Inspection on 26/09/07 for Strawberry Bank

This inspection was carried out on 26th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Strawberry Bank 04/02/10

Strawberry Bank 17/09/09

Strawberry Bank 07/08/09

Strawberry Bank 08/07/09

Strawberry Bank 16/01/09

Strawberry Bank 24/01/08

Strawberry Bank 15/05/07

Strawberry Bank 04/07/06

Strawberry Bank 19/10/05

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

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 Strawberry Bank 17 Strawberry Bank Liversedge West Yorkshire WF15 6JT Lead Inspector Helen Battle Key Unannounced Inspection 26th September 2007 09:00 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 Strawberry Bank DS0000063274.V352003.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. Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Strawberry Bank Address 17 Strawberry Bank Liversedge West Yorkshire WF15 6JT 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) 01924 410471 01924 405070 info@strawberrybankcarehome.co.uk www.strawberrybankcarehome.co.uk Prince Edward Anojan Joseph Miss Claire L Allen Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To forward a Statement of Purpose and Service User Guide within three months of becoming the registered provider. To complete Schedule 1 of the Fire Safety Officers report Date of last inspection 15th May 2007 Brief Description of the Service: Strawberry Bank Care Home provides personal care to older people. The home is located at the head of a quiet cul-de-sac, off the main Halifax road into Liversedge. The accommodation is over three floors, with a lounge and a dining area on the middle floor. Access between floors currently is by way of a stairlift, meaning that the ground and second floor are not fully accessible for people with serious mobility needs. This is in the process of being remedied by the installation of a passenger lift to all three floors. There is a mixture of both single and shared bedrooms. There is also a patio to the rear of the property, where service users may sit in the warmer months of the year. The provider informed the Commission for Social Care Inspection on 26 September 2007 that the fees range from £356.34 - £368.12 per week. There are additional charges for hairdressing, newspapers and magazines. Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this inspection, an unannounced visit to the home took place. The inspector visited the home from 09.00 hrs to 15.00 hrs. Whilst at the home, key documents that give information about how people are looked after and how the home makes sure staff are fit to work at the home were looked at, and so were all the rooms and garden. Three members of staff were spoken with. Before the visit, the manager was requested to provide CSCI with information about the people who live at Strawberry Bank, the staff that work there and any incidents or accidents that have happened there since the last inspection. This was returned to the Commission prior to the visit taking place. This information has helped form the judgements made about how the home is performing. Surveys were sent out to relatives of ten people living at the home, and to people’s doctors and social workers. At the time of writing this report, two responses had been received from relatives and one response from a GP. Feedback from the relatives was positive and comments included: “There is a homely feeling; staff try to understand my relative who has communication difficulties. Things could be improved by staff spending time talking and sitting with people on a personal level.” “I am kept well informed. The home has a friendly close knit community. I am very happy with the staff. The staff deserve a lot of praise for being so patient and dedicated in their chosen careers. Everything is satisfactory.” Comments from people living in the home on the day of the visit included: “I like living here”. “The staff are good”. “I can choose what I want to eat.” “The meals are very nice”. The inspector would like to thank all the staff and people living at the home for their hospitality and co-operation during this visit. An unannounced visit was also carried out at the home on 1 August 2007. This visit was to check specific requirements which were made during the last full inspection on 15 May 2007. An inspection by one of the Commission’s pharmacist inspectors took place on 3 October 2007 to look at arrangements within the home that support the safe Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 6 handling of medicines and involved looking at medicine records, storage and administration. What the service does well: What has improved since the last inspection? What they could do better: There are no up to date risk assessments for people who self administer their medicines. This means that there is a risk that a person may not be taking their medication correctly. There must be a better system of recording changes to medication, also guidance about those medicines prescribed to be taken “as when required” or medicines without clear directions. Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 7 A full audit of staff files needs to be carried out to ensure that all staff who were recruited prior to recent improvements in the process have had the necessary checks completed. There were two rooms where there was a noticeable odour of urine. The carpet in room 12 was stained and requires replacing. It was highlighted that there is a limited amount of spare bedding available in the home. At the time of the visit, the manager ordered some new bedding and agreed to do this on a regular basis. There were no waste paper bins in the toilets and shower room. Some of the paper towel and soap dispensers were empty. The driveway to the home is not safe. There are some potholes in it and loose pieces of tarmac which are a hazard. This must be addressed. The manager was informed about this issue during the visit. The environmental health officer visited the home in December 2006 and has been contacted by the Commission regarding their concerns about the facilities in the kitchen. These concerns relate to the cupboards and drawers being in a state of disrepair and unsafe. Hot water temperatures have not been recorded but the hot water in some of the bedrooms appeared to be extremely hot. The manager was advised to ensure that all hot water outlets are checked monthly and any remedial action taken as necessary. Thermostatic valves must be fitted to hot water outlets on baths and showers. It is also recommended that this is done to other hot water outlets. Warning stickers and thorough risk assessments must be fitted throughout to hot water outlets on sinks where there is no thermostatic valve fitted. 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. Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People are properly assessed before moving into the home with the assurance that their needs will be met. EVIDENCE: The care records of three people living in the home were examined and all were found to have appropriate community care assessments, which are carried out by Social Services, prior to admission and provided the information the home needed about these people. The home also carry out their own assessment of people prior to confirming whether their needs can be met at Strawberry Bank. Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 10 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. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit. The level of care people need, which includes their health, personal and social care needs, are clearly highlighted within their care plan. Medication is not managed adequately. EVIDENCE: The care plans of three people living at the home were examined. These were clear documents, which included assessments to identify whether individuals are at risk of falling, need help to move about the home, developing pressure sores or having problems eating and drinking. The daily records examined were detailed in their content, however where a risk is identified regarding a person’s likelihood of developing pressure sores, this should be referred to in the daily records stating the condition of their skin each day. The records relating to the social life and activities people take part in were not always documented. The people living at the home on the day of this visit, looked well cared for, comfortable and relaxed. People responded well to the staff and it Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 11 was evident from observing staff interaction with people living in the home that they knew each individual’s likes, dislikes and needs. Feedback from people living in the home spoken to on the day of this visit was positive. People said that staff are kind, pleasant and approachable, and they were able to have a laugh and a joke with them. The healthcare needs of people are met, evidence was seen of involvement from people’s doctors, opticians, dentists and other healthcare professionals where needed. An inspection by one of the Commission’s pharmacist inspectors took place on 3 October 2007, to look at arrangements within the home that support the safe handling of medicines and involved looking at medicine records, storage and administration. The evidence provided in this report regarding medication is reproduced in full from the visiting pharmacist. Medicines’ Policy There is a medicines’ policy in the home which is a copy of the guidance produced by the Royal Pharmaceutical Society of Great Britain. This is an example of good practice, as it will detail all the elements involved in medicines’ management. However, the policy needs to reflect procedures specific to the care home, for example how monthly prescriptions are ordered. The inspector advised that this guidance has been updated and will be released in October 2007. Record Keeping The current Medication Administration Record (MAR) charts were looked at. There is a list of staff authorised to administer medicines and examples of their signatures. This means it is possible to identify who was involved in administration if a query or problem occurred. There were a number of MAR charts missing photographs of the person. This means there is a risk that medication may be administered to the wrong person. Some of the MAR charts were coming loose. A system should be in place to keep them securely to prevent confidential information being lost. The recording of medicine administration is good; there were few gaps on the MAR charts. This means that there is a record of people getting the medication as prescribed. The quantity of medication supplied and the date received is recorded as well as the quantity of medication from one monthly cycle to another. This means there is a complete record of medication within the home and helps when checking if medication is being administered correctly. Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 12 A number of medicines had a dose of “when required” or “as directed” printed on the MAR and pharmacy label. Handwritten entries had been made giving specific dose times but there was nothing on the MAR or in the care plan to indicate where this information had come from. For example, the dose for an atrovent inhaler was printed with ‘as directed’ but the handwritten entries were twice a day. There was no record made of who had supplied these instructions. If the dose is correct then the pharmacy should be contacted to advise them and ask for an accurate chart to be produced. Changes made to the entries on the MAR chart were missing the date of entry and who authorised the change. For example, an entry for amisulpride for one person had ‘please stop and monitor for one week’ written on. However, there was no indication on the MAR chart or care plan of who authorised the changes. To make sure there is an accurate record the date of entry, the signature of the person making the entry and details of the person authorising the change should be included. Some medicines listed on the MAR charts were no longer in use. The pharmacy should be advised of medication not in use and asked to provide up to date charts. This makes sure people are only getting medication that is currently prescribed. There was no record of administration on the MAR chart for medication that is administered by a member of the healthcare team. For accurate records, any administration activity that is performed by someone other than the care home staff must be indicated on the chart. One MAR chart had medication not given because there was no stock available. It is important to make sure that the quantity of medication is regularly checked so that a prescription can be ordered in plenty of time to prevent people being without. There is an accurate record of medicines returned to the pharmacy for disposal. This means there is a complete record of medication entering and leaving the home. Administration The morning round was observed. Time was taken to support people in taking their medication. An audit of current stock and records showed that some medication had been signed for but not given. For example, one medication had 28 tablets on the pharmacy label and on the MAR. 13 entries had been made on the MAR chart but 17 remained in the box. Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 13 Storage There is a lockable medicines’ trolley that is kept in a lockable office. At the time of the visit, the room was open. There is no facility to chain the trolley to the wall. The fridge in the office for storing medication is not locked. This means there is a risk that medication may be removed or tampered with. The room is warm and has no ventilation; this puts people at risk of receiving medication that has been stored at temperatures greater than the manufacturer’s recommendation. A thermometer should be put in place to monitor the room temperature. The fridge requires defrosting and the temperatures are not recorded. This means there is a risk that medication may not be stored correctly and safe to use. There was a large amount of insulin in the fridge for one person. There is a risk that some of the insulin may go out of date before it is used. The manager has identified this as a problem and will not order further supplies. A check of the expiry dates should be done before administration to make sure the insulin is in date. There is inconsistency in the recording of the date of opening of eye drops. Dates of opening should be recorded to reduce the risk of administration beyond 28 days and to make sure that medication is safe to use. Two devices to aid the administration of asthma inhalers were dirty and did not have a pharmacy label to show who they belonged to. Such devices should only be used by the person it has been prescribed for and should be kept clean to prevent infection. Paracetamol used as homely remedy stock was from a prescription only supply. Only medicines bought should be used as homely remedies. Prescribed medicines should not be used; they should only be used for the person they have been prescribed for. Controlled drugs The controlled drugs’ cabinet and register are suitable for use. The recording of administration in the register was not consistent. There were many gaps. The manager has addressed the problem and recent entries have improved. There was some confusion over the recording of diazepam. This does not legally require an entry in the register. However, some staff had started to make entry but others had not and the balance did not tally. The inspector advised that one system should be adopted and followed by all staff to make sure there is consistency. It is important that accurate records are kept of these drugs to make sure they are managed safely. Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 14 Other Three care plans were looked at. One of the care plans was for a person who self administers. There was no evidence of a risk assessment being done. The inspector advised that a risk assessment should be done on all who self administer to make sure the medication is taken correctly and the medical treatment is not affected. There was inconsistency in the recording of blood sugar results for this person. The inspector advised that a separate form should be used to make it easier to see the results. The care plans for other people were missing information on changes to the doses of medication. The inspector advised that all information and conversations about a person’s medical treatment should be recorded. The entries made in the daily care record for medicine administration did not match the information recorded on the MAR. For example, the MAR recorded that the person had refused their medication but the daily care record had medicines given. It is important that accurate records are made so that the correct information is provided if a review is required. The ordering of prescriptions needs to be improved. The person in charge of ordering medication must have a copy of the prescription request and have sight of the prescriptions before a supply is made. The prescription is the authority for the staff to administer medication to the resident. This also provides an opportunity to check if any new medicines or dose changes are included. Any problems with prescriptions can be addressed at this point rather than after the supply has been made. During this visit staff were observed to maintain the privacy and dignity of people. Staff approached and spoke to people in an appropriate manner. Strawberry Bank DS0000063274.V352003.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. The lifestyle at the home satisfies the needs of the people living there, and encourages the involvement of family and friends. EVIDENCE: During the visit, individual people were seen to be participating in various activities including watching television, looking at newspapers and receiving visitors. Visitors were seen to come and go to the home throughout the day. The hairdresser visits the home every week. Records indicated that people living at the home have various activities to choose from, such as a weekly visit from an aromatherapist, motivation class, karaoke, arts and crafts, dominoes, card games, personal library service. Staff said that other activities included playing dominoes and a small number of people are taken out by families on a regular basis. Staff also take people out for short walks. This was seen to happen on the day of this visit. The manager’s dog is a much loved pet, which the people at the home evidently enjoy seeing. During this visit, one person was taken out for a walk by one of Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 16 the staff and other people were seen to be enjoying playing a game of bingo. People spoken to during this visit stated that they choose what time they get up and go to bed, where and how they spend their day and what they have to eat. The lunchtime meal on the day of the visit was mushroom soup, roast chicken, roast potatoes, carrots, green beans, stuffing and gravy, or scampi, salad and onion rings. People living at the home appeared to enjoy the meal and were assisted in an appropriate manner. Where possible, people are encouraged to maintain as much independence as they can. Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People can be confident that their complaint will be dealt with effectively. Staff have received suitable training and understand the adult protection policies and procedures, which makes sure that the people they support are safe. EVIDENCE: All staff have previously received training in adult protection issues, and the training has been refreshed this summer. The adult protection policy and procedure in place at the home gives adequate information for staff to refer to. Staff spoken to appeared to have an adequate understanding of adult protection issues. The complaints procedure is displayed at the home and in the policies and procedure file. The home has not had any complaints since the last key inspection in July 2007. People spoken to said that they would feel comfortable in approaching the manager if they had any concerns. Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit. The home is generally safe and maintained and the standard of decoration and furniture in the home is adequate. The home is clean but there are some unpleasant odours in some of the bedrooms. EVIDENCE: As part of this visit, a tour of the building was carried out. Since the last visit, building work has continued and is ongoing to improve the environment. Work to install a shaft lift is nearly completed. This will remove the need to use the current stair lifts and will make moving around the home easier and safer for some people. Plans to build a new extension to provide a new kitchen and to ensure all rooms are for single occupancy have not yet commenced. The Commission has written to the provider to establish what the timescales and Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 19 order of the work will be due to concerns about the poor kitchen facilities provided at present. The Commission has also liaised with the Environmental Health Authority regarding this issue. Decoration of the lower ground hallways was in progress at the time of this visit. The manager reported that new floor, and repairs to the floors where needed, were to be carried out the week following this visit, in the lower ground hallways, the dining room and the main lounge. Generally, the home was clean and odour free, however there were two rooms where there was a noticeable odour of urine. Since the last visit, the manager has worked hard to try and eliminate the odour and has taken action by renewing the carpets, decorating and looking at cleaning products and schedules. Further discussion took place as to what other measures could be taken and the manager agreed to continue to manage the issue. Window restrictors have been fitted on the three windows highlighted during the visit in July 2007. A steam cleaner has been purchased in order to clean the lounge chairs. This has commenced on a one by one basis. The carpet in room 12 was stained and requires replacing. It was highlighted that there is a limited amount of spare bedding available in the home. At the time of the visit, the manager ordered some new bedding and agreed to add this on a regular basis. There were no waste paper bins in the toilets and shower room. Some of the paper towel and soap dispensers were empty. The driveway directly in front of the home is not safe. There are some potholes in it and loose pieces of tarmac which are a hazard. A comment was made by a visitor during this visit about the damage this could do to motor vehicles and it is also a tripping hazard for pedestrians. This must be addressed. The manager was informed about this issue during the visit. The bedrooms seen during this visit were clean and had been personalised with people’s own pieces of furniture, photographs and ornaments. Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People’s needs are met by trained and qualified staff who have undergone a thorough recruitment process before they are allowed to work in the home. EVIDENCE: Training records are in place at the home and records kept in individual staff members’ files. All staff received fire training in December 2006 and moving and handling training in February 2007. Plans are in place for staff to have further fire training before the end of October 2007 and new staff to complete moving and handling training by the end of October 2007. Other training has included medication administration, aggression management, food hygiene and dementia care. Adult protection training (safeguarding) was delivered to half the staff team on 16 August 2007. The other half of the staff team will receive this training on 4 October 2007. Eleven members of staff have achieved the National Vocational Qualification (NVQ) level 2 award in care, which means that 60 of care staff have achieved this standard. Recruitment processes at the home are much improved. The records of three members of staff were examined. Two were found to have in depth recruitment records with all required checks completed. The third record was in Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 21 relation to a member of staff who has worked at the home for a number of years and there were gaps in the information held. A full audit of staff files needs to be carried out to ensure that all staff who were recruited prior to these improvements being made have had the necessary checks completed, so that everything possible has been done to ensure that people are cared for by appropriate people. Staff do receive induction training when they start work at the home and records are in place for the six month induction process. Initial training given to ensure staff are safe to work in the home, such as fire safety, moving and handling and health and safety is now recorded. Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit. The home is adequately managed, people are generally kept safe by health and safety practices; they are involved in making improvements as part of the home’s quality assurance system. EVIDENCE: Miss Allen is the registered manager of the service and is currently working towards achieving the Registered Managers Award. Monthly management visit reports by the provider are documented and were available for inspection. Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 23 The environmental health officer visited the home in December 2006 and has been contacted by the Commission regarding the concerns about the facilities in the kitchen. The concerns relate to cupboard doors and drawer fronts being in a state of disrepair and being unsafe. Weekly checks of the fire system and emergency lighting system are recorded as being carried out. Any faults which need rectifying are recorded and any action required to remedy faults is taken. Hot water temperatures have not been recorded and the hot water in some of the bedrooms appeared to be extremely hot. The manager was advised to ensure that all hot water outlets are checked monthly and any remedial action taken as necessary. Thermostatic valves must be fitted to hot water outlets on baths and showers. It is also recommended that this is also done to other hot water outlets. Warning stickers and thorough risk assessments must be fitted throughout to hot water outlets on sinks where there is no thermostatic valve fitted. The records of three people’s personal monies were examined. The amounts held all tallied with the records kept in the home. Quality assurance surveys are sent out by the home annually and these results are published and posted on the notice board. Copies are available should anyone wish to look at them. Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 24 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13 (2) Requirement There must be enough stock of medication to administer to a person. This ensures that people do not go without their medication, which may adversely affect their medical condition. Medication must be stored securely. This reduces the risk of medication being tampered with or removed and makes sure it is safe to use. Care plans must accurately record how a person’s medications are being administered. This includes risk assessments for those who self administer. A full audit of staff files needs to be carried out to ensure that all staff who were recruited prior to these improvements being made have had the necessary checks completed. To prevent accidents, the driveway to the home must be made safe. To protect people from the risk of scalding, hot water temperatures must be recorded DS0000063274.V352003.R01.S.doc Timescale for action 15/10/07 2. OP9 13 (2) 15/10/07 3. OP9 17 Sch3 15/10/07 4. OP29 19 30/11/07 5. 6. OP19 OP38 23 13 31/10/07 30/11/07 Strawberry Bank Version 5.2 Page 26 monthly and thermostatic valves must be fitted to hot water outlets on baths and showers. Warning stickers and thorough risk assessments must be in place throughout to hot water outlets on sinks where there is no thermostatic valve fitted. 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 OP9 Good Practice Recommendations The storage of medicines should be secure and the temperature of the fridge and the room storing the medicines should be taken. This makes sure medicines are safe to use. A copy of the prescription request should be made and the prescription checked before sending to the pharmacy. This makes sure there are no problems before the supply is made. Photographs should be attached to MAR charts to make sure that medication is given to the correct person. Changes to MAR entries should detail who authorised the change, the date, and the person making the change. This makes sure there is an accurate record of the changes. To maintain good hygiene and improve the environment of the home, the lounge chairs should be cleaned or replaced and the corridor carpets should be cleaned or replaced with a more serviceable carpet. To improve the facilities in the home, the building work and programme of refurbishment should be continued. To help people move around safely, the home should provide handrails in corridors. To support the home’s hygiene and infection control measures, the laundry floor finishes should be impermeable and wall finishes cleanable. To make sure people’s rooms are pleasant, the odour in the two bedrooms identified should be eliminated. To maintain good hygiene, waste paper bins should be provided in the toilets and shower room and soap and DS0000063274.V352003.R01.S.doc Version 5.2 Page 27 2. OP9 3. 4. OP9 OP9 OP19 4. 5. 6. 7. 8. 9. OP19 OP22 OP26 OP26 OP26 Strawberry Bank 10. OP19 11. OP38 paper towels should be available at all times. Any action identified by the environmental health officer regarding the concerns about the facilities in the kitchen should be taken to ensure the safety of staff working in this area. Thermostatic valves should be fitted to all hot water outlets on sinks. Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Strawberry Bank DS0000063274.V352003.R01.S.doc Version 5.2 Page 29 - 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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