Inspection on 20/06/06 for South Hayes Care Home

This inspection was carried out on 20th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

South Hayes Care Home 04/04/07

South Hayes Care Home 09/08/05

South Hayes Care Home 16/05/05

South Hayes Care Home 22/12/04

South Hayes Care Home 19/10/04

South Hayes Care Home 06/07/04

South Hayes Care Home 16/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE South Hayes Care Home 101 London Road Worcester Worcestershire WR5 2DZ Lead Inspector Andrew Spearing-Brown Unannounced Inspection 15:00 20 and 27th June 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South Hayes Care Home Address 101 London Road Worcester Worcestershire WR5 2DZ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01905 357429 01905 357429 Regal Care (Worcester) Limited Vacant Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Reduction in the maximum number of residents who may be accommodated from 48 to 30 until there is agreement with CSCI that an increased maximum number may be reinstated. 9th August 2005 Date of last inspection Brief Description of the Service: South Hayes care home is a large, detached, three storey building, which attracts a listed status. Situated approximately half a mile from Worcester City Centre, it occupies an elevated position set back from the road, and is approached by a short drive leading to a car parking area. The home is registered to provide personal care for up to 48 elderly residents, who may also have a physical disability, although this number is currently subject to a condition of registration as detailed above. The home is not registered to provide care for residents with dementia or who suffer a mental health problem. The stated aim of the home is to provide the best quality life for residents in an environment which is clean, comfortable, safe and welcoming, and where people are treated as individuals with respect and sensitivity. The home has been owned by Regal Care (Worcester Ltd) since 1998. At the time of this inspection a manager designate managed the home. The Commission for Social Care Inspection awaits the registration application in order that the registration process can proceed. Information recorded upon the Pre-Inspection Questionnaire received on 2nd June 2006 stated that the fees at South Hayes are currently £343.00 per week. South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector from the Worcester office of the Commission for Social Care Inspection (CSCI) carried out this inspection. The focus of any inspection carried out by the CSCI is to assess the outcomes for people who use the service. As part of the overall inspection of the service offered at South Hayes two visits to the home were undertaken. The visits to the home were unannounced and lasted a total of 10 ½ hours. The last visit to the home comprised of an additional inspection to follow up from a statutory inspection visit on the 9th August 2005. This inspection takes into account information received by the CSCI since the previous inspection as well as the visits to the home. Prior to the visit a pre inspection questionnaire was posted to the manager designate requesting certain information. The inspector received the completed document prior to this inspection visit. In addition to the preinspection questionnaire a number of other questionnaires were also sent to the home. A number of these were returned to the CSCI prior to the inspection and included comments made on behalf of residents by relatives. Comments from these questionnaires are included within this report. In addition to the manager designate discussions took place with the owner and two carers. Discussions took place with a number of residents throughout the inspection. South Hayes is currently registered to care for 30 older people until such time that with agreement with the CSCI the number of residents may be increased. While the home was registered as a care home proving nursing care the registration was for 48 residents, this number however included the use of a number of double bedrooms. What the service does well: The general atmosphere within the home is welcoming. Information is available regarding the services offered within the home. Potential residents and their representatives are able to visit the home prior to admission. During a discussion with a number of residents in the lounge they were all very complementary about the home. Residents looked well cared for. Staff interactions with residents were good and residents spoke highly of the staff team. South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 6 The home has an activities coordinator and residents spoke highly of the outings they have attended recently. A craft room is provided to undertake art and craft activities. The home was clean and free from any offensive odours. The grounds to the front of the home are well maintained. At the time of this inspection a number of staff were awaiting confirmation of their NVQ (National Vocational Qualification) level 2 award. These persons in addition to staff already qualified means that 50 of carers will hold this qualification. Recruitment procedures are sufficiently robust to safeguard residents. What has improved since the last inspection? What they could do better: Pre admission assessments need to be in detail to ensure that the home is able to demonstrate its ability to meet identified care needs and commence an initial care plan. Improvements are needed in relation to care planning and risk assessments. These need to include all areas of need and risk such as oral care, nutritional screening and pressure care. A number of shortfalls were noted regarding the management and safe keeping of medication. As a result of the concerns regarding medication an immediate requirement notice was issued. The acknowledged improvements to the environment need to continue to ensure that residents have a safe and homely place to reside. South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 7 Staffing levels at certain times are insufficient to meet care needs; in addition care staff are required to carry out other tasks such as preparing residents tea. The formal supervision of staff needs to be improved. A number of health and safety concerns were apparent during this visit. Concerns regarding a number of fire safety matters need attention to ensure that residents and staff are safe by means of training and suitable checks to equipment. Recording needs to be improved following checks to water temperatures to ensure that any faults found are attended to in a timely manner. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3, 4 and 5. Standard 6 is not applicable Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of a pre admission assessment results in the care home failing to have suitable systems in place to ensure that care needs of potential residents can be met. Care staff have received some specialist training required to care for older people with an identified care need. EVIDENCE: Copies of both the Statement of Purpose and Service Users Guide were available in the administrator’s office in the basement. The owner confirmed that the copy held at the local office of the CSCI is the most up to date version. One member of staff consulted knew of the service users guide and one resident confirmed that her relative sought information prior to her admission into the home. A previous inspection report described the documents as ‘ comprehensive’. South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 10 On the day of the second visit of this inspection the home was expecting two residents to be admitted. The pre admission information was viewed and found to be limited in its detail. The home had not received a copy of the Community Care Assessment (CCA) prepared by the purchasing social worker. Although the home had arrangements to consult with the residents previous care home the information available to prepare an initial care plan was insufficient and failed to demonstrate the homes capability to meet potential care needs. Potential residents and or their representatives are able to visit the home prior to admission, which is on a trial basis. South Hayes is registered to care for older people, not failing into any other category, therefore nobody with dementia as a primary care need can be admitted into the home. Notwithstanding the registration a number of people do have a degree of memory loss. It is vital that staff collectively and individually have the skills to meet the needs of residents. Senior staff and some other carers were reported to of recently received training regarding ‘peg feeding’ in preparation for a planned admission of a resident requiring this level of care. In addition the manager designate reported that she had made contact with the local district nurse team and that they would provide assistance as required. South Hayes does not offer intermediate care. South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of care plans and risk assessments in a range of areas can potentially place residents heath safety and wellbeing at risk. Records seen and a lack of suitable security regarding the management of medication gave cause for concern. EVIDENCE: Individual care plans are in place for each resident. A representative sample of care plans were viewed and assessed during the inspection. Due to South Hayes now providing personal care only as opposed to nursing care the dependency levels of residents were described as lower than they were in the past with many residents being mobile. The manager designate is aware that care plans are in need of improvement and discussed some proposed new documents. The new style cover a range of care needs and have certain elements of possible need pre printed under each main element. Some shortfalls with the proposed documents were apparent in South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 12 that they tended to cover physical needs only and left little room for individual details to be entered. A number of concerns were raised with the owner and manager designate regarding the care plans and risk assessments viewed. Care plans in place are reviewed on a monthly basis. Care plans need to be reviewed on at least a monthly basis or more frequently as necessary to support individual residents needs. From other evidence it was apparent that some information needed to be transferred to the care plan prior to the regular monthly up date. Care plans did not cover all potential areas of need as listed under standard 3.3 of the National Minimum Standards and therefore gaps were apparent. It was noted that the pre admission form of a relatively new resident stated ‘ false teeth – not seen a dentist for sometime’ however the admission assessment stated ‘ dentures – none’. No care plan regarding oral care existed, one carer consulted was unable to recall whether the individual resident had false teeth or not. An identified care need to see a chiropodist and therefore to be referred via a GP was recorded at the end of March 2006. It was stated that the referral had taken place and that an appointment was awaited however this was not recorded nor was a care plan in place regarding foot care. A waterlow risk assessment showed that a resident was at a high risk of potential pressure sores. The risk assessment was reviewed regularly as required however no care plan was in place. Therefore having established a high risk carers were not given any instructions to either prevent pressure sores or strategies identified in an attempt to reduce the overall risk. It was evident that one resident had some sore areas. Information included as part of a care plan entitled ‘pain’ was insufficient and unclear. No care plan regarding pressure care existed, in addition no evidence was available to demonstrate that the treatment carers are carrying out was as directed by a district nurse. A review and suitable care plan in relation to these areas is urgently required. Similar issues were identified regarding the risk of falls whereby no care plans were in place to demonstrate how the fall prevention strategies are implemented. One resident needs to be hoisted. No care plan or risk assessment was evident. In one case were bedrails are in use the buffers are not in place as the resident concerned wishes to use the bars to pull him/herself up. The use of bedrails without such buffers can be potentially hazardous; a risk assessment was in place but in need of review to ensure that all parties are aware of the risk and to ensure that alternatives are sought in consultation with other professionals. South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 13 The daily notes of one resident highlighted an acute infection and the affect of this infection on behaviour over a short period of time up until hospitalisation. No care plan was drawn up following return from hospital to reduce the risk of reoccurrence or how to manage a similar situation should it happen again. Residents are weight regularly although no indication as to why individuals are weighed or when to report weight gain / loss was recorded. Nutritional screening is not taking place. The daily evaluations written by carers were generally satisfactory in content. They contained information regarding physical care needs as well as some information regarding social care needs. The vast majority were factual and not opinionated. Handover sheets are also used as a means of capturing the information needed to pass from one shift to the next, these tended to concentrate on physical needs. Residents seen looked well cared for. Carers consulted were able to verbally give a reasonably good account of the care needs of two residents who were case tracked As part of the inspection the management of medication was assessed. In order to carry out this assessment the storage and recording of medication was examined. Concerns were noted regarding some elements of recording upon the Medication Administration Record (MAR) sheets, which required immediate improvement. A small number of gaps were evident whereby staff had failed to either sign for medication as given or enter a code to explain why it was omitted. One of the gaps related to a course of antibiotics. Another MAR sheet contained 23 signatures for a course of 21 antibiotics, therefore on 2 occasions staff had signed for medication not given. Staff were not recording the date when medication not included within the monitored dosage system is opened this makes a full drug audit difficult. The majority of creams and ointments were not signed as applied. The manager designate stated that this is due to the fact that carers who apply these items do not sign the MAR sheets. As all prescribed medication must be signed for suitable procedures must be put into place in order that cares are able to fulfil this requirement. A container of prescribed cream was found in the wrong residents bedroom. South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 14 Two storage cupboards contained some stock medication, it was pleasing to note that oral medication was held separate to external items, however the cupboards were not lockable. As the clinic door was left open unauthorised persons could have accessed these items. Even if the door is shut staff with knowledge of the door code can still gain unauthorised access to the room. A copy of the guidance issued by the Royal Pharmaceutical Society of Great Britain needs to be readily available to staff. The homes medication policy was briefly viewed this needs to be more detailed. Since the previous inspection suitable facilities for the storage of controlled medication have been fitted. Due to the shortfalls noted regarding the management of medication an immediate requirement notice was issued. As part of the inspection on the second visit a number of care plans were viewed. The files contained previous months MAR sheets and these were briefly viewed. The sheets seen confirmed many of the shortfalls identified above in addition to incidents when a ‘?’ was inserted into the space where a signature should be. Observations made during the inspection indicated that staff uphold residents privacy and dignity. Staff consulted gave clear accounts of their actions, which showed suitable awareness to privacy and dignity. Residents spoken to praised the staff and confirmed that they were well cared for. South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A relaxed atmosphere and a range of activities enables residents to choice how they spend their time. Resident spoke highly of the food provided. EVIDENCE: Visitors are able to visit at any reasonable time. Visitors are able to use communal areas such as the lounge or dining room as well as resident’s own rooms as they wish. Involvement with the local community does take place; at the time of this inspection preparations were in hand for the homes summer fate. On arriving at the home for the first part of this inspection a game of bingo was underway within the main lounge. A game of bingo was also going to take place during the second visit. Resident consulted confirmed that activities take place both in house and in the community. Residents stated that they had enjoyed a trip to an Old Time Musical Hall at the local theatre and an outing to Tewkesbury Abbey. South Hayes has its own mini bus; this still refers to the home as a nursing home as opposed to a home providing personal care. One resident spoke about how she enjoyed the quizzes that take place. One South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 16 questionnaire returned to the CSCI stated ‘ I love all the trips out and enjoy it all very much . . . looking forward to next trip out very much.’ Holy communion undertaken by a minister from a local Church of England is provided for residents once a month. The religious needs of any Roman Catholic residents can be met by means of links to a local priest. An activities organiser is employed 3 days per week. The activities organiser carries out a range of art and craft activities such as recycling cards, which were on sale in the home to raise funds. A dedicated craft room is provided. This inspection coincided with the football World cup. The home was decked with flags and other information regarding this sporting event. The owner is keen to provide facilities to encourage residents to have a interest in the garden and plans to purchase a greenhouse. Although through consultation with residents and via some written records it was evident that activities are taking place care plans do not include sufficient details regarding the meeting of residents individual social, religious and cultural needs. Recording of activities was inconsistent and in need of improvement. Fresh fruit was available in the lounge however as the grapes had gone off it is questionable how often staff check the bowl and how often residents are either offered fruit or help themselves to fruit. Jugs of squash were available within lounges and it was noted that residents frequently had drinks in front of them. Residents consulted were complementary of the food provided. Residents stated that a cooked breakfast is available if desired. A choice of menu for lunch is available on the second day of this visit the choice was beef casserole or egg and bacon pie. In order to assist the kitchen residents are requested to make a choice the day beforehand. South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Training regarding vulnerable adults has taken place and staff had sufficient knowledge to safeguard residents. EVIDENCE: Information recorded upon the pre-inspection questionnaire stated that residents are aware of how to make a complaint. Although the questionnaires were completed by staff on behalf of residents comments included ‘ . .go to Lyn (manager designate)’ and ‘matron’ Residents consulted stated that they had no concerns regarding the home. Comments made included ‘ wouldn’t fault it’ and ‘ Best one’. Since the last inspection the CSCI have not received any complaints in relation to South Hayes. It was reported that staff have received recent training regarding the protection of vulnerable adults. During consultation carers were able to demonstrate a good understanding of their responsibilities regarding reporting any actual or alleged abuse to a senior member of staff. The only concern raised was upon the need to ensure that the homes policies and procedures are compliant with national and local guidance and include reference to the adult protection coordinator. South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 18 South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The continuing improvement in the environment is providing an increasingly attractive place for individuals to live; the maintenance plan needs to continue. On going discussions regarding the use of double bedrooms and dining facilities should further enhance residents choice. EVIDENCE: Recent inspection reports have acknowledged the improvements to the environment that have taken place over the past 12 months. A number of bedrooms have been redecorated to enhance their appearance; further bedrooms need redecorating in the future. As part of this inspection a number of bedrooms as well as communal areas were viewed. Some bedrooms have very pleasant views over the front lawn and Worcester while others face a brick wall. A number of the double bedrooms are currently used as singles, in consultation with the CSCI the South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 20 future of some of the double bedrooms needs to be determined. The manager designate is looking at improving the screening available in one double bedroom. It was stated that one residents representative had made a positive choice about their relative moving into a double bedroom while the other occupant of the room was offered a single room. Following the inspection undertaken in August 2005 a number of requirements were issued regarding the environment, the majority of these have received suitable action and are met while others are part met. A maintenance plan was drawn up by a consultant following the above inspection, which the owner is currently working towards. Once completed the owner will need to draw up a routine maintenance plan showing the renewal of fabric and decoration. Work is currently in progress on the top floor (currently not in use) whereby the traditional bath is to be removed and a shower fitted. Another bathroom on this floor contains a Parker bath (currently out of commission); the door to this room contains a glass panel. Although a curtain may be used the glass panel remains a possible infringement of privacy and should be removed and replaced with a wooden panel. A small number of bedrooms also have a glass panel in the door; these also need to be changed. A new shower room on the first floor is not yet finished in that the emergency call system needs fitting and a lock needs to be fitted to the door. Another bathroom on the first floor has a new bathroom suite in place and the walls are newly tiled. The radiator was not covered; this needs to be done to safeguard against the potential risk of scalding. Sluices are provided they are functional and traditional. The home was clean tidy and free from any offensive odours. It was noted that one en-suite door has a hole in it following the removal of a bolt; this needs to be filled in. One bedroom has water damage on the ceiling. The flooring in one bedroom is a vinyl style; this needs to be reviewed prior to admitting a new resident into this bedroom. Some wardrobes were secured to the wall to prevent them falling over. Remaining wardrobes need to be secured unless a risk assessment can demonstrate otherwise. Bedroom doors now have locks fitted as required within the previous inspection report. One bedroom door has an old style devise fitted which needs to be removed It was noted during this inspection that the television picture within both the smaller lounge and the dining room was very hazy. The owner stated that he is purchasing some plasma screen televisions and having sky installed. South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 21 The previous inspection report made reference to the fact that there is inadequate space and seating in the dining room. Using the tables in place it would only be possible to seat 17 residents at the same time, space is not sufficient to add additional tables. As South Hayes was formally a care home providing nursing care it is likely that a percentage of residents have historically taken their meals within their own bedrooms, this may not be so common with a care home providing personal care. A review of dining facilities is therefore needed. The communal lounges were homely in appearance the lighting is domestic in character. The home currently only has one washing machine, the second was reported to of been out of order since April 2006. Although one machine may be sufficient currently it will not suffice an increased demand. South Hayes has well maintained grounds including an attractive lawn to the front of the building. South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are at certain times insufficient to ensure good outcomes for residents and need improvement to safeguard residents. Recruitment procedures are sufficiently robust whereby suitable checks take place prior to employment commencing. In additional sufficient staff hold a suitable qualification these areas help to protect residents interests. EVIDENCE: Staffing levels are within the minimum standards but are in need of reviewing. The number of staff on duty will not be sufficient as resident numbers increase. The rota demonstrates that 3 carers and the manager designate are on duty during the morning. 2 carers cover the afternoon shift and this is the area of greatest concern. In addition to the caring duties other duties need to be covered including the preparation or completing of residents tea. Although staff were reported to have overalls and to hold a basic food hygiene certificate concerns remain. Having a member of staff in the kitchen does despite the overalls bring about risks of cross infection furthermore while 1 person is in the kitchen the number of carers available is diminished. It also needs to be taken into account that a carer needs to administer the tea medication as apart of the afternoon routine. As a result of the above concerns the registered person South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 23 must review staffing during this period of time. Staffing levels need to be appropriate to the assessed needs of residents with additional staff on duty at peak times throughout the day. Residents consulted spoke highly of the staff. One stated ‘ staff excellent – not us and them.’ A relative commented on a questionnaire returned to the CSCI ‘ The home is very well run. The staff are helpful and cheerful. Residents are very happy and well cared for’ The laundry is staffed between 8.00 am – 2.00 pm Monday – Friday. At other times carers need to carry out laundry duties. The file of a recently appointed member of staff evidenced that two written references and a criminal records bureau disclosure (CRB) was obtained prior to the commencement of duties. The manager designate had evidence that she was awaiting a response from the CRB prior to two new carers starting work. CRB’s are also awaited for two 6th form students who are going to undertake some volunteer work, as these persons will be volunteers and less than 18 years old they are not permitted to carry out are personal care tasks and risk assessments will need to be carried out . A list of employees included with the pre-inspection questionnaire indicated that South Hayes has a stable workforce. From information included upon the pre-inspection questionnaire and discussed during the inspection it was concluded that 3 carers who work during the day shifts currently hold a National Vocational Qualification (NVQ) level 2. One carer is awaiting her level 3 certificate and 3 carers are undertaking their level 2 award. Three carers on nights hold a NVQ and one carer is a trained nurse. Another carer is awaiting her level 3 certificate. Using the above figures and accepting that 2 carers are awaiting their certificate South Hayes has the minimum 50 of carers trained to this level. It was not possible to fully assess the level of training undertaken by staff, as the records seen did not readily provide this information. It would be beneficial if a training matrix were devised showing each member of staff and the training undertaken with the date it was done. South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The appointment of a manager (designate) is having a positive impact on the development of the service. Improvements are necessary in staff supervision and quality assurance to maintain the development. A number of health and safety concerns could potentially place residents, staff and others at risk. EVIDENCE: At the time of this inspection the home was being run by a manager designate who was until March of this year working as the deputy manager. The Commission for Social Care Inspection currently awaits the completed application form and associated documents in order that the process towards registration can commence. The home does not have a deputy manager. South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 25 The owner undertakes reviews of the home and prepares written reports as required under Regulation 26. These reports are held at the home and copies are provided to the CSCI. A recent residents survey took place; the results of this survey need to be collated and made available to residents, potential residents and others such as the CSCI. The home does not routinely hold money in safe keeping for residents preferring relatives to carry out this function or making use of the safes that are available in some bedrooms or upon request. A small amount of cash is however retained for two residents. Formal supervision is not taking place this is in need of improvement. As reported elsewhere within this report it was evident that some records are not sufficiently up to date in order to ensure effective and efficient running of the home. No policies and procedures were viewed during this inspection; these will form part of future inspections at South Hayes. It was brought to the attention of the manager designate that an individual was wearing some heavy jewellery. Rings with stones can be hazardous to residents as well as a source of infection. Jewellery such as necklaces and earrings can be hazardous if pulled or caught while carrying out care tasks. The fire risk assessment needs to be reviewed. This should include an assessment of all soft furniture within the care home in relation to The Furniture and Furnishing (Fire) (Safety) Regulations 1988 (as amended in 1989 and 1993). A number of areas requiring action upon the risk assessment dated June 2005 have no record of the action taken since. It was noted that some bedroom doors did not have a smoke seal or intumescent seal fitted. The fire records showed a number of areas of concern as follows: • • It was evident that some staff have not received recent fire training, the fire records indicate that staff ‘did not attend’ The records relating to the annual checking of the fire fighting equipment did not match with a list of equipment within the home. It appeared that some extinguishers and fire blankets were missed when the service took place The monthly review of fire fighting equipment last took place on 12th May 2005 The weekly testing of the fire alarm is not taking place as required. The weekly testing of the alarm is not in sequential order Concern was raised regarding the fact that zone 6 covered both up stairs and down stairs of the new wing. As a result if the alarm were to sound and indicate zone 6 it would not be possible to establish whether the alarm was raised on the first or ground floor. • • • • South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 26 Records of water temperatures are maintained, it was concerning to note that one wash hand basin was consistently recording at over 50 °C since January 2006 with no action having taken place to remedy the findings. Bath water temperatures were recorded as 37 –38 °C, one was however recorded as 30 °C, this appeared to be cool. The testing of portable electrical appliances needs to take place. It is understood that the handyperson is going to undertake this task following instruction; the registered person needs to be confident that persons carrying out this task are suitably competent. As highlighted earlier within this report South Hayes has the benefit of its own mini bus and therefore residents can enjoy trips out to places such as the theatre, restaurant or places of interest. As part of the planning stage is concerned outings need to be more formalised. No risk assessment process takes place before outings to establish things such as toilet facilities or whether steps need to be negotiated in order to safeguard the health safety and welfare of all concerned. The home has no formal checklist to ensure the safety of the mini bus. It was noted that one wheelchair was without its footrests in place; the manager designate stated that this was the individual residents choice. Wheelchairs without appropriate footrests fitted can however be potentially dangerous and therefore any such decision can only be taken after suitable risk assessment and discussions. South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 2 3 3 2 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 1 South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement A full assessment of prospective service users must be undertaken prior to them moving into the home and to include all aspects of their needs. Care plans must be able to contain sufficient information to enable care staff to carry out all aspects of care. Timescale for action 27/06/06 2. OP7 15 27/06/06 3. OP7 15 Care plans must be reviewed and 27/06/06 up dated at least monthly or more frequently as necessary to ensure changing needs are reflected. Care plans must be able to cover all identified care needs as listed under standard 3.3 of the National Minimum Standards. This includes oral care and foot care. Staff must be given instructions as to how anxious and frustrated behaviour displayed by residents are managed consistently. 27/06/06 4. OP7 15 5. OP7 15 27/06/06 South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 29 (Not assessed during this inspection, as suitable records were not available. This requirement will be assessed as part of a forthcoming inspection visit.) 6. OP8 13 Regular weight monitoring must be undertaken, based on the residents nutritional risk assessment. (Part met – although weights are recorded this is not based on suitable nutritional risk assessment and screening) 27/06/06 7. OP8 13 Risk assessment and must be in place for residents who display any anxious or frustrated behaviours (It was noted that no risk assessment was in place in relation to a similar incident therefore the requirement issued following the inspection undertaken in August 2005 is not met) 27/06/06 8. OP8 12 (1) Risk assessments and suitable care plans must be in place regarding moving and handling, falls, use of bedrails and pressure care. 27/06/06 9. OP9 13 (2) Medication Administration Record 20/06/06 (MAR) sheets must be signed after medication (including creams and ointments) are administered / applied. The reason for non – administration of prescribed medication to residents must be clearly entered onto the MAR sheets. South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 30 10. OP9 13 (2) All medication including creams and ointments not included within the monitored dosage system must have the date of open recorded upon them. All medication including creams and ointments must be secured at all times. 20/06/06 11. OP9 13 (2) 20/06/06 12. OP12 16 (2) (m) (n) Care plans must include 27/06/06 information regarding leisure and recreational activities both in and outside the home. All areas of the home must be well maintained. Suitable arrangements must be made to ensure the health safety and welfare of residents within their own rooms by the securing of wardrobes. Adequate dining space and seating must be made available for all residents. (This requirement remains unmet – the registered provider must supply suitable proposals to the CSCI as to how this will be achieved) 30/09/06 31/07/06 13. 14. OP19 OP19 23 (2) 13 (4) 15. OP20 23 31/07/06 16. OP24 23 (2) (e) In order to provide privacy doors must have the glass section replaced. The bedroom floor covering in one bedroom must be reviewed. Any remaining uncovered radiators must be suitably covered to prevent accidental scalding. 31/07/06 17. 18. OP24 OP25 16 (2) (c) 13 (4) 31/07/06 31/07/06 South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 31 19. OP26 13 (3) Suitable facilities must be provided within the laundry. This must include sufficient washing machines with disinfection programmes. Sufficient staff must be on duty throughout the day to meet the care needs of residents. The induction training provided at the home must be checked against the Skills for Care specifications to ensure it meets the required standards. (Not assessed during this inspection, as the records were not available. This requirement will be assessed as part of a forthcoming inspection visit.) 31/07/06 20. OP27 18 27/06/06 21. OP30 12, 18 27/06/06 22. OP33 24 A quality assurance program 31/08/06 must be developed in accordance with Regulation 24 and Standard 33. (Part met – an extended timescale given) 23. OP36 18 (2) Care staff must receive formal supervision at least six times per year. Environmental risk assessments must be carried out for all safe working practices. (Part met – an extended timescale given) 31/07/06 24. OP38 13 31/07/06 25. OP38 13 Suitable policies and procedures must be in place and adhered to regarding staff wearing jewellery The fire risk assessment must be reviewed and action taken recorded. DS0000004144.V297706.R01.S.doc 27/06/06 26. OP38 23 (4) 31/07/06 South Hayes Care Home Version 5.2 Page 32 27. OP38 23 (4) All members of staff must receive fire training and up dates in line with guidance issued by Hereford and Worcester combined fire authority. All fire extinguishers and fire blankets must be serviced annually (some not serviced on last visit) and visually checked monthly. 31/07/06 28. OP38 23 (4) 07/07/06 29. OP38 23 (4) The fire alarm must be tested 27/06/06 weekly and in sequential order to ensure all break glass points are checked. The zones currently in place and appearing upon the fire panel must be reviewed. Appropriate action must be taken in the event of high hot water temperatures becoming apparent. Action taken must be recorded. Suitable procedures must be in place to ensure that all portable electrical items are safe. A competent person must carry out this assessment of safety. Risk assessment must be in place regarding outings involving residents. Suitable documentation demonstrating the safety of the mini bus must be in place and carried out before each use involving residents. Suitable risk assessments must be in place regarding the safe and correct use of wheelchairs. 31/07/06 30. OP38 23 (4) 31. OP38 13 27/06/06 32. OP38 13 31/07/06 33. OP38 13 (4) 27/06/06 34. OP38 13 27/06/06 South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 33 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP10 Good Practice Recommendations The reduction in the numbers of double rooms should be considered to ensure residents privacy and dignity is maintained. The use of the bedrooms, which fall below 10 sq. metres, should be reviewed. 2. OP23 South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI South Hayes Care Home DS0000004144.V297706.R01.S.doc Version 5.2 Page 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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