CARE HOMES FOR OLDER PEOPLE
St Michaels View Care Home Hallcroft Road Retford Nottingham Nottinghamshire DN22 7NE Lead Inspector
Richard Ramsden Unannounced Inspection 15th February 2006 10:15 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 St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 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. St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service St Michaels View Care Home Address Hallcroft Road Retford Nottingham Nottinghamshire DN22 7NE 01777 702218 01777 710318 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) Nottinghamshire County Council Mrs Louise Shirley Gladwin Care Home 34 Category(ies) of Dementia (14), Dementia - over 65 years of age registration, with number (14), Old age, not falling within any other of places category (34), Physical disability (5) St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Out of the total number of beds (34), there will be 14 beds for DE 55 and over and/or DE(E) Out of the total number of beds (34), 5 may be used for PD 55 and over Service users shall be within category OP Date of last inspection 11/08/05 Brief Description of the Service: St Michaels View is a purpose-built care home owned and managed by Nottinghamshire County Council Social Services. It provides care and accommodation for up to 34 older people including 14 people who have dementia. The home also has a day centre, which operates seven days a week. The accommodation is provided over two floors with a shaft lift to assist independent access. All bedrooms are for single occupancy and none have ensuite facilities. There are two lounges, two dining rooms and a separate lounge for people who wish to smoke. Additional communal areas compensate for some bedrooms that do not fully meet National minimum standards size requirements. There are small well-maintained gardens which are accessible to service users. The home is situated in a residential area relatively close to Retford town centre. St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. One Inspector completed this unannounced inspection over one day; it took approximately 5 1/2 hours. It included the inspection of care and other records, a discussion with four residents, three visitors to the home, a team leader and a member of care staff. A partial tour of the building was also completed. What the service does well:
All of the residents spoken with during this inspection said that they were very satisfied with the services provided by the home. They stated that the staff work extremely hard but that they are always friendly, helpful and considerate. One person said that the staff are ‘ wonderful’ and will do anything they can to ensure that peoples privacy and dignity is maintained. None of the residents spoken with could think of anything, which could be changed to improve the services provided at the home. The visitors spoken with during the inspection said that they are very satisfied with the care that their family members receive. They confirmed that they can visit the home at any time and that they are always made to feel welcome. The home is committed to providing appropriate training for staff. The records show that 56 of the staff have completed their NVQ training and that a further eight members of staff were completed training at the time of this inspection. The residents spoken with stated that they are satisfied with their bedrooms and confirmed that they had been encouraged to personalise them with small items of furniture photographs and electrical appliances such as TVs and videos etc. They all confirmed that the home is always kept spotlessly clean. All areas of the home viewed as part of this inspection had been well maintained. The care plans viewed as part of this inspection all contained relevant information which was being reviewed and updated at least once a month to ensure that staff are always aware of what assistance and support each resident requires. Residents and where appropriate their representatives were signing the care plans to confirm that they had been involved in the planning and review process.
St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 6 There were many aspects of good practice highlighted the main body of this report. What has improved since the last inspection? What they could do better:
The manager must ensure that all prospective residents and their representatives have sufficient written information about the home to enable them to make an informed decision as to whether the home will meet their individual needs. The homes complaints procedure must inform people how to contact the Commission for Social Care Inspection and records must be kept of all ‘informal’ complaints received by the home. All staff must be aware of their responsibilities in relation to the homes Whistle Blowing Procedures to help ensure that residents are protected from abuse. Staff must answer residents call bells promptly. St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 7 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. St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 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 St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1. The literature supplied the prospective residents does not contain sufficient information to enable them to make an informed choice as to whether the home will meet their individual needs. EVIDENCE: There is a folder in the main reception area, which contains all of the required information for the Service User Guide and the Statement of Purpose except for the resident’s views of the home. It was also noted that not all of this information is provided to prospective residents and their representatives. This information should enable people to make an informed choice as to whether the home will meet their individual needs. The registered person must ensure that all of the information identified in Standard 1 of The Care Homes Regulations is provided to all prospective residents and their representatives.
St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 10 St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8. Residents care plans appear to contain sufficient information to ensure that staff are always aware of what support and assistance each resident requires. However the registered person must ensure that care plans are produced for all residents within seven days of their admission to the home. Residents health care needs are being fully met. EVIDENCE: Three residents records were assessed as part of this inspection. Two of the resident’s records contained comprehensive care plans, which appeared to address all of the issues identified in their individual assessments. The care plans were being reviewed and where necessary updated on a monthly basis. Residents or where appropriate their representatives had signed the care plans to confirm their involvement in the planning and review process. (This is good practice). One of the resident’s records did not contain a care plan. The senior staff stated that this resident had been admitted to the home as an emergency
St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 12 admission and at the time of inspection a care plan had not been produced. The inspector advised the senior staff that care plans must be produced for all residents within seven days of their admission to the home. It is important that staff are all aware of what support and assistance each resident requires. Appropriate risk assessments had been completed with the two residents who had comprehensive care plans. Records show that peoples health care needs are being appropriately met. The residents spoken with during this inspection confirmed this. St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14. Some people would like the home to provide a wider variety of activities. Residents are encouraged to maintain contact with their family and friends. People are helped and encouraged to exercise choice and control over their lives. EVIDENCE: The home provides some activities on a regular basis. Three of the people spoken with during the inspection said they would like a more varied programme of activities. One person said that they would like the home to provide quizzes, which they believed, would help to keep their minds active. One person said that they do not participate in any of the activities provided in the home as none of them were of any interest to him. The home does not display the programme of activities and consequently not all of the residents were aware when the activities were available. All of the residents stated that they enjoyed the entertainment provided and that they had enjoyed the Christmas festivities. All of the residents and the visitors spoken with during this inspection said that visitors are made welcome at any time. They said that they are offered
St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 14 refreshments, and to people believe there visitors could have a meal in the home if they booked this in advance. Residents confirmed that they were happy with the way their finances are managed. The senior staff stated that all residents are asked as part of the admission process how they would like their finances managed and this is discussed as part of the formal review process. Each resident is provided with literature informing them how to contact external advocates and the procedures they must follow to have access to their records. (This is good practice). St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The homes complaints procedure is acceptable, except it does not inform people how to contact the Commission for Social Care Inspection. The registered person must ensure that all staff are aware of their responsibilities in relation to the homes Whistle Blowing Policy. This will help to ensure that residents are protected from abuse. EVIDENCE: The senior staff stated that as far as she is aware there have been no formal complaints made at the home in the last 12 months. The home has a book in which ‘informal’ complaints are recorded, however only one complaint had been recorded in this book. The inspector noted that residents had raised some concerns during a residents meeting about their clothes going missing. This had not been recorded in the complaints book. The inspector advised that all complaints must be recorded to provide an overview of the nature and frequency of complaints received and to confirm that they had been dealt with appropriately. The complaints procedure must inform people how they can contact the Commission for Social Care Inspection if they wish to discuss any concerns about the home. All of the residents spoken with confirmed that they are confident that the senior staff would deal with any concerns they may have appropriately.
St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 16 A copy of Nottinghamshire County Councils Whistle Blowing Procedure was displayed in the home. (This is good practice). However a member of staff who was spoken with during the inspection was unable to demonstrate a clear understanding of her responsibilities with regard to the Whistle Blowing Procedure. The senior staff was advised that all staff must be made fully aware of this procedure. The home has a copy of the local Vulnerable Adults Procedure; the staff were advised to ensure that this procedure contained all the appropriate updated information. The senior staff stated that there have been no allegations of abuse in the home in the last 12 months. St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Residents live in safe comfortable bedrooms with their own possessions around them. EVIDENCE: All of the residents spoken with during this inspection said that they are very happy with their bedrooms. They confirmed that they had been encouraged to personalise their rooms with small items of furniture, photographs, televisions etc. The bedrooms viewed by the inspector were all pleasantly decorated and comfortably furnished. The call bell in one bedroom was tested as part of the inspection. It took staff 12 minutes to answer the call bell. The staff stated that she had been delayed because she had only recently commenced duty and was being briefed by the staff that had completed the morning shift.
St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 18 This issue was discussed with the senior member of staff who agreed that it was not acceptable that staff took 12 minutes to respond to a residents call bell. St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30. Resident’s needs are met by the numbers and skill mix of staff. The homes recruitment policies and practices are supporting and protecting residents. The home is able to demonstrate a commitment to staff training. EVIDENCE: At the last inspection the manager stated that due to the high dependency levels of the residents, there was not always sufficient staff to meet all of the residents assessed needs. The senior staff on duty at the time of this inspection stated that they are monitoring the dependency levels of all new residents, referred to the home, to ensure that there are sufficient staff to meet the residents assessed needs. The personal records of the two most recently recruited members of staff were assessed as part of this inspection. The records contained two written references and an appropriate Criminal Records Bureau check for each member of staff. (This is good practice). The senior staff was reminded that all staff records must contain a copy of their proof of identity e.g. a passport, birth certificate, or driving licence. The staff training records viewed as part of this inspection showed that the home has a strong commitment to staff training. In October 2005 56 of staff
St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 20 had completed NVQ training and a further eight members of staff were completing this training. (This is good practice). St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35,38. Resident’s financial interests are being safeguarded. The aspects of health and safety assessed as part of this inspection were ensuring the safety and welfare of residents and staff. EVIDENCE: The records of residence finances and items handed in for safekeeping were checked at random and had all been well maintained. A Sample of the homes risk assessments for safe working practices and the COSH procedures were assessed as part of this inspection and found to be satisfactory. The homes Fire records and Legionella risk assessments were checked and all appeared satisfactory on superficial inspection.
St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 22 The senior staff stated that there is a member of staff with an up-to-date first aid qualification, on duty in the home at all times. (This is good practice). Staff training records were sampled to confirm this. St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 23 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 4 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X X X X X 2 X X STAFFING Standard No Score 27 3 28 X 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 3 St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? No 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 4 5 Requirement It is required that the information provided to prospective residents or their representatives must contain the residents views of the home. All of the information identified in Standard 1.2 must be provided to every resident. It is required that the homes complaints procedure contains details of how to contact the Commission for Social Care Inspection. It is required that the Registered Person keeps a record of all complaints to provide an overview of the nature & frequency of complaints received. It is required that all staff are aware of their responsibilities in relation to the homes Whistle Blowing Procedure. It is required that staff answer residents call bells promptly Timescale for action 03/04/06 2 OP16 22 (7) 16/02/06 3 OP16 Schedule 4 (11) 16/02/06 4 OP18 18.1 (c) 03/04/06 5 OP24 13 16/02/06 St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 25 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 12 Good Practice Recommendations It is recommended that the Registered person provides a wider variety of activities that are planned in consultation with the residents. Residents must be informed when activities will be provided in a format that meets their individual needs. St Michaels View Care Home DS0000036238.V282810.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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