CARE HOMES FOR OLDER PEOPLE
Tapton Edge Shore Lane Fulwood Sheffield South Yorkshire S10 3BX Lead Inspector
Mrs Janis Robinson Unannounced Inspection 24th November 2005 08:45 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 Tapton Edge DS0000003020.V265774.R01.S.doc Version 5.0 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. Tapton Edge DS0000003020.V265774.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Tapton Edge Address Shore Lane Fulwood Sheffield South Yorkshire S10 3BX 0114 268 5566 0114 268 5566 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) Tapton Edge Rest Home Limited Mrs Megan Rowley Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Tapton Edge DS0000003020.V265774.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15th July 2005 Brief Description of the Service: Tapton Edge is a large converted victorian house providing care and accommodation for up to 24 older people. The home is situated in the Fulwood area of Sheffield, close to shops, churches and bus routes. Tapton Edge Rest Home Ltd privately owns the home. Communal lounge and dining rooms are provided and sufficient bathing facilities are available. There are twenty-two single bedrooms and one double bedroom. Accommodation is provided over two floors, which can be accessed by a passenger lift. To the rear of the home is a large landscaped garden, provided with seating. A car park is available. Tapton Edge DS0000003020.V265774.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 3.15 hours from 8.45 am to 12.00 pm. An inspection of the environment was undertaken. A proportion of records were checked, including care plans, rotas, staff training, recruitment, health and safety and fire records. Interactions between staff and residents were observed. Eight residents, a proportion of staff and two visitors were spoken with. One member of care staff was formally interviewed. Discussions with the homes manager took place. What the service does well:
A warm, welcoming and happy atmosphere was apparent. Residents were well cared for and a very good quality of life was promoted. The interactions observed between residents and staff appeared patient and respectful. Staff spent time to sit and chat to residents, and it was evident that positive, caring relationships existed between staff and residents. Relatives and friends had a positive influence at the home and were encouraged and supported to be involved an all aspects of residents’ lives. 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’, ‘excellent’ and ‘considerate and kind’. The two visitors said they were always made to feel very welcome, and were very happy with the care their relative received. A service user guide had been provided to each resident to give him or her information about the home. Contacts had been undertaken with each resident to inform them of their rights and obligations. 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. Tapton Edge DS0000003020.V265774.R01.S.doc Version 5.0 Page 6 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. Care plans evidenced that residents’ wishes regarding dying and death were sought and recorded. A full 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. All of the residents said the food was ‘very good’ and ‘plentiful’. 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. 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?
Care plans had been expanded to develop recordings on residents’ wishes regarding dying and death. Medication administration records were fully completed and up to date. Employment records contained the full range of information required. The management systems at the home had been reorganised to enable some managerial responsibilities to be shared. Regular fire drills had taken place to ensure all staff had the skills needed to respond in an emergency.
Tapton Edge DS0000003020.V265774.R01.S.doc Version 5.0 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 DS0000003020.V265774.R01.S.doc Version 5.0 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 Tapton Edge DS0000003020.V265774.R01.S.doc Version 5.0 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, 2, 4 and 5. 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. 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. All of the residents said the home met their needs. One resident said ‘I am very well looked after, we are lucky to live here’ and a further resident said ‘the staff are very good, you only have to ask and it is there’ and ‘we share lots
Tapton Edge DS0000003020.V265774.R01.S.doc Version 5.0 Page 10 of laughter in this home’. 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. Staff undertook a range of training to develop their skills. 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 DS0000003020.V265774.R01.S.doc Version 5.0 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, 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. Staff appeared respectful towards residents. Residents’ wishes regarding funeral arrangements had been sought to ensure they were carried out. 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 DS0000003020.V265774.R01.S.doc Version 5.0 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. Medication Administration Records were fully completed and up to date. The wishes of residents were sought regarding death and dying, since the last inspection care plans had been expanded to ensure that any wishes were specifically identified. Tapton Edge DS0000003020.V265774.R01.S.doc Version 5.0 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 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. Relatives and friends of the home were actively encouraged and involved in fundraising and activities. This was greatly appreciated by the staff. On the afternoon of the inspection a reminiscence quiz was taking place. This was very well attended and enjoyed. Plans were in place to hold a fancy dress Xmas party, and several shopping trips had been organised.
Tapton Edge DS0000003020.V265774.R01.S.doc Version 5.0 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 relatives visiting the home said that they were always made to feel very welcome, and were kept well informed by the home. 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. Staff had access to food supplies at all times, to meet residents needs. Tapton Edge DS0000003020.V265774.R01.S.doc Version 5.0 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 A clear and accessible complaints procedure was in place, to ensure residents’ rights were protected and any concerns listened to and taken seriously. 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 not received any complaints since the last inspection. Staff were clear how to record any complaints received. Tapton Edge DS0000003020.V265774.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 21 and 24. 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 DS0000003020.V265774.R01.S.doc Version 5.0 Page 17 There were sufficient communal bathrooms and showers, with appropriate aids and adaptations in place, which met residents’ needs. Toilets were provided with tablet soap. Liquid soap would improve systems for the control of infection. 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 DS0000003020.V265774.R01.S.doc Version 5.0 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 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, 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. Staff undertook periodic training to keep them up to date. A staff training plan and individual training records were kept to monitor staff training. Induction training had not been fully provided to one member of staff. EVIDENCE: The homes rota indicated that agreed levels of staff were being maintained. Residents felt that enough staff were provided. Over 50 of the care staff were trained to NVQ level 2 or 3 in care. 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 all of the required information, and included written references from last employers and CRB checks. 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
Tapton Edge DS0000003020.V265774.R01.S.doc Version 5.0 Page 19 requirements of their role. However, records evidenced that one recent employee had not fully undertaken the homes formal induction training. The inspector acknowledges that the employee had alternative employment during the week, and worked weekends only at the home. Nevertheless, systems must be in place to ensure all staff receive full induction training within the first six weeks of employment. 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 DS0000003020.V265774.R01.S.doc Version 5.0 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 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): 31, 32, 33, 35, 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. A quality assurance system, to seek the views of residents and their representatives, was in place. Staff received formal supervision for development and support. Residents’ finances were safely managed. 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. Staff fire drills took place at the required frequency. EVIDENCE: The manager was experienced and qualified. Staff and residents said the manager was approachable and supportive.
Tapton Edge DS0000003020.V265774.R01.S.doc Version 5.0 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. Annual questionnaires were undertaken with residents and their representatives. The results of these surveys were audited and published. Systems were in place to ensure residents’ finances were safely managed. Records were up to date and well organised. 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. Staff were up to date with mandatory training to equip them with the essential skills needed to promote the well being of residents. Records of fire practice drills had been improved to ensure they could be monitored efficiently. All staff had participated in drills over and above the required minimum frequency. Tapton Edge DS0000003020.V265774.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 2 X X 3 X X STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Tapton Edge DS0000003020.V265774.R01.S.doc Version 5.0 Page 23 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. 2. Standard OP21 OP30 Regulation 12 18 Requirement Liquid soap must be provided in all toilets. Systems must be in place to ensure all staff are provided with full induction training within the first six weeks of employment. Timescale for action 31/01/06 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Tapton Edge DS0000003020.V265774.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Sheffield Area Office 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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