Inspection on 25/04/05 for Springbank Road 152

This inspection was carried out on 25th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Springbank Road 152 17/07/07

Springbank Road 152 31/10/06

Springbank Road 152 12/10/05

Springbank Road 152 22/09/04

Springbank Road 152 05/05/04

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Chatsworth Care - Tudor Lodge

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

NURSES AGENCY All Care Cover Limited Victoria House victoria Mount Birkenhead Wirral CH43 5SQ Lead Inspector John McCabe Announced Wednesday, 10 August 2005 th 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 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 agency are those for Nurses Agencies. 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. All Care Cover Limited F52 F02 S56031 All Care V232284 100805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service All Care cover Limited Address Victoria House, Victoria Mount, Oxton, Birkenhead, Wirral, CH43 5SQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0151 670 0077 0151 670 0022 All Care Cover Limited Joan Stanley NA Nurses Agency 0 Category(ies) of NA nurses Agency registration, with number of places All Care Cover Limited F52 F02 S56031 All Care V232284 100805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13th January 2005. Brief Description of the Service: All Care Cover Limited is owned by Michael Stafford and managed by Joan Stanley. The agency has been operating for over ten years. The office is based in a shared building in Oxton Village, however it is self contained. The agency is an employment business and provides qualified nurses and health care assistants to care homes and hospitals within the area. The agency does not supply staff to service users in their own homes.The office is open Monday to Friday 0900 hours to 1700hours, with an on call-all system operating out of hours seven days a week. The manager and administrator cover the on-call hours. All Care Cover Limited F52 F02 S56031 All Care V232284 100805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took five hours in the Wirral office of the agency. The registered manager, the administrator, and the agency secretary were present during the inspection. Documents reviewed included the agency’s policies and procedures, staff hand book, and the personal files of the staff, which included recruitment, contracts, terms and conditions and CRB/POVA checks. The inspector spoke by telephone to six of the agencies clients, re the service provided by the agency. What the service does well: What has improved since the last inspection? What they could do better: The must improve on documentation relating to new nurse applicants to the agency. This includes completion of the applicants health records especially immunisation data. Interview forms of the applicants should be available for all applicants in their personal file, signed and dated by the interviewer. CRB/POVA checks must be undertaken on all new applicants to the agency All Care Cover Limited F52 F02 S56031 All Care V232284 100805 Stage 4.doc Version 1.40 Page 6 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. All Care Cover Limited F52 F02 S56031 All Care V232284 100805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Information (Standard 1) Registered Persons (Standard 2) Recruitment and Supply of Nurses (Standards 3-6) Complaints and Protection (Standards 7-11) Management and Administration (Standards 12-18) Scoring of Standards Staffing (Standards 31-36) Statutory Requirements Identified During the Inspection All Care Cover Limited F52 F02 S56031 All Care V232284 100805 Stage 4.doc Version 1.40 Page 8 Information The intended outcome for Standard 1 is: 1. Prospective service users have the information they need about the agency in order to make an informed decision on whether to engage its services. JUDGEMENT – we looked at outcomes for standard(s) 1 The agencies Statement of Purpose includes all relevant information as regards the qualifications of nurses and services offered to potential clients, this helps to safeguard both nurses and service users. EVIDENCE: The Statement of Purpose was available for inspection and contains relevant up to date information including a reference to the Commission for Social Care Inspection. Details of the aims and objectives of the company are supplied as well as information on the qualifications and experience of the qualified nurses supplied by the agency to care homes The Statement of Purpose is summarised in the service users guide. The agency does not supply-qualified nurses to individual services users in their own home All Care Cover Limited F52 F02 S56031 All Care V232284 100805 Stage 4.doc Version 1.40 Page 9 Registered Persons The intended outcome for Standard 2 is: 2. Service users are assured of the integrity of the agency and have confidence that it is run by a fit person or organisation. JUDGEMENT – we looked at outcomes for standard(s) 2 The manager of the agency is able to demonstrate that she has the knowledge, experience and expertise to manage the agency in an effective and efficient manner, ensuring the welfare of both clients and nurses. EVIDENCE: The manager of the agency is registered with the Commission for Social Care Inspection, which included a thorough background check, health check, references and an enhanced CRB disclosure. The manager, Joan Stanley RN, continues to demonstrate her competency and ability to manage the branch efficiently. Mrs. Stanley provided evidence of a current up to date personal identification (PIN) with the Nursing Midwifery Council (NMC). The agency manager has completed a basic skills computer course. All Care Cover Limited F52 F02 S56031 All Care V232284 100805 Stage 4.doc Version 1.40 Page 10 Recruitment and Supply of Nurses The intended outcomes for Standards 3 - 6 are: 3. 4. 5. 6. The process for recruitment and selection of nurses meets all the requirements of legislation and employment law including that related to equal opportunities and anti-discriminatory practice. Service users are confident that nurses supplied by the agency will provide good quality care and will not jeopardise the safety of patients. The agency has documentary evidence demonstrating the personal identification, registration, ongoing eligibility to be employed as a nurse, and relevant qualifications of each nurse to be supplied. Nurses supplied by the agency are competent and trained to undertake the activities for which they are employed and responsible. The Commission considers Standards 3, 4 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,4,5,6. Recruitment policies have not been consistently followed resulting in service users receiving care from staff members who have not been properly vetted. This potentially leaves people who use the service at risk. Also, there is lack of evidence to demonstrate the agency is facilitating relevant and appropriate care training for the nurses. These inconsistencies could result in inappropriate nurses being employed by the agency, or, the health and safety of service users being compromised. EVIDENCE: The Agency ensures that a first level nurse, (the registered manager), interviews qualified nurses. The agency continues to advertise in the local press and the yellow pages for new recruits. There were inconsistencies in the personal files of the qualified nurses. The interview questions forms for the nurse applicants were not in every file. Interview checklist should be recorded in every applicants file to demonstrate, fairness and equity in the employment process. Many of the interview question forms had not been signed and dated by the interviewer. Also, the health check forms of some of the nurse applicants were not in the file, or the health questionnaire was not fully completed or signed by the nurse All Care Cover Limited F52 F02 S56031 All Care V232284 100805 Stage 4.doc Version 1.40 Page 11 applicant. The applicants health record should be checked including obtaining a copy of the applicants immunisation record and current status showing the necessary immunisations for practice are current, in line with the UK Health Departments publication: Immunisation Against Infectious Disease. The agency should ensure that applicants are no risk to potential service users or themselves. In two of the personal files inspected, the Criminal Records Bureau CRB /POVA check was from a previous employer and not in the name of the All Care Cover Nurse Agency, this not safe practice To ensure the credibility of the nurses application, and safety service users, all new nurses recruits to the agency must have a CRB/POVA clearance certificate in the name of the employing agency. Nurses PIN’s are verified at interview via the Nursing and Midwifery Council (NMC). All files personal files inspected contained two references for the applicant, and a recent photograph. Evidence was provided that personal information on all employees including trained nurses are kept safe and secure within the branch, in accordance with the Data Protection Act 1998. Induction training is offered to all staff, which includes an introduction to the agency’s policies and procedures the agencies Induction Booklet needs to be updated to encompass up to date rights of the employee. The inspector was informed that all staff must have up to date moving and handling training and an awareness of infection control before their first shift. There was evidence that four (4) staff had completed Moving and Handling, There no evidence to support any other training had been undertaken by nursing staff employed by the agency. All new staff are instructed to familiarise themselves with each establishments fire safety procedure when on duty as well as abiding by the NMC code of conduct. All Care Cover Limited F52 F02 S56031 All Care V232284 100805 Stage 4.doc Version 1.40 Page 12 Complaints and Protection The intended outcomes for Standards 7 - 11 are: 7. 8. 9. 10. 11. Service users are confident that their complaints will be listened to, taken seriously and acted upon. Service users who are also patients are protected from abuse, where the agency is an employment business. Service users who are patients are protected by the agency’s procedures for assistance with medication, where the agency is an employment business. Action is taken to protect confidentiality of information relating to service users who are also patients, their carers and advocates. The health, safety and welfare of service users who are also patients, and of nurses, are promoted and protected, where the agency is an employment business. The Commission considers Standards 7, 8, 9 and 11 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11. The agency policy for complaints and protection are robust, the health and safety of service users are promoted and protected. EVIDENCE: The complaints policy operated by All Care Cover Limited was available for inspection and met this standard in full. Details of how to complain and to who were included in the policy, and reference to the contact details of the local office of the Commission for Social Care Inspection were also available. The inspector was told that details of any complaints would be recorded together with an outcome. Nurses would be made aware if a complaint is lodged about them and invited into the agency office for discussion. The agency does not supply staff including trained nurses to patients in their own homes. All staff is given the opportunity of accessing the Wirral Adult Protection Protocol, which is kept in the office. The agency does keep a copy of the departments of Health guidelines on the protection of vulnerable adults, there was no evidence in the agency that staff had read the document or had training on the subject. All Care Cover Limited F52 F02 S56031 All Care V232284 100805 Stage 4.doc Version 1.40 Page 13 The policies and procedures for staff to follow regarding the administration or assistance with administration of medication is safe. Staff are given clear instructions on induction regarding medication, and the trained nurses are expected to abide by their own professional code of conduct when administering medication as well as adhering to company policy. Information on the disposal of drugs in nursing homes should be included in the agencies medication policy. The agency provides safe and secure office premises and ensures all records relating to service users and staff is kept in secured locked filing cabinets. The premises are alarmed and maintained by the leaseholder. There is a keypad entry system in operation and the office is always occupied during office hours or locked with a key. The agency has a confidentiality policy and all staff is expected to abide by it. The agency has produced a health and safety document for staff guidance based on the Health and Safety at Work Act 1974 which includes advice for staff on RIDDOR, COSHH, fire safety, accident and incidents, infection control and manual handling and moving. It is recommended that a reference to health and safety is included in the staff manual. Dates and signatures of staff undertaking training via the agency should be recorded and the record kept in the individual personal file of the nurse All Care Cover Limited F52 F02 S56031 All Care V232284 100805 Stage 4.doc Version 1.40 Page 14 Management and Administration The intended outcomes for Standards 12 – 18 are: 12. 13. 14. 15. 16. 17. 18. Approved accounting and financial procedures are adopted to ensure the effective and efficient running of the business and its continued financial viability. There are designated premises suitably equipped for the purpose of the day to day operation and management of the service. An appropriate management structure and clear lines of accountability are in place. Nurses supplied by the agency know the standards of conduct expected of them and are aware of the agency’s organisational policies, where the agency is an employment business. There is a written agreement between the Agency and nurses. Service users’ and nurses’ interests are safeguarded by the agency’s record keeping policies and procedures. The agency operates in the best interests of service users and of nurses supplied by it. The Commission considers Standards 15 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15,,16,17,18. The management and administration of the agency is effective and efficient ensuring all aspects of the business comply with the regulations of the CSCI. This ensures there is employment equity and fairness for all staffs and service users, and clients. EVIDENCE: The accounts for the agency are audited by a reputable firm of accounts and are available for inspection if required. An up to date Employers Liability Insurance certificate was on display in the agency office. All Care Cover Limited F52 F02 S56031 All Care V232284 100805 Stage 4.doc Version 1.40 Page 15 The agency is well equipped with up to date modern equipment such as fax, photocopier, computers and a phone. Office based staff have sufficient space to work in safety and there is a separate office room for private discussions and interviews. Adequate kitchen and bathroom facilities are provided. The agency has been in contact with the local Fire Brigade, and was told that a visit by a fire office was not necessary. The management structure reflects the size of the agency at present. There is one administrator and a secretary. The officer administrator is also responsible for some out of hours on call duties as well as moving and handling training. The manager is a qualified nurse and also has some on call duties. The owner is prepared to cover for either of the two office based staff at short notice if needed. All nursing staff is issued with a copy of the agency’s introduction manual, which includes the agency’s policies and procedures. Staff are recommended to sign to say they have read and agree to the terms and conditions laid down in the manual. It is recommended that the introduction manual is reviewed and updated to reflect the rights of the individual in the workplace. Evidence that nurses are supplied with a statement of terms and conditions of employment known as membership agreements were available in the personnel files. The staffs are required to sign the agreements on commencement of employment. Nurses when recruited are given rates of pay for the various shifts worked. The agency does not supply staff to establishments for them to employ. Recently, the agency has introduced a Quality Assurance monitoring questionnaire from the client group involved with the agency. The completed questionnaires inspected, showed that clients were happy with the administration of the agency and the quality and professionalism of the nurses supplied. The inspector contacted six clients, all nursing homes in the Wirral area, (by phone), all clients were praiseworthy of the service offered by the agency, and the competency of the nurses supplied to them. Records are kept in accordance with guidelines for registration and are available for inspection by CSCI. Electronic records are protected by password entry and are limited to names and addresses only at present. The agency is aware of the need to retain any records of staff for a minimum of three years. All Care Cover Limited F52 F02 S56031 All Care V232284 100805 Stage 4.doc Version 1.40 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Nurses Agencies have been met and uses the following scale. 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 INFORMATION Standard No Score 1 3 REGISTERED PERSON Standard No Score 2 3 RECRUITMENT AND SUPPLY OF NURSES COMPLAINTS AND PROTECTION Standard No Score 7 3 8 3 9 3 10 3 11 3 MANAGEMENT AND ADMINISTRATION Standard No 3 4 5 6 Score 3 2 2 3 12 13 14 15 16 17 18 3 3 3 3 3 3 3 All Care Cover Limited F52 F02 S56031 All Care V232284 100805 Stage 4.doc Version 1.40 Page 17 NO Are there any outstanding requirements from the last inspection? 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 4 Regulation 12(1) Requirement The registered person must ensure that all new nures recruits to the Agency have an up to date CRB/POVA enhanced clearnace certificate intiated by the All Care Cover Ltd. The registered person must ensure applicants health record is checked including obtaining a copy of the applicants immunisation record and current status in line with the recoendations of the UK Health Depratments publication Immunisation Against Infection Disease The regsitered person must ensure that specilast care training is offered to all qualified nurses in the agency to ensure that the assessed and changing needs of the service users are emt. The registered person must ensure that applicants interview details are recorded, signed and dated by the interviewer, and kept in the personal file of the applicant Timescale for action Immediate 2. 4 12(1) Immdeiate. 3. 4 13(2) September 30th 2005. 4. 5 12(1) Immediate. All Care Cover Limited F52 F02 S56031 All Care V232284 100805 Stage 4.doc Version 1.40 Page 18 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. 2. Refer to Standard 14 15 Good Practice Recommendations It is recomended that referencesis made to health and safety issues in the staff manual/handbook. It is recomended that the staff induction handbook for newly recruited nurses should be up dated to include the employment rights of the employee. It is recomeded that all satff employed by agency sign to say they have the terms and conditions of employment. 3. 4. 16 All Care Cover Limited F52 F02 S56031 All Care V232284 100805 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Liverpool Area Office 3rd Floor, 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI All Care Cover Limited F52 F02 S56031 All Care V232284 100805 Stage 4.doc Version 1.40 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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