Inspection on 13/02/06 for Tapton Grove Nursing Home

This inspection was carried out on 13th February 2006.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 32 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tapton Grove Nursing Home 20/06/07

Tapton Grove Nursing Home 09/05/06

Tapton Grove Nursing Home 25/07/05

Tapton Grove Nursing Home 16/03/05

Tapton Grove Nursing Home 13/10/04

Tapton Grove Nursing Home 22/03/04

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Tapton Grove Nursing Home Grove Road Brimington Chesterfield Derbyshire S43 1QH Lead Inspector Bridgette Hill Unannounced Inspection 13th February 2006 09:30 Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 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 Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and Care Homes for Adults 18 – 65*. 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 Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Tapton Grove Nursing Home Address Grove Road Brimington Chesterfield Derbyshire S43 1QH 01246 274178 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) Sun Healthcare Limited Mrs Patricia Willey Care Home 47 Category(ies) of Dementia (10), Mental disorder, excluding registration, with number learning disability or dementia (37) of places Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Compliance with the identified programme of works (repair/upgrade) and refurbishment of the building as confirmed and detailed in writing letter dated 28.09.04, serious concerns - extended timescale agreement. All works to be completed in accordance with this agreement, with total completion timescale: by 31.03.05. 25th July 2005 Date of last inspection Brief Description of the Service: Tapton Grove provides nursing and personal care for up to 47 persons of both sexes, which includes up to 10 persons with dementia and 37 persons with mental disorder (excluding dementia and learning disabilities).There are separate nursing and care staff groups for each category with centralised hotel services (with satellite kitchens provided to each unit) and an overall registered manager. Service users with dementia are accommodated separately to those with a mental disorder. The home is located approximately 1.5 miles from Chesterfield town centre with a secluded setting approximately a half-mile from the nearest bus route. The older part of the building has a large double to single ratio of bedrooms. Details of room sizes are given in the statement of purpose for the home. There is level access to garden areas for service users. Good relationships and networks are establishing with outside health care professionals with regard to the specialist health care needs of those service users accommodated. Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced one which took place on 13th February 2006. Bridgette Hill was the lead Inspector and Rosemary Veale, Inspector undertook the inspection of the environment and medication. Various records including care planning records were examined the findings are recorded in the body of this report. Part of this inspection was dedicated to investigating a complaint. The Manager Pat Willey was on during the inspection. The scoring of outcomes page has not completed due to technical difficulties. Where standards have not been met requirements and recommendations are listed. What the service does well: What has improved since the last inspection? What they could do better: Risk management in the home has been identified as of concern by visiting professionals. It was found that there was poor identification of risk and therefore poor planning to limit this. Probably due to staff being accepting of some situations which had the potential to directly impact on service users without considering the need for protection of vulnerable adults interventions or adapting care plans to limit risks. The system for recording service users monies in the home was not being robustly used. Mistakes and errors were evident, as balances did not correlate. Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): See at end of section Service users were given opportunities to visit the home prior to being admitted. The system for recording pre admission assessments to ensure that service users needs would be met at the home was not being fully documented and dated. EVIDENCE: Terms and conditions of residency contracts were found in individual service users files where service users had the capacity to sign these they had. Some documents were also signed by staff where it was considered that service users had impaired capacity. Where this is the case it is acceptable to record that service users would not be able to understand the documents. This is preferable to staff signing on behalf of service users. Discussions were held with the Manager on prospective new service users. It was stated that all service users had opportunity to visit the home. Documents Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 9 available confirmed that one prospective service user had visited the home twice but had yet to be admitted. Some records were not being completed to reflect the date of the assessment undertaken by staff and were dated on the day of admission. Tapton Grove does not offer intermediate care as defined by this standard. OP standards assessed 2, 3 YA standards assessed 1, 2, 5 Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): See at end of section There was scope to improve the personalisation of the care plans available. In some files there were not documented care plans for mental health and complex needs and there was the potential for situations to be handled inconsistently or inappropriately. EVIDENCE: A sample range of care files were assessed from each unit to assess how standards in the home were being met. A standard format was in place to record assessed care needs, these were typed and easy to read. Care files contained photographs of service users, recorded preferred name and religion of the service user. Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 11 Whilst most care plans contained details of assessed needs there was scope for improvement on the personalisation of care plans for example one service user had a weakness on one side of their body but it was not documented which side. This fact would influence how care was to be delivered to service users. There was some deficits in identifying assessed needs in one care plan where it was not documented how mental health needs affected the service user. There were also some complex issues which had not recorded within care plans including situations where there was the capacity for service users to experience increased levels of anxiety/distress. The care plans that were in place had been reviewed and it was evident from the documents and speaking to some service users that there was participation from service users into the care planning process. A standard range of risk assessment tools were used and review dates for these were recorded. There appeared however to be poor risk assessment and planning where there were risks for individual service users. Staff spoken with appeared conversant with the needs of the service users and some of the associated risks however there was not sufficient assessment, planning and monitoring of risks in some cases. There appeared to be a high staff acceptance of some situations which had the potential to directly impact on service users with no risk management strategies being employed. Two separate visiting professionals have also provided information to the Commission for Social Care Inspection regarding concerns as to how risks are documented and managed in the home and this has been substantiated by the findings at this visit. OP standards assessed 7, 8, YA standards assessed 6, 9 Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): See at end of section There was varying provision of social and leisure activities. In the older persons unit there was poor provision and documenting of social activities. EVIDENCE: Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 13 Older Persons (and Younger adults combined unit) From the care files examined and associated social activities records it was apparent that there was poor recording of social activities. There was one staff member who had key responsibility to provide activities on the smaller 10 bed younger adult unit and it was observed that foot spa’s and nail painting was being offered on the day of the visit. Service users spoken to also said they enjoyed the bingo sessions held. On the older persons unit there appeared to be little social stimulation and it was said by staff that the service user group had limited capacity to participate. Feedback from one visiting professional was that they would like to see more structured activities to promote psychological stimulation. Younger Adults Unit Some service users were reasonably independent and went out to shop and access local facilities. Some service users attended local colleges to further education. Some group activities such as men’s & women’s groups were also held regularly in the home. Family contact varied for each service user and where it was possible ongoing relationships with families were supported and encouraged. Some service users were supported to go out and visit their family and friends Where bedrooms were shared there was a signed form to say service users had agreed to this. OP standards assessed 12 YA standards assessed 13, 14, 15 Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) Service users retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicines. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): See at end of section Positive relationships were reported both inside and outside of the home with a range of healthcare professionals and there was ongoing monitoring of service users needs by visiting professionals. Generally, residents were sufficiently protected by the systems in place for the safe handling of medication. EVIDENCE: In the sample of care files examined it was evident that there was adequate service provision from chiropodists, dentists and optician with visiting services being arranged. On the larger younger adult unit (27 beds) there were visits by psychiatrists routinely on a 3 monthly basis with additional visits as required. One visiting Care Manager was spoken to who visited the home for a day on a monthly basis. The Care Manager spoke of having a positive relationship with staff at Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 15 the home. An audit completed by the homes Manager confirmed that all apart from 2 service users had received multi disciplinary reviews within the past 3 months. One visiting healthcare professional was spoken to who said that they visited the home approximately 3 monthly. They spoke positively of the skills and professionalism of some of the staff. They said that staff demonstrated a good knowledge of the service users and any risks that were evident but couldn’t comment on how these were implemented into written care plans. This was a generally positive feedback regarding the home providing care for service users with complex and long term needs. The medication for both units was stored in the clinical room in the younger adults unit. Medication was securely stored. There was a medicines fridge for both units to use. There were records of daily temperatures of the fridge, but not of the daily maximum and minimum temperatures as recommended in the Royal Pharmaceutical Society, (RPS), guidelines for care homes. There were some residents in the younger adults unit who were able to selfadminister medication. The pharmacist dispensed their medication separately so that daily supplies could be given. A lockable drawer or ‘cash’ box was provided for these residents to keep medication securely. The medication administration records, (MARs), for each unit were seen. The MARs for the younger adults unit appeared to be completed correctly. Some of the MARs for the older people’s unit had handwritten entries, which had not been signed by the person writing them or countersigned by another person who had checked them as correct. This is recommended in the RPS guidelines. The policy / procedure for the administration and safe handling of medication was seen. Parts of the policy referred to another nursing home. The system in the home for the disposal of medication had changed but the procedure had not been updated. There was no mention in the policy that medication must be retained in the home for 7 days following the death of a resident in case of a coroner’s inquest. This was included in another policy in the home. There was a section of the recording format for service users post death wishes for the majority of files examined these had been completed and where the service user had declined to express a view this had been recorded. OP standards assessed YA standards assessed 8, 9, 11 19, 20 , 21 Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): See at end of section Adequate procedures were in place on how to handle allegations of abuse however there appeared to be an unacceptably high threshold in place as to where it was considered that Protection of vulnerable adults referrals were required. There was poor administration of service users monies. EVIDENCE: There had been any complaints received at the home since the last inspection. One complaint had been received by the Commission for Social Care Inspection and this was in the process of being investigated with some aspects being examined as part of this inspection report. Complaints procedures were available and displayed in the home. A Protection of vulnerable adults information file was available in the home which described how to access locally agreed procedures. From examination of care files it was established that there appeared to be a high tolerance of challenging and inappropriate behaviours in the home and that there had been occasions where there had been potential abuse of service users which had not reported through appropriate Protection of vulnerable adults procedures. There were also no records to evidence that this had been Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 17 considered. Where this had happened there were also deficits in how potential risks were to be managed. There had been two protections of vulnerable adults strategy meetings since the last inspection one concerning tissue viability issues on the older persons unit and staff had subsequently received training to improve knowledge and practice. At the second Protection of vulnerable adults meeting there was found to be insufficient evidence to prove the allegations made. Some training records could not be found to verify if staff had staff had received Protection of vulnerable adults training. This is an outstanding requirement from previous inspections. Some monies are stored safely in the home on service users behalf. Balances were recorded and double signatures were evident on transactions. Where the service user had capacity to sign they were involved in the recording process. Receipts were held for purchases made. Balances of monies being held were checked. These were found to inaccurate to the amount recorded as being available. No coins were available in the individual wallets and the Manager said that balances were held to the nearest pound. Some balances were over and some under the actual amounts which should have been available. Some of the discrepancies were for significant amounts of money. This was partly attributed to the process of pocket monies being paid into the Providers bank account and being transferred into individual wallets. It appeared however that whilst this cash was available it had not been distributed into service users wallets. No regular audits of monies were completed and the system in place was not robustly being implemented giving potential for the mistakes and errors listed to be made. OP standards assessed YA standards assessed 16, 18, 35 22,23 Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): See at end of section Improvements have been made to the home, but further work is needed to ensure the environment is comfortable for residents and meets National Minimum Standards. EVIDENCE: Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 19 The home is split into two units one accommodating 10 older persons and 10 younger adults. The second unit accommodates 27 younger adults 18 - 65 Older Persons/ Younger adults combined unit The unit for older people was a modern, purpose built building attached to the older part of the home. A tour of the building was carried out including the communal areas and most of the bedrooms. The unit was on two floors and the first floor was accessed by stairs or a shaft lift. There was a lounge / dining room on each floor and both had been recently redecorated and new carpets provided. Some new chairs had also been provided. The lounge / dining rooms appeared clean, comfortable and pleasant. The lounge areas lacked natural light but it was reported that lamps were used to address this. There was a comfortably furnished ‘quiet’ area on the first floor. Radiator covers had been fitted to all radiators throughout the unit but had not been decorated. The bathroom and toilets on the ground floor appeared clean. There were ceiling tiles missing in the bathroom and toilets. The bathroom was in need of redecoration. The bathroom and toilets on the first floor appeared clean. The bathroom was in need of redecoration. There were three sluice rooms, two with ‘hopper’ type sinks and the third with a mechanical sluice / disinfector. Some of the bedrooms had been decorated, (except for the radiator covers), and were pleasant and bright. New furniture and carpets had been provided in some bedrooms. Most of the bedrooms were personalised. Residents spoken with said they were satisfied with their bedrooms. There were three bedrooms which smelled strongly of urine. There were several bedrooms in need of redecoration, including some with marks caused by wheelchairs on the doors and walls. The unit was generally clean and free from offensive odours, (apart from the identified bedrooms). The small area to the outside of the lounge is identified on previous inspection reports as requiring risk assessing due to loose bark chippings being used as a floor covering. This had not been completed. Discussions on this revealed that there were plans to change the bark chipping to a more stable type surface. Younger Adults Unit A tour of the younger adults unit was carried out, including all the communal areas, the kitchen, laundry, and most of the bedrooms. A monthly audit of the unit is carried out and this was seen for January 2006. Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 20 The younger adults unit is in the older part of the home where most of the original features are retained. The main lounge appeared clean and comfortably furnished. The curtains appeared worn and were not hanging properly from the rails in places. The dining room appeared clean. It was noted that new chairs and tables had been ordered and were due to arrive soon after the inspection. The smoking lounge appeared in need of general redecoration. There was a small kitchen for use by residents which appeared clean and tidy. The door to this kitchen was wedged open which was potentially unsafe in the event of a fire. It was reported that the kitchen area would be better utilised as a laundry for residents for use. At present, residents were using the main laundry with staff supervision. The kitchen was used for both units and appeared clean and well equipped. There was an area of flooring which had previously been patched. The patch was coming up at the edges and needing replacing to ensure safety. The laundry was used for both units and was equipped with a commercial type washing machine and dryer. The washing machine had a disinfection / sluice cycle. There was also a domestic type washing machine which was used by residents for personal laundry. There were sufficient toilets and bathrooms provided for residents. One toilet did not have a blind or curtain to the window for privacy and the bin did not have a lid. The bathrooms seen all needed blinds or curtains fitted to the windows to ensure privacy. One bathroom had been recently refurbished but unfortunately was in need of further work because of misuse by residents. The bathrooms and toilets seen appeared clean. All except one of the shared bedrooms seen had a partition fitted for privacy. Most of the partitions were newly constructed and had not been decorated. Residents spoken with were pleased with the new partitions and were generally satisfied with their bedrooms. Most of the bedrooms seen were well personalised. Some bedrooms had been recently redecorated and appeared bright and clean. New furniture had been provided in some bedrooms. There were several bedrooms where new furniture and / or redecoration were needed and these rooms were identified to the manager. Radiator covers had been fitted to all radiators seen throughout the younger adults unit. OP standards assessed YA standards assessed 19,20,21,23,24,25,26 24,25,26,27,28,29,30 Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): See at end of section The staffing levels at the home and skill mix of staff was appropriate for the service users being cared for. Recruitment procedures are not always being implemented fully to ensure all necessary checks are completed prior to commencing employment. EVIDENCE: The home is arranged into two units for staffing purposes one for 27 younger adults and the second unit has a staff group caring for 10 older persons and 10 younger adults. The Manager of the home worked on a supernumerary basis and was supported in each of the two units by a Deputy Manager. The Deputy Manager of the older persons/younger adults is recently new in post. Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 22 Older Persons/younger adults combined unit Staffing rota’s indicated that typically there was one qualified nurse on duty for all shifts with 3 care staff on day shifts and 2 care staff on night shifts. Staffing rota’s indicated that staffing levels were appropriate for the number of service users being cared for in the home. Younger Adults Unit One concern has been raised to the Commission for Social Care Inspection regarding the supervision of service users and that visitors had difficulty locating staff. The inspectors also had some difficulty locating staff on arrival and service users informed staff that there were visitors. The home is a large home and the staff office is located on the first floor and the lack of a loud doorbell (there is a door knocker in place) appears to be affecting the welcome visitors receive. Staffing rota’s indicated that staffing levels were appropriate for the number of service users being cared for in the home. Shared information The total number of care staff employed at the home are 27 of which 15 hold at least NVQ (National Vocational Qualification) level 2 qualifications. A number of bank care staff are also employed who are undertaking nurse training. A sample of staff personnel files were examined these revealed that evidence of some key aspects of required pre recruitment checks were not in place for example references, proof of identities and Criminal Records Bureau checks. There were letters to staff demonstrating that there had been some attempts to secure these. Where Criminal Records Bureau checks were in files not all of these had been obtained by the provider and they had been supplied by the employee from previous employments. Criminal Records Bureau checks were also being stored as complete documents which is against the guidance given for storage and handling arrangements. Staff training records were examined. There was not an overview available of what training staff had undertaken and when updates were due. The method of recording training was for certificates to be placed into individual staff files. It was established that some certificates could not be located particularly moving and handling and Protection of vulnerable adults training. It could also not be evidenced if staff had received equal opportunities training as identified on previous reports. Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 23 Some certificates were available indicating that some staff had received training in fire safety, initiating care, health and safety, and Basic Food Hygiene. OP standards assessed 27, 28,29,30 YA standards assessed 33,34,35 Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): See at end of section There was stable management of the home and positive efforts are made to involve service users, families and healthcare professionals to contribute opinions regarding the running of the home. EVIDENCE: Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 25 The Manager of the home has been in post for 18 Years and has achieved a relevant managerial qualification. There was some appropriate delegation of tasks in the home to Deputy Managers such as quality assurance. A range of forms were available to try to ascertain the views of service users, visiting professionals and families. There was an ongoing process of giving/sending out forms and of those returned the feedback was generally good. Where aspects of concern were recorded it was evident that these had been followed up. A monthly visit was made and recorded by someone on behalf of the providers. The records of these were brief and it is recommended that details of the scope of the visits could be improved. Care records were found to be held within offices apart from one record relating to social activities it must be ensured that information relating to individuals care needs must be securely held. OP standards assessed 31, 37 YA standards assessed 37, 39 Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT Standard No Score 37 X 38 X 39 X 40 X 41 X 42 X 43 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Tapton Grove Nursing Home Score X X X X DS0000002079.V283083.R01.S.doc Version 5.1 Page 27 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Care plans must be in place for all assessed needs and detail how care is to be delivered to the service user Previous timescale 30.9.05 Where assessed risks and needs are identified these must be supported by a plan of care to describe how needs are to be met Where medication administration records are hand written these must be signed, checked and counter signed by a second staff member The procedure for the safe handling and administration of medication must be updated to include correct information regarding disposal instructions Where there are potential alleagtions of abuse these must be handled in accordance with the Protection of vulnerable adults procedures in the home A documented risk assessment must be undertaken in relation to the use of loose tree bark DS0000002079.V283083.R01.S.doc Timescale for action 31/03/06 2 YA9OP7 15 31/03/06 3 OP9YA20 13 31/03/06 4 OP9YA20 13 30/04/06 5 OP18YA23 13 31/03/06 6 OP19 13 31/03/06 Tapton Grove Nursing Home Version 5.1 Page 28 chips as a covering for the patio area and the potential for increased risk of falls for older service users/those with dementia.Action must be taken in accordance with the risk assessment and to ensure the safety of those service users who may access this area. Previous timescales 31.4.04 & 30.9.05 A bedroom redecoration programme must be drawn up and implemented Radiator covers throughout the home must be decorated There must be regular training updates in relation to the protection of vulnerable adults and associated procedures. Previous timescales 30.6.05 & 30.10.05 An audit must be undertaken of service users monies held in the home to estalish if there are discrepancies All financial records made on service users behalfs must be accurately maintained and recorded at all times Fire doors must not be wedged open The missing ceiling tiles must be replaced in toilet /bathroom areas The home must be kept free from offensive odours Staff must undertaken equal opportunities training Previous timescales 31.3.05 & 30.10.05 All records relating to service users must be held securely The home must ensure robust DS0000002079.V283083.R01.S.doc 7 8 9 OP24YA26 YA24OP19 YA23OP18 23 23 13 18 30/06/06 30/05/06 30/05/06 10 OP35YA23 13 31/03/06 11 YA23OP35 13 31/03/06 12 13 14 15 YA24OP19 OP19 OP26 YA32 23 23 16 12 15/03/06 30/04/06 31/03/06 30/04/06 16 17 OP37 YA34OP29 17 18 31/03/06 31/03/06 Page 29 Tapton Grove Nursing Home Version 5.1 18 YA35OP30 18 19 YA42OP38 23 recruitment procedures are adhered to which includes all the checks as required by Schedule 2 pre commencement of employment Training records must be kept 30/06/06 and made available to demonstrate staff are adequately trained to undertake the role for which they are employed The Provider must ensure that 31/03/06 the electrical installation is checked, safe, fit for purpose and any identified works are completed Work said by Manager to be completed certificate not available Previous timescale 30.9.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP9YA20 YA26OP24 YA28 OP33YA39 Good Practice Recommendations Maximum and minimum temperatures of the fridge used to store medication should be recorded daily. There should be ongoing investment into a furniture replacenment programme to ensure standards are maintained The registered person should consider providing a separate laundry facility from the main laundry, where service users who are able may wash and iron their own clothes. It is recommended that more details are recorded on the monthly providers visits forms on the aspects considered during the visit Tapton Grove Nursing Home DS0000002079.V283083.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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