Inspection on 04/04/07 for South Hayes Care Home

This inspection was carried out on 4th April 2007.

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 20/06/06

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 4th April 2007 11:15 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.V334940.R02.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.V334940.R02.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 F/P 01905 357429 Regal Care (Worcester) Limited Lynette Rose Thomas 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.V334940.R02.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. 20th June 2006 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 older people, 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. Residents bedrooms are located on the ground, first and second floors of the home. A passenger lift is in place to afford access to all areas of the home. Regal care (Worcester Ltd) have owned the home since 1998. Since the last inspection the commission has approved the application made by the manager designate to become the registered manager. The commission received a pre-inspection questionnaire completed by the registered manager during November 2006, which included some information regarding the fees at South Hayes. Fee levels were discussed with the registered manager as part of this inspection when they were reported to be currently £353.00 to £500.00 per week. Fees do not include items such as hairdressing, newspapers and chiropody (private). South Hayes Care Home DS0000004144.V334940.R02.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. As part of the overall inspection of the service offered at South Hayes two visits to the home were undertaken both of which were unannounced. The last visit to the home was in June 2006 This inspection takes into account information received by the CSCI since the previous inspection as well as the visits to the home. A pre inspection questionnaire was posted to the manager a number of months prior to this inspection requesting certain information. The completed preinspection questionnaire was used during this visit. Comments from residents included within questionnaire sent to the home at the same time as the preinspection questionnaire are included within this report. In addition to the manager discussions took place with a number of carers and residents. 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. At the time of this inspection the home accommodated 26 residents. What the service does well: A representative of the home carries out an assessment of an individuals care needs before offering a place within the home to ensure that needs can be met. Residents are initially admitted into the home on a trial basis. Care plans have improved in some areas however they continue to fail to ensure that carers have sufficient and up to date information in order to carry out their duties. The management of medication continues to have shortfalls some of which were similar to the previous inspection. An immediate requirement notice was issued. An activities organiser is employed and a range of events have taken place with others planned in the future. Residents consulted were complementary regarding the food provided. South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 6 The commission received the following comment upon a questionnaire completed by a resident’s representative. ‘Always very friendly – nice atmosphere they are happy for me to visit in ** bedroom.’ What has improved since the last inspection? What they could do better: The service users guide available to residents and their representatives needs to be reviewed as it contains some incorrect information. Insufficient staffing levels were identified which could potentially place residents at risk and could result in a failure to meet care needs. An immediate requirement notice was issued. Recruitment procedures were found to be weak and placed residents at potential risk of harm. An immediate requirement notice was issued. South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 7 Improvements in the training provided for staff needs to continue and needs to include good practice matters as well as mandatory subjects. The practice carried out following an allegation of potential abuse needs to improve. It was evident that Worcestershire guidelines regarding the protection of vulnerable people were not implemented leaving residents at potential risk. The home has no deputy manager resulting in the registered manager having to be on call each evening. A director of the company regularly visits the home and prepares a written report upon his findings. Despite visits by the director other quality assurance and service development systems are weak and in need of improvement. The availability of lockable facilities for residents to keep valuables safe needs improvement. Staff training and supervision are in need of improvement to safe guard residents and ensure that care needs can be met. Some shortfalls identified as part of the previous inspection remain to be a concern. Fire safety concerns noted in June 2006 were not fully implemented by the time of this visit. In addition concerns about the recording and subsequent action regarding water supply remain. Documentation regarding hoisting equipment was insufficient. 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. The summary of this inspection report can be made available in other formats on request. South Hayes Care Home DS0000004144.V334940.R02.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.V334940.R02.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. 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. Information available to prospective residents and their representatives is incorrect in places therefore fails to assist individuals choose whether the home will meet their care needs. Residents have their needs assessed but staff training regarding the conditions of old age is lacking. EVIDENCE: A copy of the homes statement of purpose and service users guide was obtained and briefly viewed following the conclusion of the visits to the home. A copy of the service users guide was available in the entrance lobby where visitors sign themselves into the home and another was in a document holder near to the front door. South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 10 The service users guide is an important document as it may form part of the decision making process about the suitability of the home by a potential resident and / or their representative. Therefore it is vital that it contains full and accurate information regarding the service available. On a brief viewing of the service users guide a number of statements within it did not match up with the findings obtained during the visits to the home. No contracts were viewed as part of this inspection; it was however noted that letters were due to be circulated to residents representatives notifying them of a change in fees. The file of a recently admitted resident was viewed. Although the resident had formally lived a long way away the registered manager had made efforts to obtain pre admission information. Information was available to enable staff draw up an initial care plan. The unexpected arrival of a new resident was well handled by the registered manager who arranged for the necessary documents to be obtained without delay. Sufficient evidence was gained throughout the inspection that residents are initially admitted to South Hayes on a four-week assessment period. 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. It was evident that a number of residents do however have some degree of memory loss. It is vital that staff collectively and individually have the skills to meet the needs of residents. Some staff have received training regarding peg feeding however other training regarding good practice matters was limited and needs to be improved. South Hayes does not offer intermediate care therefore standard 6 is not applicable. South Hayes Care Home DS0000004144.V334940.R02.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. 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. Care plans do not fully demonstrate that the health and personal care needs of residents are met and fail to provide carers with sufficient information both of which have the potential of placing individuals at risk. Shortfalls in the management and administration of medication are a course for concern and present further risks to residents. EVIDENCE: Individual care plans are in place for each resident. A representative sample of care plans were viewed and assessed during the inspection. Although care plans have improved the registered manager is aware that they are in need of further improvement in order to fully meet the regulations. The registered manager and some staff consulted stated that senior cares are now South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 12 playing an active role in care planning and that other staff will also be taking on this role in the future. 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 to support individual residents needs therefore it is vital that important information is captured, this was not always taking place despite the monthly updates. Care plans did not cover all potential areas of need as listed under standard 3.3 of the National Minimum Standards although information regarding oral care was now in place. Risk assessments including nutritional screening have improved since the last inspection. On discussing the care provision within the home and establishing potential care needs with residents it became evident that some areas described by residents were not included within the care plans. The previous inspection highlighted a bedrail in use without buffers as the resident concerned wished to use the bars to pull him/herself up. It was noted that the use of bedrails without such buffers could be potentially hazardous. The above practice was still happening and the risk assessment and other documents continued to be insufficient to demonstrate that all parties are aware of the risk and evidence that alternatives are sought in consultation with other professionals. 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 although this was not always the case. Following the previous inspection an immediate requirement notice was issued in relation to the management of medication. As a result of the above serious concern and due to the management of medication forming part of the key standards the storage and recording of medication was assessed as part of this inspection. Although many of the current months Medication Administration Record (MAR) sheets were satisfactorily completed a number of concerns were noted on some of the sheets. A 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. This was one of the shortfalls identified as part of the previous inspection and therefore a serious concern that the shortfall remains. One MAR sheet contained 16 signatures for a course of 15 antibiotics, a similar error was also noted on the previous inspection. Despite highlighting the concern as part of the previous inspection staff continue to not record the date when medication not included within the South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 13 monitored dosage system is opened. As stated within the previous report failing to record the date of opening makes a full drug audit difficult. It was noted that separate sheets to record the application of creams and ointments were kept within individual bedrooms. Suitable facilities for the storage of controlled medication are in place. A small number of items were check against the entries within the controlled drugs register and found to balance and be in order. A copy of the guidance issued by the Royal Pharmaceutical Society of Great Britain was available to staff within the office. The homes medication policy was not viewed as part of this inspection. The previous inspection report concluded that the medication policy needed to be more detailed; this policy will be assessed as part of a future inspection. The homely remedy policy was discussed as it contained medication which can not be administered by non nursing staff and therefore needs to be reviewed. As a result of the above concerns and following a management review at the commission a letter including an immediate requirement to improve the management of medication was posted to the registered owner. The registered owner was informed within the letter that failure to fully comply with the given regulation might result in the commission considering enforcement action. The inspector observed staff communicating well with a resident while using a hoist. Staff showed due respect for the up holding of the individual resident’s dignity. Residents seen looked well cared for and were suitably attired taking into account gender issues and weather conditions. Carers consulted were able to give a reasonably good verbal account of the care needs of two residents who were case tracked. South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 14 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. 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. Residents are able to participate in social activities and keep in contact with family and friends. 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. An activities organiser is employed 3 days per week totalling 15 hours. Information on display showed a recent trip to view daffodils as well as planed events including a coffee morning, a visiting singer / guitarist, summer fair and a boat trip. An Easter raffle was in place as part of the homes fund raising activities. A chalkboard detailed the days lunch and tea on both visits. The main mid day meal on the first day of this inspection consisted of soup, braising steak with South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 15 mushrooms, potatoes and spring greens or chicken drumsticks followed by bread and butter pudding and custard. On a comment card received by the commission completed by a resident the following statement was made: ‘Meals can not be faulted the food is excellent and alternatives are always offered.’ Residents consulted during this inspection spoke favourably about the food provided. It was reported that some new menus were about to be implemented following consultation with residents. It was noted that squash was poured out prior to residents going into the dining area for lunch. Although this may demonstrate staff having knowledge of residents likes and dislikes it does remove the opportunity to make a choice between the alternatives available. The previous report stated that the owner intended to provide facilities including a greenhouse for residents who expressed an interest in gardening. In was stated that a facility was in place and in use. South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. A complaints procedure is available to residents and residents know who to complain to. Practice following allegations of abuse need to be more robust in order to safeguard residents. EVIDENCE: The homes complaints procedure was available within the entrance lobby and in a documents holder in the entrance hall near to the front door. It was noted that the procedure made reference to the Worcester office of the commission. The displaying of this information could be made more prominent within the home. The complaints log was not viewed during this inspection however the registered manager stated that the home had not received any complaints since the previous inspection. The commission have received no complaints about the service offered at South Hayes since the last inspection. A small number of residents consulted during this inspection stated that they would see the manager if they were unhappy about any aspect of the care they receive. Staff stated that they would refer any complaints to the manager. South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 17 It was of concern to note that a delay in taking the required action to inform authorities such as the local protection of vulnerable coordinator and the commission recently took place. The notification once sent did not give suitable details to alert the commission of the potential seriousness of the incident. Although it was reported that an individual did not want to make a complaint it was however necessary to safeguard other residents by taking appropriate action. A more recent incident was reported to the police as necessary and to the commission as part of this inspection. It is imperative that the commission are informed without delay of any further incidents within the home. A number of staff consulted were able to give a satisfactory response when asked about the actions they would take if they witnessed physical abuse occurring within the home. A poster highlighting that adult abuse is everybody’s business published by Worcestershire Vulnerable Adults Protection Committee was displayed within the home. The training records evidenced that some staff undertook training entitled challenging behaviour towards the end of 2006. It was stated that the challenging behaviour training included elements upon the protection of vulnerable adults, other staff received training during 2005. It is important that staff receive training, which leads to consistency in knowledge and practice within the home. South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Improvements to the standard of the environment have continued in order to provide residents with a more comfortable place to reside where care needs can be met. Further refurbishment is needed to provide a more comfortable and safe environment. EVIDENCE: The décor in communal areas was generally in good order. Some corridors showed signs of damage to wallpaper and paintwork properly caused by wheelchairs. Although seating within the main lounge was traditionally arranged (seats around the wall) the room was homely in appearance and comfortable. A number of residents had left items such as open books or knitting on their chairs while in the dining room having lunch. South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 19 A number of freestanding wardrobes were checked and were secured to the wall to prevent accidental toppling. Recent improvements have included the refurbishment of bathrooms on the ground and first floor; the bathroom on the second floor is currently not fit for purpose and is in need of refurbishment. Residents consulted stated that they were satisfied with their bedrooms. Containers of antibacterial hand rub were located around the home for use by staff and visitors. Paper towels and liquid soap were in place within toilets and the laundry in line with infection control procedures. Residents consulted confirmed that the home is kept clean. South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is poor 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 had a number of short falls, which could potentially place residents at risk. EVIDENCE: At the time of the inspection the home had a number of staff vacancies totally 90 hours per week. The rota and discussions with staff evidenced that four carers were on duty during the morning and three during the afternoon. Due to the timing of shifts a period between 2.00pm and 4.00pm left the home with two carers on duty. The level of staff on duty was assessed to be insufficient to meet the care needs of residents and potentially left residents at risk of not having care needs addressed appropriately. Following both this inspection and an internal management review meeting at the commission a letter of serious concern including an immediate requirement to ensure suitable and sufficient staff are on duty was sent to the registered provider. South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 21 Additional staff are employed to carry out catering and domestic tasks. However as these persons are only employed during the morning / early afternoon it is necessary for carers to carry out these roles during the late afternoon / evening in addition to care duties. No domestic or laundry staff are employed over the weekend, therefore relying on carers. The rota highlights staff who have completed either a level 2 or a level 3 NVQ (National Vocational Qualification). The registered manager confirmed the number of staff who hold these qualifications as 3 persons with a level 2 and 5 with a level 3. As South Hayes currently employees 15 carers these figures equate to just over 50 of carers, which is the required level. It is anticipated that the number of qualified carers will increase as other staff are currently awaiting their certificates while others are undertaking either level 2 or level 3 training. The files of two recently appointed members of staff were viewed both of these files contained some of the necessary documents such as an Enhanced CRB (Criminal Records Bureau) disclosure. However a number of serious shortfalls in the recruitment process were noted which could of placed residents at serious risk. Following a management review at the local office of the commission a letter highlighting the particular concerns was issued to the registered provider requiring significant improvement. The recruitment of staff will form part of forthcoming inspections to South Hayes; failure to fully comply with the associated regulation may result in the commission considering enforcement action. Training records were viewed including a matrix of training undertaken during 2006. The majority of staff have undertaken mandatory training such as moving and handling and fire awareness however some gaps were noted which need to be addressed to safeguard both residents and staff. Infection control training was due to take place later during the month of this inspection. Other training identified as needed include areas around sexuality and older people. Some training certificates were on display however these dated back to 2005 and were therefore generally out of date. South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36, 37 and 38 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. A suitably qualified person manages the home, however a number of management and administration matters are in need of attention. Quality assurance systems are insufficient to support a well run home. A number of health and safety matters are in need of urgent attention in order to safeguard the welfare of residents and others within the home. EVIDENCE: Since the last inspection at South Hayes the manager designate has become the registered manager following the approval of her application by the commission. South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 23 The registered manager is a nurse holding a RGN (Registered General Nurse) and RMN (Registered Mental Nurse) qualification. In addition the registered manager also holds the Registered Managers Award. The home does not have a deputy or a senior staff structure resulting in the registered manager needing to be on call each evening. A certificate showing details of the homes public liability insurance was displayed as required. Page one of the certificate of registration was on display; page two which shows details of the current condition in registration was not displayed. A director of the company undertakes regular visits to the home and prepares written reports as required under Regulation 26. These reports are held at the home and copies are provided to the commission. A document was available reporting upon improvements that have taken place but this was not suitable to be called a development plan. The previous inspection report stated that a survey seeking residents comments had taken place. The results of this survey were not collated. The registered manager indicated that another survey is due to take place; this should seek the views of residents, their representatives and other interested parties. Following any future surveys it is imperative to collate the results and demonstrate that suitable action is taken on any shortfalls identified. The results need to be made available to residents, potential residents and others such as the commission in order to evidence that the views of these persons are valued and taken into account. It was confirmed that the home does not 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. Safes or facilities for the safe keeping of valuables need to be available in every bedroom. The home invoices residents or their representatives for expenditure such as hairdressing. Formal supervision is not taking place in line with the national minimum standard, however appraisals are reported to of happened. The frequency of formal supervision is therefore in need of improvement; the registered manager is aware of this and intends to address this shortfall. As reported elsewhere within this report it continues to be evident that some records are not sufficiently up to date in order to ensure effective and efficient running of the home. South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 24 The previous inspection report noted a number of shortfalls in relation to fire safety. Since the last inspection fire safety legislation has changed and a review of the fire risk assessment has taken place. The risk assessment, which an external consultant completed, highlighted a number of improvements that were needed, including the lack of smoke seals or intumescent seals around doors (this shortfall was mentioned within the last report and therefore did not receive suitable action at that point). It was noted that the records regarding the number of fire extinguishers within the home did not tally (this shortfall was identified as part of the previous inspection). The records regarding the testing of emergency lighting within the home were not in line with the former guidance issued by Hereford and Worcester Fire Authority. The previous report stated: ’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.’ The situation described above remains to be the case. An emergency plan and a plan of the building describing the fire zones was on display. The previous inspection reported stated that: ‘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 records regarding water temperature were viewed as part of this inspection and brought about some concerns. As the previous report highlighted concerns it was anticipated that the record of action taken following any problems or shortfalls would of improved. This expectation was not founded in that the records showed continuing problems and the action recorded as needed had not taken place. One bedroom has water delivered at 34 °C, the record dated 04/04/07 states ‘ adjust or replace regulator’ – the same or similar comment was made on previous months dating back to September 2006 (total of 8 months). A shower was reported as having a temperature of 30 °C for a period of 5 months. A notebook was in place within bathrooms for staff to record bath temperatures however these records were either poorly maintained or evidenced that baths take place infrequently. The vast majority of radiators are covered to prevent the risk of scalding. Two uncovered radiators were noted during this inspection. Suitable risk South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 25 assessments and appropriate action needs to be undertaken regarding both the identified radiators and any other uncovered radiators within the building. Under health and safety legislation all hoisting equipment has to be tested on a 6 monthly basis. Records seen were dated 28/08/06 therefore a retest should of happened at the end of February 2007, at the time of this report this retesting was outstanding. A number of potential shortfalls were recorded regarding some lifting equipment on the documents dated August 2006; records to evidence that suitable action had taken place were not available. The registered manager was well aware of the need to ensure that window restrictors are in place to prevent either accidental or deliberate falling to the ground. It was reported that a monthly check of restrictors was introduced however the records to evidence this were not available on request. It is important that the suitability of window restraints forms part of regular risk assessments to ensure the health, safety and welfare of residents. Wheelchairs seen around the home both in use and stowed had footrests in place as required. 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 a local beauty spots or garden centres. Since the last inspection risk assessments have commenced before the 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. Although the documents seen were an improvement further information such as staffing details is needed. South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 26 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 2 X 3 2 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 2 2 South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 27 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 OP1 Regulation 5 Requirement The service users guide must provide potential residents with the information enabling them to make a choice about the homes suitability to meet care needs. Care plans must contain sufficient information to enable care staff to carry out all aspects of care. Previous timescale of 27/06/06 not met. Revised timescale given. 3 OP7 15 Care plans must be reviewed and 14/05/07 up dated at least monthly or more frequently as necessary to ensure changing needs are reflected. Previous timescale of 27/06/06 not met. Revised timescale given. Timescale for action 30/06/07 2 OP7 15 21/05/07 South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 28 4 OP8 12 (1) Risk assessments and suitable care plans must be in place regarding moving and handling, falls, use of bedrails and pressure care. Previous timescale of 27/06/06 not met. Revised timescale given. 21/05/07 5 OP9 13 (2) Medication Administration Record 06/04/07 (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. Previous timescale of 20/06/06 not met. This requirement must be met. 6 OP19 23 (2) All areas of the home must be well maintained. A revised and extended timescale is given. 31/08/07 7 OP25 13 (4) Any remaining uncovered radiators must be suitably covered to prevent accidental scalding. Previous timescale of 31/07/06 not met. Revised timescale given. 31/05/07 8 OP27 18 Sufficient staff must be on duty throughout the day to meet the care needs of residents. 06/04/07 South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 29 Previous timescale of 27/06/06 not met. This requirement must be met. 9 OP29 19 Staff recruitment must be robust to safeguard residents from potential harm. 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. This requirement will be assessed as part of a forthcoming inspection visit. 11 OP33 24 A quality assurance program 30/06/07 must be developed in accordance with Regulation 24 and Standard 33. Previous extended timescale of 31/08/06 not met. Revised timescale given. 12 OP38 23 (4) The fire risk assessment must be reviewed and action taken recorded. Previous timescale of 31/07/06 not met. Revised timescale given. 13 OP38 13 Appropriate action must be taken in the event of high hot water temperatures becoming apparent. Action taken must be recorded. Previous timescale of 27/06/06 not met. Revised timescale given. South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 30 06/04/07 10 OP30 12 18 31/05/07 31/05/07 07/05/07 14 OP38 13 (4) 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. Previous timescale of 27/06/06 part met. Revised timescale given. 21/05/07 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. This recommendation is on going until the number of registered places is fully resolved. 2. OP23 The use of the bedrooms, which fall below 10 sq. metres, should be reviewed. This recommendation is on going until the number of registered places is fully resolved. South Hayes Care Home DS0000004144.V334940.R02.S.doc Version 5.2 Page 31 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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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