CARE HOMES FOR OLDER PEOPLE
Tapton Edge Shore Lane Fulwood Sheffield S10 3BX Lead Inspector
Sue Turner Unannounced 15 July 2005 08:45am 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 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. Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Tapton Edge Address Shore Lane Fulwood Sheffield South Yorkshire S10 3BX 0114 268 5566 0114 268 5566 Not Available Tapton Edge Rest Home Limited 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) Mrs Megan Rowley PC Care Home Only 24 Category(ies) of OP Old Age (24) registration, with number of places Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 22 February 2005 Brief Description of the Service: Tapton Edge is a large converted victorian house providing care and accomodation for up to 24 older people. The home is situated in the Fulwood area of Sheffield, close to shops, churches and bus routes. The home is privately owned by Tapton Edge Rest Home Ltd. To the rear of the home is a large landscaped garden, provided with seating. Communal lounge and dining rooms are provided and sufficient bathing facilities are available. There are twenty-two single bedrooms and one double bedroom. Accomodation is provided over two floors, which can be accessed by a passenger lift. A car park is available. Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 5.15 hours from 8.45am to 1pm. A second inspector was present during the morning of this inspection. An inspection of the environment was undertaken. A proportion of records were checked, including care plans, complaints, menu, rotas, staff training, recruitment, health and safety and fire records. Interactions between staff and residents were observed. Ten residents, the majority of staff and two visitors were spoken with. Discussions with the homes manager took place. What the service does well:
The interactions observed between residents and staff appeared patient and respectful. All of the comments made by residents were positive. They said that they were `very well cared for and looked after’. Residents said staff were `very good’, `hardworking’, and `considerate’. The two visitors were visiting the home for the first time, and said they had been made to feel very welcome. A service user guide had been provided to each resident to give him or her information about the home. The manager undertook assessments prior to admission, to ensure individual needs could be met. Trial visits took place, to enable prospective residents and their representatives to make informed choices. Staff undertook a range of training to keep them up to date and ensure they were able to meet residents’ needs. Care plans were in place for all residents. These were well set out and easy to read. They set out all aspects of personal, social and health care needs and recorded the staff action required to ensure all identified needs were met. Residents’ health care was monitored and access to health specialists was available. Residents confirmed that staff were respectful towards them. Medication at the home was stored securely. Staff that administered medication confirmed that they had undertaken training in medication administration, to equip them with the skills needed to carry out the procedure safely. The routines at the home were flexible and residents were free to choose how to spend their day. A range of activities was available, which residents were free to participate in. All of the residents said they enjoyed the activities provided. There was an open visiting policy, to encourage contact with relatives and friends. The menu was varied, and choices were offered at mealtimes to respect residents’ preferences and maintain health. All of the residents said the food was `very good’, and `plentiful’.
Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 Page 6 There was a complaints procedure and Adult Protection procedure in place, to promote residents safety. All of the residents said they had confidence in the homes manager and staff, who would listen to any concerns and take them seriously. Residents said that they felt safe at the home. The environment was well decorated, well maintained, clean and fresh smelling. Communal areas contained homely touches to provide a comfortable environment. Bedrooms contained personal belongings, which enabled residents to have some control over their personal space. Sufficient bathing facilities were provided to ensure residents personal care needs were met. The central laundry and kitchen were well equipped to meet residents’ needs. Agreed levels of staff were being maintained. A staff training record was in place, and individual training records were maintained. A recruitment procedure was in operation to ensure the safety of residents. A business plan was in place, and insurance cover was provided. Staff supervision took place, to support and give guidance to staff on an individual basis. Records within the home were stored securely, to safeguard confidentiality. Health and safety procedures were identified and carried out, and systems were checked and serviced to maintain a safe environment. Mandatory training took place, to equip staff with the essential skills needed. What has improved since the last inspection?
Risk assessments in care plans had been updated to make sure they reflected identified need. Residents had signed care plans to evidence that they had been involved in the drawing up of the plans. Staff training had continued. Required levels of NVQ trained staff had been achieved. Staff files contained proof of identification, in line with safe recruitment procedures. A proportion of the environment has been redecorated to maintain the high standard at the home. Water temperatures were regularly tested and recorded to minimise risks. A gas safety certificate was in place. Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 Page 7 What they could do better: 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. Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 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 standard(s) 1,2,3,4 and 5. Standard 6 does not apply to this home. A statement of purpose and service user guide were available, to inform residents about the home. Contracts were drawn up with each resident, to inform them of their rights and obligations. Assessments of needs were undertaken prior to admission to ensure that the needs of prospective residents could be met. Trial visits were encouraged to enable prospective residents to look around the home, meet residents, staff and give them the information needed to make informed choices. Staff undertook periodic training to keep them up to date and access to specialist services was arranged, in order that all assessed needs were met. The information available and actions taken ensured that standards were met. EVIDENCE: Each resident had a service user guide, to inform him or her about the home. These were provided in each bedroom. Contracts (statements of terms and conditions) were drawn up with each resident upon admission, these were kept in care plans. Assessments of needs were in place, and copies of social
Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 Page 10 workers assessments were obtained prior to admission, if available, so that a decision could be made about whether the residents’ needs could be met. All of the residents said the home met their needs. One resident said ‘I am very well looked after’, and a further resident said `the staff are very good’. Residents confirmed that they had access to specialists at hospitals, and health professionals, such as dentists, opticians and chiropodists, so that all of their health care needs were met. Residents confirmed that they had been able to look around the home, stay for a meal and meet residents and staff, who provided them with the information they needed before choosing to move in. Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 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 standard(s) 7,8,9,10 and 11. Each resident had a care plan, to give staff the information needed to ensure all care needs were met. Health care was monitored, assessed and met. Procedures for the safe storage and administration of medication were in place. Some gaps in medication records were identified. Staff appeared respectful towards residents. Residents’ wishes regarding funeral arrangements had been sought to ensure they were carried out. These needed to be clearly identified within care plans. Each care plan contained a section on death and dying, to ensure residents wishes were sought and carried out. EVIDENCE: Care plans contained the full range of information required. These contained specific information on all aspects of personal, social and health care needs. The plans included information on the staff action required to ensure assessed needs were met. Residents were aware of their right to access their records, but chose not to do so. Staff were aware of the contents of care plans and were knowledgeable about residents individual needs. Care plans were reviewed regularly to ensure that they were up to date and relevant information was recorded. The plans contained detail of all health care contacts, appointments and treatments, to ensure health was maintained.
Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 Page 12 Residents’ health was monitored and access to specialists at hospitals, chiropodists, dentists and other health care professionals was available. Residents confirmed that they could see their GP and other professional visitors in private. Staff were observed respecting privacy by knocking on doors before entering. The interactions between staff and residents appeared respectful and caring. Residents made positive comments about their care. One resident said `I am very well looked after, the staff are very kind’. Several residents said` the home is very good’. Medication was stored securely, and the staff that administered medication had undertaken training to equip them with appropriate skills. One Medication Administration Record contained some gaps in recording, which did not follow safe procedures. The wishes of residents were sought regarding death and dying, whilst these were recorded in care plans, they were not specifically identified within the plan to ensure they were carried out. Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 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 standard(s) 12,13,14 and 15. Residents were able to make choices about how they spent their time. A range of activities was offered to residents, to promote choice and maintain interests. An open visiting policy was in place, in order to develop and maintain good relationships with residents’ family and friends. A varied menu was provided and choices were offered to respect personal preferences. EVIDENCE: Residents said they were able to get up and go to bed when they chose, and were seen to use different areas of the home according to their preference. A senior carer had been identified as responsible for activities, to ensure a range of appropriate social opportunities were available. Forthcoming activities were on display to inform residents. These included weekly quizzes, bingo, massage, knitting, baking and reminiscence. Entertainers visited the home on a regular basis. Trips out of the home took place, and included visits to pubs, shopping centres and the seaside. Residents were free to join in any organised activities, all said they enjoyed the range of activities offered. Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 Page 14 Residents confirmed that they were able to see their visitors in private. Those spoken to said their visitors could come at any time, and the home helped them maintain contact. Two people were visiting the home for the first time, and said that they had been made to feel very welcome. One resident informed the inspector that they had held a small birthday celebration, which their family had attended. Residents were able to bring personal items with them into the home. All of the bedrooms were individually personalised and very homely. This was important to residents as it helped them retain control over their immediate environment. The menu was varied and a balanced diet was provided to maintain residents health. Choices were offered on a daily basis. All of the residents said the food at the home was very good. Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 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 standard(s) 16 and 18 A clear and accessible complaints procedure was in place, to ensure residents’ rights were protected and any concerns listened to and taken seriously. An Adult Protection procedure was in place, to ensure residents safety was promoted EVIDENCE: Each resident and representative had been provided with a copy of the homes complaints procedure. This contained relevant detail and informed the reader of who to contact outside of the home to make a complaint, should they wish to do so. All of the residents said they had no concerns and could go to the manager and staff to sort out any worries they had. The home kept a record of complaints, which detailed the action taken and outcomes. The home had received one complaint since the last inspection, which had been properly dealt with. The CSCI had not received any complaints about the home. Staff were clear how to record any complaints received. An adult protection procedure was in place, which contained information on the Department of Health guidance `No Secrets’. Staff undertook training on adult protection to equip them with the skills needed to respond appropriately to any allegations. All residents said that they felt safe at the home. Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 Page 16 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 standard(s) 19,20,21,22,23,24,25 and 26. The home was maintained to a high standard. The environment was very clean, and fresh smelling. Appropriate facilities were provided to meet residents needs. All areas of the home were accessible. Homely touches had been provided to create a comfortable environment. Communal areas were well maintained, and residents’ bedrooms were well decorated and personalised. EVIDENCE: The environment was decorated to a high standard. Communal areas were attractive, comfortable and the furniture provided was of a good standard. There was a pleasant garden, and garden seating was provided for residents’ enjoyment. All of the bedrooms seen were well decorated and highly individual, reflecting the residents’ personal taste. Bedrooms contained personal belongings, which enabled residents to have some control over their personal space.
Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 Page 17 There were sufficient communal bathrooms and showers, with appropriate aids and adaptations in place, which met residents’ needs. A rolling redecoration programme was in place to maintain standards. All of the residents said that they were very happy with the accommodation provided. Several residents said that they really enjoyed the lovely gardens at the home, and appreciated the view from their bedrooms. The homes kitchen and laundry contained the equipment needed to provide for residents. A maintenance programme was in place to ensure the home was kept safe and well maintained. Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30. Agreed levels of staff were being maintained. Some staff undertook NVQ training to improve their skills. Recommended levels of NVQ trained staff had been achieved. The homes recruitment practices ensured a thorough procedure was in operation. Some of the required documentation was not retained on staff files. Staff undertook periodic training to keep them up to date. A staff training plan and individual training records were kept to monitor staff training. EVIDENCE: The homes rota indicated that agreed levels of staff were being maintained. Residents felt that enough staff were provided. Of the fifteen care staff, eight staff had achieved NVQ level 2 in care. Two further staff were undertaking the training at level 2. There was a thorough recruitment procedure, to uphold the safety of residents. Systems were in place to ensure CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) checks were carried out, to promote safe and efficient recruitment procedures. Staff files contained the majority of required information, and included written references from last employers. One staff file did not contain all of the required documentation. Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 Page 19 Staff training records were maintained to ensure all staff had undertaken relevant training. Staff confirmed that they undertook induction and foundation training to familiarise themselves with the home and understand the requirements of their role. Staff said that they received sufficient training to be able to carry out their duties. Residents said that staff had the skills to do their job well. Staff appeared competent to carry out their duties; they displayed an understanding of individual residents needs and were able to give examples of good practice. The interactions between staff and residents appeared positive. Staff had a caring and patient approach. Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,36,37 and 38. The management’s clear leadership benefited residents and staff. Regulation 26 visits by the responsible individual to monitor the service took place. Staff received formal supervision for development and support. The records were stored securely, to respect residents’ rights. Policies and procedures for the smooth running of the home and care of residents were in place and accessible to staff. Staff undertook mandatory training. A health and safety policy was in operation. Fire systems had not been checked at the required frequency to ensure they were in working order. Records of staff fire drills required some improvement to ensure they could be monitored and managed. EVIDENCE: The manager was experienced and qualified. Staff and residents said the manager was approachable and supportive.
Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 Page 21 Monthly monitoring visits by the responsible individual took place. Records of these visits required some further information to ensure all aspects of the home were being monitored. Budgets were in place to ensure the home was financially well managed. Formal staff supervision, to develop, inform and support staff took place at the required frequency of six times each year. Records were stored securely in the home to respect residents’ confidentiality. A health and safety policy was in place to protect staff and residents. Fire exits were clear and fire doors closed on their rebates. Records confirmed that fire-fighting equipment was checked and serviced. However, weekly checks of the fire alarm to ensure it was in working order had not taken place on a regular basis. The alarm was checked during this inspection and found to be in working order. Staff were up to date with mandatory training to equip them with the essential skills needed to promote the well being of residents. However, records of fire practice drills needed some improvement to ensure that they could be easily monitored and managed. Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 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 Standard No 16 17 18 Score 3 x 3 3 3 3 3 x 3 3 2 Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 13,15 Requirement Care plans must contain a risk assessment confirming that moving in wheelchairs without footplates in use is in response to identified need. Residents wishes regarding funeral arrangements must be clearly identified within care plans. Staff that administer medication must sign for all medication at the time of administration. (Previous timescale of 31/03/05 not met) Staff files must contain all of the required information. Records of staff fire drills must be organised to ensure that they can be efficiently monitored. All staff must participate in a practice drill a minimum of twice each year. Timescale for action 31/08/05 2. 9 13 312/08/05 3. 4. 29 38 18 13,18 31/08/05 31/08/05 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 Good Practice Recommendations
J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 Page 24 Tapton Edge 1. Standard 33 Records of Regulation 26 monitoring visits should contain further detail. Tapton Edge J55-J06 S3020 Tapton Edge V236338 150705 UI Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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