Inspection on 12/12/06 for Spring Bank

This inspection was carried out on 12th December 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

Spring Bank 13/11/08

Spring Bank 21/05/08

Spring Bank 27/11/07

Spring Bank 04/06/07

Spring Bank 16/05/06

Spring Bank 11/10/05

Spring Bank 17/05/05

Spring Bank 07/09/04

Spring Bank 05/05/04

Spring Bank 14/01/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Spring Bank Howden Road Silsden Keighley West Yorkshire BD20 0JB Lead Inspector Mary Bentley Key Unannounced Inspection 12th & 13th December 2006 09:30 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 DS0000019888.V314213.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. DS0000019888.V314213.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spring Bank Address Howden Road Silsden Keighley West Yorkshire BD20 0JB 01535 656287 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) Mrs Diane Hudson Mrs Diane Hudson Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places DS0000019888.V314213.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 2006 Brief Description of the Service: Spring Bank is a converted extended property situated in a residential area above Silsden, close to local bus routes and within easy reach of the railway station and the main road to Bradford and Skipton. The home is registered to care for thirty-three residents who require personal and nursing care. Accommodation is provided in a combination of single and double rooms. The single rooms with en-suite facilities are in the newer part of the home, shared rooms are in the older part of the building. Residents have a choice of two lounges, and there is also a dining room. Original features such as oak panelling have been retained where possible. The home is situated in extensive and attractive gardens to which there is level access from the home. There is a car park at the side of the building. The weekly fees range from £495.00 to £515.00. Hairdressing and chiropody are available at an additional cost. DS0000019888.V314213.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 we made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate”, and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk The last inspection was in May 2006 and 35 requirements were made. Since then there have been three additional visits to the home. In July 2006 enforcement notices were served about the Statement of Purpose, Service User guide, residents’ contracts and CRB (Criminal Records Bureau) checks for staff. In July 2006 we met with the provider and discussed her plans for making improvements and achieving compliance with the Care Homes Regulations and National Minimum Standards. This unannounced inspection was carried out over two days by two inspectors and in total we spent 28.5 hours in the home. The purpose of this visit was to check on progress with meeting the requirements from the last inspection and to assess how the needs of people living in the home are being met. There are 34 requirements from this inspection, 22 of which are unmet requirements carried forward from previous inspections. During the inspection we looked at care records and other records such as staff files, training and maintenance records. We looked at all parts of the home, observed care practices and talked to residents, staff, and management. A pre-inspection questionnaire was completed by the home and this information was used during the inspection. At the end of the inspection we discussed our findings with the owner and the acting manager. Before the visit we sent comment cards to some residents, relatives, and other professionals, and we contacted some relatives by phone. Comment cards give people the opportunity to tell us what they think about the service. We share the information we get with the home but we do not identify where it has come from. We received nine comment cards and the information is included in this report. DS0000019888.V314213.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Earlier this year the owner stepped down as registered manager and appointed an acting manager who has made improvements. Some of the requirements following the last inspection have been fully dealt with. Others are being addressed although in many cases there has not been enough progress for us to judge that the home has reached compliance. A Statement of Purpose and Service User guide have been produced. This means that people who are using the service, or thinking about using it, can get clear written information about the range of services being offered. Contracts of residency have been drawn up and the home is in the process of making sure that every resident has a contract. Safer systems for dealing with oxygen have been put in place. There has been an improvement in the way complaints are dealt with and records of complaints are now available. Information about how to complain is included in the Statement of Purpose and Service User guide. Some new bedroom furniture has been provided, with a lockable drawer. Some improvements have been made to the laundry. The systems for dealing with residents’ money have been improved so that a clear audit trail is provided. Some staff training has taken place and further training is scheduled, this will help staff to get the knowledge and skills they need to meet residents’ needs. DS0000019888.V314213.R01.S.doc Version 5.2 Page 7 What they could do better: The pre-admission assessment procedures must be improved so that prospective residents can be assured the home is suitable to meet their needs. In order to make sure that they can meet residents’ needs the home must not accept residents with needs that are outside of the registration category. Care planning must be improved so that residents’ needs are met in a consistent way and every resident must have a care plan. Residents and/or their representatives must be given the opportunity to take part in care planning so that the way care is delivered takes accounts of residents’ wishes. Improvements are needed to the systems for dealing with medicines, particularly with regard to the practice of giving medicines in a covert way. More attention must be given to social care so that all residents are given the opportunity to take part in social and leisure activities that reflect their needs, preferences, and abilities. The menus must provide more detailed information about the meals available so that residents can make an informed choice. To protect residents all staff, particularly those in charge, must be aware of what to do if suspicions or allegations of abuse are reported. Improvements are needed to some parts of the home for the benefit of residents. Door locks must be provided and every bedroom must have a lockable drawer where residents can keep valuables or money. There must be enough equipment provided, such as hoists and wheelchairs, so that residents can be helped to move safely and without having to wait an unreasonably long time. The dining room can only accommodate about half of the residents at any one time and the home must look at how mealtimes are managed so that all residents have the opportunity to eat in the dining room if they choose to. The home must provide proper facilities to reduce the risk of cross infection and must make sure that staff work in accordance with control of infection procedures. There must be enough staff available at all times to meet residents needs in a timely way and in a way that respects their dignity. To make sure that residents are protected the home must improve the procedures for employing new staff. New staff must not be allowed to start work until all the required checks have been completed satisfactorily. DS0000019888.V314213.R01.S.doc Version 5.2 Page 8 To make sure that staff have the knowledge and skills to meet residents’ needs the home must continue with the work that has been started on providing training for all staff. The home must continue to develop systems for monitoring the quality of the services provided. Opportunities must be provided for residents and/or their representatives to share their views of the service and contribute to the development of the service. 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. DS0000019888.V314213.R01.S.doc Version 5.2 Page 9 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 DS0000019888.V314213.R01.S.doc Version 5.2 Page 10 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): 1, 2 & 3. Standard 6 does not apply to this service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There has been some improvement in this area. Written information about the range of services is now available although some more work needs to be done to make sure that the documents cover all the required areas. The pre-admission assessment process is not detailed enough to make sure that prospective residents can be assured the home will be able to meet their needs. EVIDENCE: The Statement of Purpose and Service User guide have been reviewed. Both documents are well laid out and information is presented clearly. The Statement of Purpose includes information on local advocacy services. There DS0000019888.V314213.R01.S.doc Version 5.2 Page 11 is no information on room sizes and no information on how to get copies of inspection reports in the home. The acting manager said copies of the Statement of Purpose are available in the home and staff have been made aware of the contents. She said residents had been consulted about the Service User guide and when it is completed copies will be available in all bedrooms. There were contracts of residency in most of the files seen although some had not been signed. The acting manager said she was meeting with residents and/or their representatives to discuss the contracts and get them signed. Four residents said they had received sufficient information before admission and had received contracts. Pre-admission assessments had been done however they were not very detailed. It was not clear from the pre-admission assessments how the home had decided they could meet the needs of prospective residents. For example a resident had recently been admitted although the pre-admission information suggested there was a history of confusion. There was no evidence that the home had tried to get more information about this despite the fact that the home is not registered to provide care for people with dementia. The registration certificate was displayed so that only one page could be seen, both pages must be displayed. DS0000019888.V314213.R01.S.doc Version 5.2 Page 12 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): 7, 8, 9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The standard of care planning is poor. Staff are not given the information they need to make sure that care is delivered in a planned and consistent way and residents and their representatives are not given the opportunity to have a say in how their care needs will be met. To make sure that residents are protected some of the practices relating to the management of medicines need to be improved. The privacy and dignity of residents is compromised by some working practices. EVIDENCE: There were no care plans for a resident who had been living in the home for two weeks. The pre-admission assessment showed a history of confusion, a DS0000019888.V314213.R01.S.doc Version 5.2 Page 13 history of falls and that the person had a pressure sore. The only information available was a partially completed admission assessment. In the absence of care plans and risk assessments it is not clear how the resident’s care needs were being met. This indicates that the management and nursing staff do not understand that care planning is an integral part of the delivery of care. It suggests care planning is seen as a paper exercise and calls into question the value of other care plans. We looked at the care records of another four residents. There was no evidence that residents or their representatives had been involved in care planning. There were care plans in place covering aspects of health, personal and social care. Most care plans had been reviewed monthly up to October 2006. There was conflicting information in some care plans, for example a care plan about safety said the resident should be helped to change position every two hours and the same resident’s care plan for mobility said this should be done hourly. In one resident’s records there was an entry in October 06 about weight gain and in November 06 about weight loss. However the records showed the resident had only been weighed once, in September 06. It was not clear how nursing staff had reached their conclusions about weight gain and loss; there was no information available on alternatives ways in which weight loss or gain could be measured. The wound care plans did have some description of the wounds, but there were no measurements or grading. Without this information it is difficult to assess whether a wound is improving or deteriorating. The treatment plan did not make it clear how often the wounds should be redressed. The dressing that was being used was not on the resident’s medication chart. There was an entry about making a referral to the Tissue Viability nurse in early November 06 but there was no evidence that this had been followed up. A consultant from the local hospital had visited to assess one of the resident’s wounds. There was detailed information in some care plans, for example one resident’s care plan about communication provided staff with clear instructions. However this was the case in all the plans, for example a care plan said a resident had a short concentration span but did not give any information for staff on how to deal with this when trying to engage the resident in recreational activity. DS0000019888.V314213.R01.S.doc Version 5.2 Page 14 Another care plan said the resident would need “extra assistance” with personal care because of a broken arm but did not give any detail on what this would be. The resident had fallen on more than one occasion but there was no falls risk assessment. One resident, an insulin dependant diabetic, did not have a care plan for the management of diabetes or for eating and drinking. Another resident’s records showed that they were having some difficulty taking tablets and suggested that the medicines should be requested in liquid form. It was not clear if this had been followed up. The nurse in charge said it was not necessary, as the resident would take medication if told it was a “sweetie”. This is a form a covert medication and should only be done in exceptional circumstances and following consultation. Residents confirmed that they have eye tests, regular chiropody and that a physiotherapist visits the home, we saw evidence of this in the records. The home has had some problems with the supplying pharmacy due to a change of ownership; they are trying to resolve these. The prescriptions are sent directly from the doctors’ surgeries to the pharmacy, they should be returned to the home to be checked before they are sent to the pharmacy. It is the home’s responsibility to sign the prescription exemption declaration on behalf of residents who are unable to do so. The systems for recording the receipt and disposal of medicines were generally satisfactory but for anyone not familiar with the system it was difficult to establish a clear audit trail. Some recommendations were made about how this could be improved. A random selection of controlled drugs was checked and was correct. The drugs fridge was locked, the temperature was recorded but only monthly, this should be done daily. Some medical supplies were stored in an unlocked cupboard in a resident’s bedroom; this is not acceptable. The dignity of some residents was compromised by comments made by staff in the dining room when they were helping residents to the tables; we shared this information with the acting manager. DS0000019888.V314213.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home offers a reasonable range of activities. However, more attention needs to be given to making sure that the social and recreational needs of less able residents are met. Residents are supported in keeping in touch with their families and friends and visitors are welcomed. The food is traditional and residents enjoy it, particularly the home baking. The menus must provide more detailed information so that residents can make an informed choice about what they want to eat. EVIDENCE: A weekly activities programme is now available. Activities include bingo, quizzes, chair exercises, musical entertainment and sing-a-longs. DS0000019888.V314213.R01.S.doc Version 5.2 Page 16 Some residents’ records had detailed information on the activities they had taken part in. One resident’s file had a detailed personal profile and the staff are trying to introduce these for all residents. Some residents prefer to spend time in their own rooms and are supported in doing this. During our visit there was a communion service one day and a clothing sale the next day. Several residents had enjoyed buying new clothes for Christmas. There are very few opportunities for residents with dementia to take part in meaningful activities; they spend most of their time in the small lounge where the radio is usually on. Preferred times for going to bed and getting up were recorded in one resident’s care plan. Visitors said they are always welcome and offered refreshments. They can visit in private. Information on visiting is included in the Statement of Purpose. The acting manager gave an example of where an advocacy service had been contacted to support a resident. The menus do not have enough detail, for example the lunch menu states roast beef, but there is no information on what vegetables will be served. The alternative lunch menu is on a separate sheet and therefore not easily accessible to residents. The teatime menu refers to “various sandwiches” and there is no information on what is available for breakfast and supper. The cook knows what residents like but this information is not recorded anywhere. She said the winter menu had started in October and residents had been consulted about this. She said residents had been consulted about the Christmas menu and there would be a choice of turkey or beef. The cook was aware of special dietary needs for example one resident that had been identified as needing additional nutrition. She said residents could have toast, sandwiches or home baked cakes for supper. There were food supplements such as Fortifjuice in the kitchen store; these were not named for individual residents. Food supplements are usually given to residents at breakfast time by the catering staff. Residents said they enjoyed the food and there is always lots of home baking. We observed the lunchtime meal being served on the second day of the inspection. There were 5 residents in the dining room at 12.30pm. Staff helped other residents to get to the table but this took a long time, a lot of DS0000019888.V314213.R01.S.doc Version 5.2 Page 17 residents needed the hoist to make sure they were transferred safely and there seemed to be a shortage of wheelchairs. It was 1.15pm before any food was served. The meal was well presented and looked appetising, residents enjoyed it. Residents were offered a drink with their meal but there were no condiments on the tables. Staff sat at the table to help residents with their food, however a lot of people needed help and some staff were helping more than one person at a time. Some residents had their meals in their rooms. The residents in the small lounge had their meals served there. DS0000019888.V314213.R01.S.doc Version 5.2 Page 18 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): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There has been an improvement in the way the home deals with complaints and most people are aware of how to raise concerns. There are policies and procedures to make sure that residents are protected. However, for these procedures to be effective staff that are left in charge of the home must be familiar with them. EVIDENCE: Information about the complaints’ procedure is included in the Statement of Purpose and Service User guide. Residents said they knew who to talk to if they had any concerns. Two of the four relatives who completed comment cards said they were aware of the complaints’ procedure. The home has received 3 complaints since the last inspection. These were dealt with appropriately and details of the complaint, the action taken, and the outcome were recorded. The nurse in charge was aware of how to deal with complaints. Some staff have had training on Adult Protection and further training is planned. However the nurse in charge was not aware of the correct procedure DS0000019888.V314213.R01.S.doc Version 5.2 Page 19 for responding to allegations or suspicions of abuse despite the fact that she had attended training. The home has a copy of the local authority Adult Protection procedures but the nurse in charge was not familiar with this document. DS0000019888.V314213.R01.S.doc Version 5.2 Page 20 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): 19, 20, 21, 22, 24, 25 & 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is clean and comfortable and generally the standard of décor is satisfactory. However, many aspects of the environment do not enhance residents’ quality of life and some potentially place residents at risk. Specific areas of concern are that the bedrooms and many of the communal toilets do not have door locks, there is not enough moving and handling equipment, and there is no mechanical sluice. EVIDENCE: The home was clean and tidy. DS0000019888.V314213.R01.S.doc Version 5.2 Page 21 The home has two lounges and a dining room on the ground floor. The dining room is relatively small, there are 16 places, and the home can accommodate up to 33 people. Therefore it is not be possible for all the residents to eat in the dining room at the same time. It is quite difficult to manoeuvre the hoist in the dining room and where people sit is determined by access to the table for the hoist or wheelchairs rather than by residents’ choice. The dining room carpet needs to be cleaned thoroughly or replaced. The small lounge is where the more vulnerable residents spend most of their time during the day. The windows in this lounge are low and are not protected in any way to reduce the risk of people injuring themselves should they fall in the direction of the window. The home has only one hoist, this means that residents often have to wait for help. Staff said they had been asking for a new hoist for some time, the owner said she was aware a new hoist was needed but was unable to say when one would be available. There were no records available to show when the hoist had been serviced. Staff said it did not always work properly, the owner said she was aware of this. Staff said there was a shortage of wheelchairs on the ground floor but there were a number of wheelchairs stored in one of the first floor bathrooms. There are no locks on bedrooms doors and several of the toilets and bathrooms do not have door locks. This compromises residents’ privacy. Some new furniture has been provided and the new bedside lockers have a lockable drawer. However the majority of rooms do not have a lockable space where residents can store money or valuables. Some rooms did not have call bell leads so residents would not be able to summon help. The acting manager said that call bell leads were not available in some rooms because there was a risk that residents could injure themselves. She said this was recorded in the care records but we did not see any evidence of this. Some rooms did not have any bedside lights and others had wall lights over the bed. However residents lying in bed are unlikely to be able to reach the switch. Ceiling tracking for screens has not been removed from rooms where it is no longer in use. Portable screens were available in shared rooms. Overall the condition of the bedding was satisfactory; there were some lumpy pillows, which should be replaced. DS0000019888.V314213.R01.S.doc Version 5.2 Page 22 One of the bathrooms on the first floor was being used for storage, this is not appropriate, and it should be available for use. There were plenty of gloves and aprons and hand washing facilities for staff have been provided in most areas although there are none in the sluice room. One of the clinical waste bins was not a pedal bin; pedal bins reduce the risk of cross infection. There was evidence that incontinence pads had not been double bagged, thereby increasing the risk of cross infection, and creating an unpleasant odour. There were bars of soap in shared bathrooms and disposable razors that had not been thrown out after use. The use of communal soap and razors is unhygienic and creates a risk of cross infection. These issues are of particular concern because in November 2005 we served an enforcement notice in relation to control of infection practices. There is no mechanical sluice and the owner was unable to say for certain when one would be provided. The home continues to store food, cleaning materials and chemicals together in the storeroom in the basement despite the fact that this has been raised in previous inspections. The laundry floor has been painted and the laundry was clean and tidy. Some hazardous chemicals were stored in unlocked cupboards in communal bathrooms. Some cleaning materials had been decanted into containers that were not suitably labelled. The owner said a new boiler had been installed. The water temperatures are checked regularly but the records show that temperatures are consistently below the recommended level (43 degrees C, plus or minus 2) and there was no evidence that any action had been taken to address this. A fire risk assessment has been done. Other work identified by the fire officer, such as fitting smoke detectors, had not been done. DS0000019888.V314213.R01.S.doc Version 5.2 Page 23 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): 27, 28, 29 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Recruitment practices are poor and this puts residents at risk. There are not always enough staff to make sure that residents’ needs are met in a timely way. Some training has taken place and a training programme is being developed to provide staff with the necessary skills to meet the residents’ needs. EVIDENCE: We looked at the duty rotas for three weeks; only one rota showed the actual hours worked. Although a rota is now available for ancillary staff it did not show the full names of staff or their roles. The rotas showed that there are between 3 and 6 care assistants on the morning shift and 3 and 4 on the afternoon and evening shifts. The rota showed that on some days there were only 2 care staff on duty, the acting manager said agency staff had been used on these occasions. This was not shown on the rota. There is always at least one nurse on duty during the day. Overnight there is one nurse and two care assistants. DS0000019888.V314213.R01.S.doc Version 5.2 Page 24 Residents spoke very highly of staff but some said there were not always enough of them available. One resident said staff were too busy to knock on bedroom doors. In October 2006 we visited the home and looked at the recruitment records. There were serious shortfalls; the required checks had not been completed before new staff started work in the home. During this visit we looked at the files of five staff, three of them were new. The files showed that the required checks were still not being done before employment. In two files there was no proof that overseas staff were eligible to work in the UK. There was no proof of identity in any of the files. Two files had references but they were not from previous employers. There were no references in two files. None of the files had information on the date people started work, a record of induction training, a job description or a contract of employment. Despite the fact that an Enforcement notice was served in July 2006 about CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) checks there was no evidence that these checks had been done for any of the three new staff. We have received confirmation that the home has checked that nurses are registered with the Nursing & Midwifery Council, (NMC). Four care staff have an NVQ (National Vocational Qualification) level 2, this is equal to 19 of the care staff team. The National Minimum Standards recommend that 50 of care staff are qualified to NVQ level 2 or above. Five staff are doing NVQ training and a further 3 are scheduled to start in January 2007. Two staff are training to be NVQ assessors. The records showed that some training has taken place on subjects such as dementia, diabetes, adult protection, control of infection and food hygiene. There was no training plan and it was not clear how training needs are identified. Some staff have not had any induction training. DS0000019888.V314213.R01.S.doc Version 5.2 Page 25 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): 31, 32, 33, 35, 36, 37 & 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There have been some improvements since the appointment of the acting manager. However, there are still a significant number of outstanding issues that compromise the well being and in some cases the safety of residents. EVIDENCE: Since the last key inspection the owner has stepped down as registered manager and appointed a new manager. The acting manager is a nurse and is doing an NVQ level 4 in management. She is in the process of applying for registration. DS0000019888.V314213.R01.S.doc Version 5.2 Page 26 In September 06 when the owner stepped down as registered manager we asked her to carry out monthly visits and produce a report following these visits. We gave her a suggested format on which to record these visits. During this inspection she told us she had done one visit and showed us the draft report. Some staff meetings have taken place and staff have been made aware of the improvements that need to be made to make sure the home complies with the National Minimum Standards and Care Homes Regulations 2001. No residents’ meetings have taken place. One relative said they would welcome the opportunity to have meetings. Some questionnaires have been issued to residents and relatives, the results have not been analysed and it was not clear how the home was going to use the information provided. The home does not act as appointee for any residents and is not involved in managing residents’ personal finances. Some small amounts of money and some valuables are held on behalf of residents. The records relating to these were satisfactory. The acting manager said the system for staff supervision was not yet fully underway. One or two people have had supervision. All the records required by regulation were not available for example: • • • • Staff files did not have the required documentation The service records for the hoists were not available There were no photographs of residents and The gas safety certificate was not available. Records of the weekly checks on the fire safety systems were seen. DS0000019888.V314213.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 2 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 2 1 X 1 2 1 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 1 1 1 DS0000019888.V314213.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 2 Standard OP1 OP3 Regulation 4 Sch. 1 14 Requirement Timescale for action 31/03/07 3 OP7 15 (1) The statement of purpose must include information on the size of rooms. New residents must not be 31/01/07 admitted until a suitably qualified person has assessed their needs and the registered persons have confirmed that the home is suitable to meet their needs. Every resident must have a care 31/01/07 plan setting out in detail the action which needs to be taken by staff to make sure that all aspects of health, personal and social care needs of the resident are met. This is outstanding from 07/09/2004, 17/05/2005, 11/10/2005, and 01/08/2006. Evaluation of care plans must be more robust; evidencing a thorough process, with existing care plans amended and new plans implemented as required. This is outstanding from 07/09/2004, 17/05/2005, DS0000019888.V314213.R01.S.doc Version 5.2 4 OP7 15 31/03/07 Page 29 5 OP7 13 (4) 11/10/2005, and 01/08/2006. Risk assessments must be completed for all areas of resident risk. This is outstanding from on 17/05/2005, 11/10/2005, and 01/07/2006. 31/01/07 6. OP8 12 Pressure area care plans must be 31/01/07 in place for all residents who are at risk of developing a pressure sore. Where wound care plans are in place the following must be recorded: • • • • The date for review of the wound. Instructions on how the wound is to be dressed. Wound mapping. Grading of the wound. Advice from the tissue viability nurse must be obtained. This is outstanding from 17/05/2005, 11/10/2005, and 01/07/2006. Residents must not be given medicines covertly unless appropriate consultation has taken place and there is documentary evidence to demonstrate that the decision has been taken in the resident’s best interests. Medical supplies must not be stored in residents’ private accommodation unless they are specifically for use by that resident. DS0000019888.V314213.R01.S.doc 7 OP9 13 (2) 31/01/07 8 OP9 13 (2) & 12 (4) 31/03/07 Version 5.2 Page 30 9 OP10 12 (4) 10 OP12 16 (2) (n) The registered persons must make sure that the home is conducted in a way that respects the privacy and dignity of residents. Recreational opportunities must be provided for all residents. This is outstanding from 11/10/05 and 15/07/06. The manager must make sure the wishes of individual residents are respected, and that routines and practices are in the best interests of the residents. This must be evidenced in the individual care plans. This is outstanding from 11/10/2005 and 01/07/2006. The registered persons must make sure the menu is sufficiently detailed to enable residents to make a choice and that this is made available to residents in a suitable format. The registered persons must make sure the staff that take charge of the home are aware of the correct action to take in response to suspicions or allegations of abuse. The registered persons must provide the CSCI with a plan, including timescales, for implementing the safety measures identified in the fire officer’s report. This is outstanding from 11/10/2005 and 01/07/2006. Call leads must be provided in all rooms, or the reason for not doing so must be explained in the care plan. DS0000019888.V314213.R01.S.doc 31/03/07 31/03/07 11 OP14 12 (1) (a) & 15 31/03/07 12 OP15 12 31/03/07 13 OP18 13 (6) 31/01/07 14 OP19 23 (4) 31/03/07 15 OP22 16 (2) (c) 31/03/07 Version 5.2 Page 31 16 OP22 13 (5) 17 OP24 16 This is outstanding from 11/10/2005 and 30/06/2006. The registered persons must provide another hoist and make sure there are enough wheelchairs available. Lockable storage space must be provided for all residents. This is outstanding from 11/06/2002, 23/10/2003, 23/07/2003, 14/01/2004, 05/05/2004, 07/09/2004, 17/05/2005, 11/10/2005, and 15/07/2006. Door locks must be provided to residents private accommodation, suited to their capabilities. Keys must be provided unless a risk assessment suggests otherwise. This is outstanding from 11/06/2002, 23/01/2003, 23/07/2003, 14/01/2004, 05/05/2004, 07/09/2004, 17/05/2005, 11/10/2005, and 15/07/2006. Food and cleaning materials must be stored in separate areas. This is outstanding from 11/10/ 2005 and 01/07/2006. The registered persons must make sure that staff follow safe working practices to reduce the risk of cross infection. Pedal operated clinical waste bins must be provided in all areas where clinical waste is disposed of. A washer disinfector must be provided in a separate sluice room, which also incorporates hand-washing facilities. DS0000019888.V314213.R01.S.doc 31/01/07 31/03/07 18 OP24 16 31/03/07 19 OP26 13 (3) 31/03/07 20 OP26 13 (3) 31/03/07 21 OP26 13 (3) 31/01/07 22 OP26 23 31/03/07 Version 5.2 Page 32 23 OP27 18 This is outstanding from 11/06/2002, 23/01/2003, 23/07/2003, 14/01/2004, 05/05/2004, 07/09/2004, 17/05/2005, 11/10/2005, and 30/09/2006. Staff rotas must: • • Show the actual hours worked by staff. Show the full names of staff and designation of staff. 31/03/07 24 OP27 18 This is outstanding from 07/10/2006 and 15/06/2006. The registered persons must make sure that there are always enough staff on duty to meet residents’ needs in a timely way. This is outstanding from 07/03/ 2006 and 01/07/2006. The home must achieve a ratio of 50 of care staff with NVQ level 2 or 3. This is carried forward from 07/09/2004, 17/05/2005, 11/10/2005 and 31/12/2006. Application forms must contain full details of employment history. Any gaps in employment must be explored. Two written references must be obtained before any offer of employment is made. Recruitment files must include all the information specified in DS0000019888.V314213.R01.S.doc 31/01/07 25 OP28 18 31/03/07 26 OP29 19 Sch. 2 31/01/07 Version 5.2 Page 33 Schedule 2. The recruitment policy and procedure must be amended in line with these requirements. This is outstanding from 25/10/2006. The registered persons must make sure that all nursing and care staff undertake training relevant to the needs of the resident group. This is outstanding from 11/10/2005 and 01/08/2006. Induction training must be linked to the Skills for Care Induction Standards and be recorded. This is outstanding from 01/08/2006. The registered manager must obtain a relevant management qualification. This is carried forward from 07/09/2004, 17/05/2005, 11/10/2005, and 31/12/2006. 29 OP33 24 Quality assurance measures such 31/03/07 as residents and relatives meetings, staff meetings, completion of an audit tool, and satisfaction questionnaires to health care professionals must be developed. This is outstanding from 11/06/2002, 23/01/2003, 23/07/2003, 14/01/2004, 05/05/2004, 07/09/2004, 17/05/ 2005, 11/10/2005 and 01/08/2006. 27 OP30 18 31/03/07 28 OP31 9 (2) (b) (i) 30/06/07 DS0000019888.V314213.R01.S.doc Version 5.2 Page 34 30 OP36 18 All care staff must receive formal supervision at least six times a year. This is outstanding from 11/06/2002, 23/01/2003, 23/07/2003, 14/01/2004, 05/05/2004, 07/09/2004, 17/05/2005, 11/10/2005, and 01/08/2006. Records required by The Care Homes Regulations 2001 must be made available for inspection at all times. This is outstanding from 19/09/2006. When cleaning materials are decanted into other containers those containers must be clearly labelled with details of the contents, the usage and the precautions/hazards. This is outstanding from 11/10/2005 and 19/06/2006. The registered persons must provide the CSCI with copies of the hoist service records and the gas safety certificate, (Landlords certificate). The registered persons must carry out a risk assessment of the windows in the small lounge and if necessary put in place measures to reduce the risk of injury to residents. 31/03/07 31 OP37 17 31/03/07 32 OP38 13 (4) 31/03/07 33 OP38 13(4) 31/01/07 34 OP38 13(4) 31/03/07 DS0000019888.V314213.R01.S.doc Version 5.2 Page 35 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000019888.V314213.R01.S.doc Version 5.2 Page 36 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000019888.V314213.R01.S.doc Version 5.2 Page 37 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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