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Inspection on 30/07/04 for Snydale Care Home

Also see our care home review for Snydale Care Home for more information

Care Home For Older PeopleSnydale Care HomeNew Road Old Snydale Pontefract West Yorks WF7 6HDUnannounced Inspection30th July 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) Physical disability over 65 years of age (52) Registration number J520002012 Date first registered with NCSC 31st July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 12th May 2004 YES NO 10/02/20 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 330th July 2004 11:30 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 inspectionMrs T Holroyd (Registered Proprietor) Mrs Diane Rose (Acting Manager)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 unannounced inspection made at Snydale care home on 30th July 2004. At the time of the inspection a new manager had just been appointed and had commenced work the week of the inspection. As the home had not obtained an enhanced criminal records bureau check, as required by regulation, the new manager was only able to work within the office environment until clearances were obtained. As the new manager has not yet gone through the Commission for Social Care Inspections processes to be registered as the manager, she is referred to for the purpose of the report as the acting manager. The inspectors would like to wish the new manager well in her new post and look forward to working with her in the future. They would also like to thank everybody at the home for their assistance during the inspection. Choice of Home (Standards 1-6) 3 of the 4 standards inspected on this occasion were met 1 was not met and standard 6 does not apply as intermediate care is not provided at the home. A comprehensive statement of purpose has now been developed and is available at the home. The service user guide provides clear information about the home and the facilities offered it also contains a statement of terms and conditions, which includes all required detail. The home does not yet write to potential service users to confirm that, following their assessment the home is able to offer a place and can meet with all of the individuals assessed needs and a requirement has been made in this regard. 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. Health and Personal Care (Standards 7-11) 1 of the 4 standards inspected was met, 1 was partially met and 2 were not met. The inspectors examined a selection of care plans and were disappointed to find that for the two most recently admitted service users no assessments, risk assessments or care plans had been commenced. Some care plans had not been reviewed since before the last inspection of the home in February and another had not been reviewed since November 2001. Requirements have been made regarding the assessment and care planning process. The home employs the services of all available community health professionals. There was evidence of a deterioration of the systems in the homes procedures for maintaining a safe system for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home and a requirement has been made in this regard. Service users confirmed to the inspectors that staff at the home are respectful of their needs with regard to the maintenance of privacy and dignity. Daily Life and Social Activities (Standards 12-15) Both of the 2 standards inspected on this occasion were met. Care staff try to provide activities on a daily basis although this can sometimes be Snydale Care Home Page 6 problematic due to staff shortages when they are unable to dedicate time within their care hours to activities. Trips out are organised on a regular basis and the home has recently ordered a new mini bus to facilitate this. Outside entertainers are booked on a regular basis to provide entertainment to service users at the home. Within the home service users enjoy watching television, videos and DVDs on wide screen television. The home does not impose restrictions on visitors and assists residents in maintaining social relationships. Complaints and Protection (Standards 16-18) The 1 standard inspected on this occasion was partially met. The registered provider said that she has a positive attitude to complaints and will organise training for staff in this area to promote this attitude throughout the home. A recommendation has been made that complaint recordings demonstrate any actions taken to resolve the complaint and that the complainants feelings regarding the outcome are recorded and where possible signed by the complainant. Environment (Standards 19-26) 2 of the 6 standards inspected on this occasion were met, 2 were partially met and 2 were not met. The location and layout of the home is suitable for its stated purpose. Routine maintenance and renewal of furnishings is ongoing with several areas having been refurbished since the last inspection. A number of lounges, including a smoking lounge, and dining areas are provided for service users. Bathroom and toilet facilities are available in sufficient number to meet with the needs of service users. However several bathroom and toilet areas were found not to meet the required standard on this occasion due to general untidiness and a lack of attention to detail with regard to cleanliness and provision of soap and toilet paper. The majority of the bedrooms seen during the inspection were nicely furnished and decorated, some having recently benefited from new decoration and furniture, and the majority had been personalised by the service user. Hot water in some areas felt to be very hot at the point of delivery and the inspectors felt that this posed a risk of scalding to service users. The majority of the home appeared clean, tidy and well maintained with a complete absence of offensive odours. Staffing (Standards 27-30) The 1 standard inspected on this occasion was partially met. The new acting manager told the inspectors that she is working on introducing a new induction programme based on the TOPSS specifications. The acting manager told the inspectors that she has a particular interest in training and will be reviewing the training processes at the home over the coming weeks. This standard will therefore be more closely assessed during the next inspection. Management and Administration (Standards 31-38) Neither of the 2 standards inspected on this occasion were met. 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 that monthly unannounced visits and reports, are produced as required by regulation 26 and send a copy of these reports to the Commission for Social Care Inspection. This requirement is now outstanding and indicates a non-compliance with regulation. The registered provider must ensure that actions Snydale Care Home Page 7 are now taken within the required timescale. During the inspection it was noticed that care plan files are kept on a shelving unit in an open area within the communal areas between a lounge and dining room, a requirement has been made that the arrangements for the safekeeping of these documents is reviewed by the home.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. 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 1 14(1)(d) OP4 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. From next admission to the home and ongoing. 31 April 20042 26 OP33Action 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 Standard 1 2 OP28 3 4 OP8 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. Page 9OP30Snydale Care Home 5 6 7OP24 OP33A 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.OP33CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Snydale Care HomePage 10 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 The registered person must confirm in writing to the potential resident that the home is able to meet with their assessed needs. The registered person must; · 2 14(2) 15(1)(2) OP7 · Ensure that assessments of service users needs are developed and reviewed. Care plans are developed and are reviewed on a recommended monthly basis. From 30th July and ongoing. From next admission to the home and ongoing.114(1)(d)OP431 October 2004313(2)OP9The registered person must ensure that a safe system is in place for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home. To prevent the risk of injury, water temperatures must be checked regularly and any adverse temperatures must be reported and adjusted immediately, meanwhile actions must be taken to prevent scalding.413(4)(a)OP25OP3 8From 30th July and ongoing.Snydale Care HomePage 11 526OP33The 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. Care plan files containing confidential information about service users must be kept securely at the home.30 September 2004 30 September 2004617OP37RECOMMENDATIONS 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 * Complaint recordings should demonstrate any actions taken by the home to resolve the complaint and the complainants feelings regarding the outcome are recorded and where possible signed by the complainant Bathroom and toilet areas should be kept clean and clutter free. Toilet paper and liquid soap should be provided in all communal toilet and bathroom areas. Individually prescribed creams and lotions should not be kept in communal bath and washroom areas. 3 4 OP24 OP30 A review should be undertaken of the floor coverings in the en-suite toilets as there is some minor remedial work identified. Work should continue to develop the induction programme to bring it in line with TOPSS specifications.1OP162OP26OP2 1* 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 NO YES NO YES NO YES NO YES YES NO NO NO YES NO NO 10 0 0 YES NO YES YES X X 30/07/04 11.30 4Snydale 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 (£) X To (£) XAny charges for extrasYESIf yes, please state what the extras are: 3 Key findings/Evidence Standard met? A comprehensive statement of purpose has now 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 and 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). 3 Key findings/Evidence Standard met? The service user guide contains a statement of terms and conditions, which includes all required detail.Snydale 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. 0 Key findings/Evidence Standard met? Not assessed on this occasion 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? The registered provider said that she would develop a letter and that it would be used for all future potential service users. The requirement made in the previous report in this regard has been carried forward to this report. 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. 3 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 is now 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 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. 1 Key findings/Evidence Standard met? The inspectors examined a selection of care plans and were disappointed to find that for the two most recently admitted service users no assessments, risk assessments or care plans had been commenced. One of these service users had been at the home for one week but the other had been there for over a month. Some care plans had not been reviewed since before the last inspection of the home in February and another had not been reviewed since November 2001. Evidence was not available in the care plans examined to demonstrate that service users or their relatives are being involved in the care planning or review process. A recommendation made in this regard in the previous report has been carried forward. Requirements have been made regarding the assessment and care planning process.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 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 documentation for such assessment is available within each care plan file. A recommendation has been carried forward from the previous two reports 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. 1 Key findings/Evidence Standard Met? The inspectors examined a selection of Medication administration record (MAR) sheets. On one MAR sheet handwritten instructions had been completed for a service user taking varying amounts of the drug warfarin. The handwritten instructions were not at all clear as to how much of the drug should be given and when it should be given. The acting manager agreed with the inspector that, from the handwritten instructions available, she would not be able to confidently administer the warfarin. Further examination of this MAR sheet suggested that a mistake may have already occurred in the administration of this drug. Amounts of medications received at the home were not being recorded on the MAR sheets examined which made stock balance checks very difficult. Medicines awaiting return to pharmacy were not kept within locked cupboards and the drug fridge was found to be unlocked and regular temperature recordings had not been made. The above demonstrates a deterioration of the systems in the homes procedures for maintaining a safe system for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home and a requirement has been made in this regard.Snydale Care HomePage 18 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. 3 Key findings/Evidence Standard met? Service users confirmed to the inspectors that staff at the home are respectful of their needs with regard to the maintenance of privacy and dignity. 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 19 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. 3 Key findings/Evidence Standard met? The registered provider told the inspectors that two of the care assistants at the home have completed an activities course through Selby College. They and other care staff try to provide activities on a daily basis although this can sometimes be problematic due to staff shortages when they are unable to dedicate time within their care hours to activities. Trips out are organised on a regular basis and the home has recently ordered a new mini bus to facilitate this. Outside entertainers are booked on a regular basis to provide entertainment to service users at the home. Within the home service users enjoy watching television, videos and DVDs on wide screen television. The inspectors appreciate the efforts made by the home to provide entertainment and activities for service users. It is recommended that once staffing has settled down and the new manager has had time to review current arrangements, that, after consultation with service users, a programme of daily activities is developed for the home. 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.Snydale Care HomePage 20 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. 0 Key findings/Evidence Standard met? Not assessed on this occasion 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. 0 Key findings/Evidence Standard met? Not assessed on this occasionSnydale Care HomePage 21 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 1 1 0 0 0 0 100 2 Key findings/Evidence Standard met? Examination of the complaints book showed that no complaints had been recorded as being received by the home since December 2003. Recordings of complaints did not always demonstrate what actions had been taken to resolve the complaint or that the complaint had been finalised to the satisfaction of the complainant. The registered provider told the inspectors that a complaint had been made to the home the previous day which had not yet been recorded. The registered provider said that this complaint was fully substantiated and that it would be entered into the complaints book. The registered provider said that she has a positive attitude to complaints and will organise training for staff in this area to promote this attitude throughout the home. A recommendation has been made that complaint recordings demonstrate any actions taken to resolve the complaint and that the complainants feelings regarding the outcome are recorded and where possible signed by the complainant.Snydale Care HomePage 22 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. 0 Key findings/Evidence Standard met? Not assessed on this occasion 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 Key findings/Evidence Not assessed on this occasion Standard met? X X 0Snydale Care HomePage 23 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. 3 Key findings/Evidence Standard met? The location and layout of the home is suitable for its stated purpose. Routine maintenance and renewal of furnishings is ongoing with several areas having been refurbished since the last inspection. The grounds are well maintained and made comfortable for service users to enjoy. 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. 3 Key findings/Evidence Standard met? A number of lounges, including a smoking lounge, and dining areas are provided for service users.Snydale Care HomePage 24 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. However several bathroom and toilet areas were found not to meet the required standard on this occasion. A downstairs toilet was cluttered with various items including manual handling equipment and service users clothing and footwear. Other bathrooms and toilets also had service users personal items of clothing, toiletries and prescribed creams in cupboards and around the room. One toilet area did not have any toilet roll available and another had a bar of soap to be used communally on the wash hand basin. Deeper cleaning was needed in all of the bathroom and toilet areas inspected and the shower head above one of the baths was broken. The inspectors were told that this had already been identified as in need of replacement. Recommendations have been made with regard to the above. 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. 0 Key findings/Evidence Standard met? Not assessed on this occasionSnydale Care HomePage 25 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 Key findings/Evidence Not assessed on this occasion NO YES NO X X X X Standard met? 0 X XX X X XSnydale Care HomePage 26 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? The majority of the bedrooms seen during the inspection were nicely furnished and decorated, some having recently benefited from new decoration and furniture, and the majority had been personalised by the service user. Some bedrooms were in need of redecoration and this was acknowledged by the proprietor who said they would be done as part of the rolling programme of redecoration. The flooring in the en-suites identified at the last inspection is still in need of attention and the recommendation in this regard made in the last report has been carried forward. 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. 1 Key findings/Evidence Standard met? Hot water in some areas felt to be very hot at the point of delivery and the inspectors felt that this posed a risk of scalding to service users. The proprietor told the inspectors that this would be attended to that day. A requirement has been made regarding water temperatures. 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. As mentioned in standard 21, bathroom and toilet areas would benefit from a more thorough cleaning. The laundry was clean well maintained and organised.Snydale Care HomePage 27 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 Key findings/Evidence Not assessed on this occasion X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X Standard met? 0Snydale Care HomePage 28 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 Key findings/Evidence Not assessed on this occasion X X Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? Not assessed on this occasion 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? The new acting manager told the inspectors that she is working on introducing a new induction programme based on the TOPSS specifications. The acting manager told the inspectors that she has a particular interest in training and will be reviewing the training processes at the home over the coming weeks. This standard will therefore be more closely assessed during the next inspection.Snydale Care HomePage 29 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 had commenced work at the home within the week of the inspection taking place. The new manager has not yet gone through the process of applying 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 30 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 registered proprietor told the inspectors that work is about to commence on a quality monitoring programme. Questionnaires have been developed for obtaining the opinions of service users and other stakeholders. Results of this should be collated and a copy sent to the Commission for Social Care Inspection. 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 that monthly unannounced visits and reports, are produced as required by regulation 26 and send a copy of these reports to the Commission for Social Care Inspection. This requirement is now outstanding and indicates a non-compliance with regulation. The registered provider must ensure that actions are now taken within the required timescale. 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. 0 Key findings/Evidence Standard met? Not assessed on this occasion 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 Key findings/Evidence Not assessed on this occasion Standard met? 0 X X XStandard 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. 0 Key findings/Evidence Standard met? Not assessed on this occasionSnydale Care HomePage 31 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. 1 Key findings/Evidence Standard met? During the inspection it was noticed that care plan files are kept on a shelving unit in an open area within the communal areas between a lounge and dining room. They are therefore fully accessible to anybody within the home. As there will be times when staff are not available in this area to ensure that these files are maintained securely and in line with the requirements of the Date Protection Act, a requirement has been made that the arrangements for the safekeeping of these documents is reviewed by the home. 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. Key findings/Evidence Not assessed on this occasion Standard met? 0Snydale Care HomePage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager Date Public reportsGillian Walsh Ruth Rainey 28 September 2004Signature Signature SignatureIt 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 30 July 2004 of Snydale Care Home and any factual inaccuracies: Please limit your comments to one side of A4 if possibleSnydale 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 publicationNOAction 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 planOther: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 / 30th July 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.V161679.R01© This report may only be used in its entirety. 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