CARE HOMES FOR OLDER PEOPLE
Taptonholme 14 Taptonville Crescent Sheffield South Yorkshire S10 5BP Lead Inspector
Jayne Barnett-Middleton Unannounced Inspection 09:30 2 March 2006
nd 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 Taptonholme DS0000003021.V268615.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. Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Taptonholme Address 14 Taptonville Crescent Sheffield South Yorkshire S10 5BP 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) 0114 266 3440 0114 266 3440 Taptonholme Limited Miss Suzanne Victoria White Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th July 2005 Brief Description of the Service: Tapton home is located in the Broomhall area of Sheffield and provides personal care to 19 service users. The aims and objectives of the home are to provide a caring, safe and stimulating environment. All bedrooms are single with some having ensuite facilities. There are sufficient bathrooms and toilets, which are situated close to bedrooms and communal areas. The home is situated in its own grounds and has as large mature garden with seating areas. Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 9.30 am to 2.30 pm. Most of the residents were seen during the inspection. Five residents, four staff, one visitor and the registered manager were spoken to. A sample of records was examined and a partial inspection of the building was carried out. Throughout the inspection positive and professional relationships were observed between staff and residents. The inspector wishes to thank the manager, staff and residents for their time and co-operation throughout the inspection process. What the service does well: What has improved since the last inspection?
A new care plan format had been introduced. Three care plans were checked and all set out in detail the action that was required by staff to ensure that all aspects of the residents care needs were met. Some bedrooms had been redecorated and that there was an ongoing programme of redecoration.
Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 6 On the day the entrance and hallway were being re-decorated. Whilst not fully completed the colour scheme chosen certainly made the entrance look bright and welcoming. Formal supervision for staff had commenced, enabling them to discuss their role and personal development. Valves were not fitted to hot water outlets to ensure that the water was delivered at a safe temperature. A risk assessment had been completed and water temperatures were being monitored to protect residents from the risk of scalding. An approved contractor had checked the electrical circuits. 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. Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 7 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 Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 8 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): 3 and 5. Residents were not admitted to the home without their needs being assessed, to ensure the home was able to meet their health, social and care needs. Prospective residents and their relatives were invited to visit the home to asses the quality, facilities and suitability of the home. EVIDENCE: Three resident files were checked and each contained a full needs assessment which had been completed prior to their admission. This confirmed that the service was appropriate for the resident and provided staff with the information to formulate an individual plan of care. Residents confirmed that they and their relatives had been invited to visit the home prior to their admission. The home does not provide an intermediate care service. Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 9 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 and 10. Care plans were in place for all residents. These were detailed and had been reviewed monthly. Resident’s physical and emotional needs were met. There was evidence that a range of healthcare professionals regularly visited the home to meet the resident’s needs. Residents received personal support, which promoted their privacy, dignity and independence. A policy and procedure to ensure that staff adhered to the safe administration of medication was in place. EVIDENCE: A new care plan format had recently been introduced. Care plans were in place for all residents. Three care plans were checked and all set out in detail the action that was required by staff to ensure that all aspects of the residents care needs were met. The information provided was accessible and easy to track.
Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 10 Healthcare records were well maintained and demonstrated that residents were receiving regular visits from their general practitioner, chiropodist and dentist. All residents spoken to confirmed that their healthcare needs were met. Nutritional screening had been undertaken for residents and included any specific dietary needs. However, residents were not being weighed on a regular basis or records maintained, to ensure that any potential healthcare problems could be identified. There was a medication policy and procedure to ensure that staff adhered to safe practices. The medication was checked on a sample basis. Medication checked was stored and had been administered appropriately. Staff responsible for administering medication had received medication training, all promoting the safe administration of medication to residents. Throughout the day staff were observed to treat residents with dignity and respect. Residents spoke highly of the care that they received and confirmed that their privacy was always respected. Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 11 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. The daily routines within the home were flexible to the needs of the residents. Residents were encouraged to spend their day, as they preferred. Residents were satisfied with the level of activities and support that was offered. Residents were able to receive visitors at any reasonable time. A good choice of menu was offered and specific dietary needs were catered for. EVIDENCE: There was a relaxing atmosphere within the home. Residents were observed to be following their preferred routines. The majority of residents were spending time in the lounge areas, socialising with other residents, whilst others had chosen to spend their day in the privacy of their bedroom. Residents were satisfied with the level of activities provided, which included videos and music. On the day one resident had attended a coffee morning within the local community. The staff confirmed that regular day trips were organised during the summer. The manager commented that two volunteers
Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 12 had recently commenced to visit the residents on a regular basis, which was working very well. Residents said that their relatives and friends were able to visit the home at any reasonable time. One visitor who visited the home on a regular basis said that they were always offered a drink and the staff were always very welcoming. A good choice of menu was offered and special dietary needs were catered for. Residents were satisfied with the choice and quality of food commenting “its nice” and “very good”. Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 13 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 and 18. The complaints procedure was clear and accessible. Complaints made by residents and their relatives were listened to and action was taken to deal with complaints promptly. There was an adult protection procedure in place at the home. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home. EVIDENCE: The complaints procedure ensured that residents and their relatives were aware of how to make a complaint and who would deal with them. The manager said that no complaints had been received since the last inspection. All residents spoke positively about the attitude of the manager and the staff team describing them as “helpful”. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. Most but not all staff had attended Adult Protection training to enable them identify, and the procedure to follow, should they suspect any abuse at the home. Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 14 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 and 26. In the main residents were provided with an environment that was safe, accessible and homely. EVIDENCE: The home was clean, tidy and odour free. Residents said that they liked their home “its nice here”. One relative commented that the home was “always very clean and odour free”. The manager said some bedrooms had been redecorated and that there was an ongoing programme of redecoration. On the day the entrance and hallway were being re-decorated and whilst not fully completed the colour scheme chosen certainly made the entrance look bright and welcoming. Radiator guards had become unattached from the wall in some bedrooms. The manager said that this had been an ongoing problem and that alternative radiator guards were being considered, which would fit more securely.
Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 15 A carpet in one bedroom was loose creating a potential tripping hazard to the resident. The grounds to the home were very well maintained. Residents said that they enjoyed spending time in the garden area during the summer months. Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 16 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. Residents spoke positively about the attitude of the staff and the service that they received. Residents said that there was sufficient staff provided to meet their needs. Staff had received training to meet the resident’s general and specific needs. Residents were not fully protected by the recruitment policies and procedures EVIDENCE: Residents spoke positively about the manager and staff describing them as “helpful” and “they will do anything that you ask”. The staff said that they enjoyed working at the home and that there was good teamwork. They commented that there was sufficient staff on duty, enabling them to provide the emotional and personal support to residents. A training and induction programme for staff was in place enabling them to meet the assessed and changing needs of residents. Staff confirmed that they had attended various training courses that included food hygiene, moving and handling and First aid. Refresher training in food hygiene and first aid was scheduled to take place in April. One member of staff who had recently commenced employment at the home confirmed that they had received the appropriate support and induction, enabling them to safely care for residents.
Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 17 The manager said that 61 of the staff team held a NVQ level 2 or 3 qualification, promoting staff development and competence. Two staff recruitment files were checked. Both did not contain a recent photograph of the employee or a full list of employment. Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 18 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): 31,35 and 38. Staff said that there was good teamwork and all staff spoke positively above the management team. Service users financial interests were safeguarded by the procedures at the home. The homes policies and procedures in the main promoted the health, safety and welfare of service users and staff. EVIDENCE: The manager has been in post for several years and has completed the registered managers award and a NVQ level 4 qualification. The atmosphere within the home was relaxed and welcoming. Staff said that the management team were “supportive” and “confidential”.
Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 19 Arrangements were in place for residents who were unable to or chose not to manage their monies. Monies were securely stored and records checked evidenced that service users were able to access their monies for hair care and personal items as they wished. Systems were in place to protect service users from financial abuse and the manager carried out regular checks. A recommendation for two staff to check resident monies on a regular basis was made, to further safeguard resident finances. Formal supervision for staff had commenced, enabling them to discuss their role and personal development. The staff said that they worked well as a team and that staff meetings took place on a regular basis, enabling them to contribute to the development of the service. Valves were not fitted to hot water outlets to ensure that the water was delivered at a safe temperature. A risk assessment had been completed and water temperatures were being monitored to protect residents from the risk of scalding. An approved contractor had checked the electrical circuits. The home was generally well maintained and all areas seen were clean and safe. The staff had received regular training to promote the health, safety and welfare of residents and their colleagues. Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 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 3 X X X 3 X X 2 Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 21 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. 2. 3 4 5 Standard OP8 OP18 OP19 OP19 OP29 Regulation 15 13 13 13 18 Requirement Service users must be weighed on a regular basis and monitoring records maintained. All staff must receive adult protection training and guidance. The identified bedroom carpet must be made safe or replaced. Radiator guards must be re-fixed to the walls. (Timescale of 10/08/05 not met) Staff files must include all the information required by schedules2 and 4. (Timescale of 10/08/05 not met.) To control the water temperature and reduce the risk of scalding valves must be fitted to outlets where full body immersion takes place. (Timescale of 30/10/05 not met) Timescale for action 30/05/06 30/06/06 30/03/06 30/04/06 30/05/06 6. OP38 13 01/07/06 Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP35 Good Practice Recommendations Two staff should check resident finances on a monthly basis. Taptonholme DS0000003021.V268615.R01.S.doc Version 5.0 Page 23 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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