/10/04 10:00 8Snydale Care HomePage 13 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people 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 14 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 (£) 340 To (£) 465Any charges for extrasYESIf yes, please state what the extras are: Hairdressing, chiropody, massage. 3 Key findings/Evidence Standard met? A comprehensive statement of purpose has been developed and is available at the home. A copy has been sent to the Commission for Social Care Inspection. The service user guide provides clear information about the home, the facilities offered and includes a summary of the statement of purpose. 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). 0 Key findings/Evidence Standard met? Not assessed on this occasionSnydale Care HomePage 15 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 take place prior to any admissions to the home. The documents used are comprehensive and cover all aspects of care. The acting 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. 3 Key findings/Evidence Standard met? Following assessment, a letter is sent to all prospective service users confirming that the home is able to meet with their assessed needs. A copy of this letter is retained within the service users file. 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. 0 Key findings/Evidence Standard met? Not assessed on this occasion 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 HomePage 16 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? A selection of care plans were examined. It was evident that staff at the home have been working hard to improve the assessment and care planning process and some plans were seen to contain good detail of service users needs and personal preferences. Some care plans however lacked detail both within the plan and in the review process. Assessments had been completed but care plans did not always relate to the result of the assessment. For example service users identified as being at risk from the result of the Waterlow assessment, did not always have a care plan in place to detail how this risk was being managed and how care needed to be delivered to prevent the development of pressure sores. Moving and handling assessments had been completed but again the care plans did not give detail regarding which aids were to be used in order to meet with assessed needs. A recommendation has been made that work should continue to develop care plans to ensure that all necessary detail regarding individual care needs and personal preferences, are included to ensure that service users assessed needs are met. The acting manager is aware that the process of reviewing care plans with the service user or their relative requires further development and is working toward this. Reviews need to be documented and signatures of the service user or their relative obtained to demonstrate their agreement with the plan of care.Snydale Care HomePage 17 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. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) X 03 Key findings/Evidence Standard met? The home employs the services of all available community health professionals to assist in the maintenance and promotion of service users health. MacMillan 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 assessments are now 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 inspector was pleased to see that a number of improvements had been made to ensure that the home maintains safe procedures with regard to the receipt, recording, storage, handling administration and disposal of medicines and was satisfied that that was demonstrated on the day of the inspection. The acting manager is continuing to work toward further improvements with regard to the policies and procedures employed by staff with regard to medications. 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 occasionSnydale Care HomePage 18 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. 3 Key findings/Evidence Standard met? The registered provided is an RGN trained in palliative care and gives training to staff in this area. The acting manager has undertaken training in pain management but seeks the advice of the MacMillan nurses where necessary. Staff discuss with service users their wishes with regard to terminal care and death.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. 0 Key findings/Evidence Standard met? Not assessed on this occasionSnydale Care HomePage 19 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 service users are encouraged to manage their own finances and one person does so. Information on advocacy services is available in the home. Service users are encouraged to bring personal possessions into the home and information about this is included in the service users guide. 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? Menus are planned subject to the availability of good quality fresh meat, fruit and vegetables and are therefore not formulated more than a few days in advance. Service users are made aware of the choices on offer on a daily basis and alternatives are always available if the planned meals are not desired. Drinks and snacks are available over a 24 hour period and special diets and requirements are catered for. Service users who spoke with the inspectors expressed a great satisfaction with the quality of the meals at the home. The home has two dining areas, both of which provide a very pleasant environment for service users to enjoy their meals, although service users can choose to take their meals in their own rooms if they wish.Snydale Care HomePage 20 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 CSCI Percentage of complaints responded to within 28 days 5 3 0 1 1 0 100 3 Key findings/Evidence Standard met? Improvements have been made with regard to the homes processes for dealing with complaints. This is evidenced within the complaints book which now details what actions have been taken in response to a complaint and how it has been resolved. The registered provider and the acting manager have a positive attitude to complaints and intend to organise training for staff in this area to promote this attitude throughout the home. 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 registered provider said that all service users are registered on the electoral role and either attend the polling station or make use of a postal vote.Snydale Care HomePage 21 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 02 Key findings/Evidence Standard met? The home has its own whistle blowing policy and procedure and uses the Wakefield Metropolitan District Council adult abuse procedure. Discussions with the new acting manager and other staff demonstrated a need for an update in training particularly with regard to adult abuse procedures. A recommendation has been made in this regard.Snydale Care HomePage 22 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 occasion 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 occasionSnydale Care HomePage 23 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 2 Key findings/Evidence Standard met? Inspection of bathroom and toilet facilities showed that these are available in sufficient number to meet with the needs of service users and improvements to toilet and bathroom areas, including new soap dispensers, have been made since the last inspection. The inspector noticed that the door to the downstairs toilet could be locked using a star key, this should be disabled or removed to ensure that service users cannot accidentally become locked in the room. Waste bins in some toilet and bathroom areas did not have a lid and it is recommended that these be replaced with foot operated bins. The toilet cistern in the upstairs bathroom was broken and should be repaired. Plans are in place for the total refurbishment of one of the bathrooms to provide a tracking hoist for the comfort of service users with a physical disability. 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? Whilst a full assessment of the premises has not been undertaken, individual assessments are made, prior to admission, of the suitability of the facilities for individual service users. Aids and adaptations are available within the home to meet with the needs of the current service users.Snydale Care HomePage 24 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 X X X X 3 X XX X X XKey findings/Evidence Standard met? The home meets with current standards for individual space.Snydale Care HomePage 25 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. 3 Key findings/Evidence Standard met? The majority of the bedrooms seen during the inspection were nicely furnished and decorated, some benefiting more recently from new decoration and furniture, and the majority had been personalised by the service user. All of the rooms seen provided a comfortable and homely. Those bedrooms in need of redecoration had been identified as part of the rolling programme of redecoration. 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. 3 Key findings/Evidence Standard met? Evidence available at the home on the day of the inspection demonstrated that this standard is met. 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. 2 Key findings/Evidence Standard met? The majority of the home appeared clean, tidy and well maintained with a complete absence of offensive odours. Bath hoist seats were seen to be quite dirty and would benefit from a more thorough cleaning. The inspector noticed that some hairbrushes and combs in service users bedrooms were dirty and full of hair and a soap dish in a bedroom was found with a number of dead flies in it. Recommendations have been made regarding the above.Snydale Care HomePage 26 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 XX X X3 Key findings/Evidence Standard met? Staff rosters indicated that staff numbers are maintained in line with the requirements of the staffing notice issued by the previous regulatory authority. The acting manager is aware of the need to keep under review staffing numbers in relation to service users needs.Snydale Care HomePage 27 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 the 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 8 25 2 Key findings/Evidence Standard met? 8 care assistants now hold the level 2 NVQ award, another 5 have almost completed their studies for the award and 6 care assistants will be commencing their studies shortly. A recommendation has been made 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? A selection of staff files were examined and were found to contain the documentation required to ensure the protection of service users. The homes administrator is continuing to audit staff files to ensure that information is included is current and up to date. 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. 1 Key findings/Evidence Standard met? A new induction process based on TOPSS specifications is being introduced at the home. The acting manager said that staff training needs are identified and discussed during supervision. Documentation regarding training needs, training undertaken and planned training is available in the home but this needs to pulled together and organised into a training matrix so that training needs and updates can be easily identified. Plans are in place for 2 members of staff to become trainers in fire safety although evidence was not available to confirm that staff were up to date with fire safety training and a requirement has been made in this regard.Snydale Care HomePage 28 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. 0 Key findings/Evidence Standard met? The new manager has recently applied to the Commission for Social Care Inspection to be registered as a home manager and is therefore, for the purpose of the report, referred to as the acting manager. The acting manager is a qualified registered general nurse who has recently completed a BSc in healthcare studies. She has enrolled on the registered managers award programme and is also doing an advanced health and safety course and the intermediate certificate in food and hygiene. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Not assessed on this occasionSnydale Care HomePage 29 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. 2 Key findings/Evidence Standard met? The inspectors were pleased that the registered provider has commenced regulation 26 visits to the home and as a result of this has identified processes within the home that are in need of update and improvement. The acting manager said that she had been meeting with relatives of service users as part of the quality monitoring process although a formal system of quality monitoring is not yet in place. It is recommended that the registered proprietor and acting manager work towards formalising a system of continuous quality monitoring using questionnaires and feedback cards to gain the views of service users, relatives, staff and other stakeholders. An annual report should then be made available within the home and a copy forwarded to the Commission for Social Care Inspection. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 2 Key findings/Evidence Standard met? Certificates were on display to evidence that appropriate insurances are in place at the home. A business and financial plan should be available in the home.Snydale Care HomePage 30 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 X X X1 Key findings/Evidence Standard met? Staff were unable to tell the inspectors how many of the service users were subject to any of the above with regard to finances. Some money is held by the home on behalf of service users but it was established that in some cases the amount of money indicated by documentation as being held in the home, was not in the home but in the homes bank account. A requirement has been made in this regard. The inspector noticed that two signatures are not always obtained for transactions in relation to service users finances. A recommendation has been made in this regard. 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 is ongoing for all staff at the home on a two monthly basis. 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? The inspectors were pleased to note that care plans are now stored in locked filing cabinets in line with the requirements of the data protection act.Snydale Care HomePage 31 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. 2 Key findings/Evidence Standard met? The registered provider was not able to locate all of the documentation requested by the inspectors and was unable to contact her husband who deals with this area within the home. The inspectors did see some certification with regard to health and safety within the home. A recommendation has been made that the acting manager and other relevant staff be made aware of the whereabouts of all documentation relating to the running of the home so that this can be produced at future inspections. This standard will be fully examined at the next inspection.Snydale Care HomePage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorGillian Walsh Helen WalkerSignature Signature SignatureRegulation Manager Ruth Rainey Date Public reports 11 February 2005It should be noted that all CSCI inspection reports are public documents. Snydale Care Home Page 33 PART DD.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 11 October 2004 of Snydale Care Home and any factual inaccuracies: Please limit your comments to one side of A4 if possible We are working on the best way to include provider responses in the published report. In the meantime responses received are available on request.Snydale Care HomePage 34 Action taken by the CSCI 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. D.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 35 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of Snydale Care Home 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 D.3.2 I of Snydale Care Home 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 36 Snydale Care Home / 11th October 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000006217.V181056.R01© This report may only be used in its entirety. 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