Inspection on 14/03/07 for The Firs

This inspection was carried out on 14th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 but made no statutory requirements on the home.

Other inspections for this house

The Firs 09/02/09

The Firs 05/09/08

The Firs 18/03/08

The Firs 06/04/06

The Firs 19/10/05

The Firs 27/07/05

The Firs 21/01/05

The Firs 02/06/04

The Firs 09/03/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Firs 186c Dodworth Road Barnsley South Yorkshire S70 6PD Lead Inspector Mrs Jayne White Key Announced Inspection 08:45 14th March 2007 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 The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Firs Address 186c Dodworth Road Barnsley South Yorkshire S70 6PD 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) 01226 249623 01226 249623 none None Mr Azar Younis Mrs Susan Hunter Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th April 2006 Brief Description of the Service: The Firs is a care home providing personal care and accommodation for 33 older people. The homes registered owner is Mr Azar Younis. The Firs is situated approximately one mile from Barnsley town centre in one direction and the M1 motorway in the other direction. A main bus route passes the bottom of the drive. The home is all on one level and has 25 single and four double bedrooms. The home is on the same site as its sister home, Dorothy House. The Firs has a lawned area and a small car parking area to the front. The garden area was accessible to residents. The home’s current statement of purpose and service user guide is available in the entrance hall to the home, including the CSCI inspection report. The manager identified the fee for permanent, respite and short stay residents as £327.50, however, and this is based on a financial assessment completed by social services. Additional charges were made for hairdressing, private chiropody, toiletries, papers and magazines. This fee was that applied at the time of inspection and people may wish to obtain more up to date information from the care home. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key announced site visit carried out between the hours of 8:45 and 17:15. Two inspectors, Jayne White and Sue Stephens, undertook the inspection. A pharmacy inspector, Helen Jackson, was also involved with the inspection, specifically to undertake inspection of medication practices and procedures. The inspection was announced to facilitate the attendance of the owner at the visit. The home had not sent to the CSCI information to assist with the site visit as requested at a meeting with the provider and manager on 2 February 2007, therefore, the opportunity to undertake a wider sample of stakeholder’s opinions of the service was unable to be carried out. The inspection process included a partial inspection of the premises, inspection of a sample of records, observation of care practices and speaking with residents, their relatives/advocates and staff. The inspector spoke in detail to four of the staff on duty about aspects of their knowledge, skills and experiences of working at the home, three residents about their opinions on aspects of living at the home and three relatives of their opinions of the home. Also taken into account was other information received by CSCI about the service since the last inspection. In addition the CSCI have reviewed their guidance on requirements, therefore, some requirements have been removed if they had no direct evidence of service user outcome, or reworded. The inspector wishes to thank the residents, staff and owners for their time and co-operation throughout the inspection process. What the service does well: Residents were provided with access to health care services to promote and maintain their health care needs. The home uses a form supplied by the pharmacy to inform the pharmacist of changes to residents’ medication. A copy of this is kept in the home. This is an example of good practice, as it makes sure that the pharmacy has the most up to date information and the resident will receive the correct treatment. On the whole discussions with residents’ and their advocates described how they were helped to exercise choice and control over their lives and how the lifestyle within the home met their preferences, interests and needs. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 6 Residents maintained contact with family and friends and members of the local community as they wished. The food in the home was of good quality, well presented and on the whole met the dietary needs of residents. Residents and relatives were confident their complaints would be listened to and acted upon. There was an adult protection procedure, staff had received protection of vulnerable adults training and staff could describe action they would take to ensure residents were protected from harm or abuse. Resident’s needs were met by the numbers and skill mix of staff. Residents and/or relatives description of staff concluded they were very good, friendly, do their best, were excellent, understanding, first class and couldn’t be any better. Staff were trained to equip them with the knowledge and skills for their roles within the home, to enable them to care for residents in a safe way. Residents’ financial interests were safeguarded. What has improved since the last inspection? There has been improvement in the handling and recording of medicines within the home. Medication returned to the pharmacy is recorded. The medicines room has been tidied and is now easier to work in. The controlled drugs register has improved and is much neater and easier to follow. The medication policy has been updated. Cleanliness of the home, particularly the cleaning of the conservatory carpet, hoists and fans. Residents were spoken to/about with respect upholding their dignity and their right to privacy. The Code of Conduct and Practice set by the GSCC for carers had been implemented. Good moving and handling practices were observed. Records were in place to demonstrate weekly testing of emergency lighting and monthly testing of fire extinguishers. Regular checks of water temperatures were being carried out and documented. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 7 Sufficient staff had been employed to ensure staff received days off and did not have to work double shifts on a regular basis. What they could do better: For the provider and manager to proactively take action to meet their responsibilities in ensuring compliance with regulations and standards. Provide further information in the service user guide and contracts/terms and conditions so that prospective residents had sufficient information for them to make an informed choice about where to live and what this will cost. Ensure that residents’ assessed needs are in sufficient detail to formulate a plan of care to demonstrate those assessed needs have been met. The plan of care only demonstrated some of the resident’s assessed health and personal care needs were set out in the individual plan of care. A plan of care to meet social care needs of residents needed to be included. The recording of the administration for medication supplied in an original packs is not consistent. Residents who self-administer have not been assessed to see if it is safe for them to do so. Facilitate social care needs on an individual basis, making a charge where required. The windows in the bungalow part of the building were displaying evidence of age and rotting and replacement would enhance the appearance of the home. Implement day to day inspection of the environment to ensure that broken toilet chairs were not placed in bathroom areas, appropriate bins were provided to dispose of paper towels, pull cords were clean, smells of urine were eradicated quickly and frayed bedroom carpets were replaced before they became a hazard for residents occupying those rooms. Place pictures, mirrors and notices lower down to make it easier for residents to see them. Demonstrate the home’s recruitment policy and practices is sufficient to protect residents from harm by demonstrating appropriate police checks have taken place prior to commencement of employment and concerns raised in references have been addressed/considered as part of the process. Ensure reports/evidence is provided of implemented quality assurance and monitoring systems, so that on subsequent inspections their effectiveness can be verified and show inclusive involvement of stakeholders of the service in ensuring a quality service is provided. Implement a formal verifiable supervision process. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 8 Ensure fire drills are not predictable to staff by having them at different times of the day and ensuring staff are present on the required number of fire drills. Inform CSCI of incidents where residents have been identified as having a pressure area. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 9 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 The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for 1, 2 & 3 were inspected. The home does not provide an intermediate care service (Standard 6). Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents had some information about the home prior to admission but this was insufficient for them to make an informed choice about where to live as lots of information had still not been included in the service user guide. Resident had a written contract/statement of terms and conditions with the home but this did not always contain sufficient information for the resident and/or their relative/advocate to be clear of the fee to be paid, how it is to be paid for, who will pay for the different elements that make up the fee, the terms and conditions with which they live at the home when placed by the local authority and the notice they have to give if they wish to leave. All residents moving into the home had, had his/her needs assessed, however this was not in sufficient detail. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 11 EVIDENCE: The statement of purpose and service user guide were submitted prior to the inspection on 3 October 2006. The statement of purpose contained the majority of information but there were omissions relating to the number, relevant qualifications and experience of the staff working at the care home and the arrangements made for consultation with residents about the operation of the care home. The manager stated this had now been included. At the same inspection the service user guide did not include the CSCI inspection report, complaint procedure and the name and address of the Commission for Social Care Inspection. On this inspection, the service user guide did not include a brief description of the accommodation and services provided, including individual and communal accommodation, relevant qualifications and experience of the provider, the number of places provided, a copy of the most recent inspection report, the timescale when complainants will be responded to, a contract including the service and facilities to be provided, fees to be charged and the arrangements for paying that fee, what’s included in the fee, how items not included in the fee are to be paid for, a statement of whether any of the charges would be different if paid for someone other than the resident and where a local authority has made the arrangements a copy of the agreement between the provider and the local authority. The contracts for three residents were inspected. Two of the three contracts were in place and contained the majority of the information required. The other only identified the fee to be paid, not who paid it and it was not signed as agreed either by the home and the resident and/or their relative/advocate. Discussion with one relative, who dealt with finances on their relatives behalf identified they did not know if they had a contract/terms and conditions with the home. When asked how they knew what to pay they said, “Sue (the manager) sends a bill and then we pay it”. They did not know what the fee included. They knew they did not pay the full fee but did not know who paid the “other bit”. This does not ensure residents and/or their relative know what the costs are for living at the home, what is included in the fee and who the fee is payable by. The assessment of need for three residents was inspected. An assessment was in place for all three residents. The content of the detail in the assessments was basic/broad in detail and was not carried forward to the resident’s plan of care. For example, a resident was assessed as having Parkinson’s Disease and anaemia, but the plan of care made no reference to the care to be provided to meet those assessed needs. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for 7, 8, 9 & 10 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some of the resident’s health and personal care needs were set out in an individual plan of care, but omissions and lack of detail were evident. A plan of care to meet social care needs of residents needed to be included. Residents were provided with access to health care services to promote and maintain their health care needs. There were systems in place to make sure residents were getting medication and treatment as prescribed. Residents were treated with respect and dignity and their right to privacy upheld. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 13 EVIDENCE: All residents spoken with were happy with the care provided, as did their relatives. They said the care provided “was very good”. There had been improvements within the five care plans inspected, as the plan although basic, did reflect the care provided, with at least monthly reviews of those plans. The outcome of the inspections of the plans of care were discussed with the manager and provider. The discussion centred on how the care plans needed to improve to ensure a plan of care was implemented for each item of assessed need, where action needed to be taken by carers to meet that need. Specific examples include emotional, psychological and social care needs. Consistency was not maintained in ensuring a history profile of residents was in place. Moving and handling plans were basic and included minimal information, but did reflect current moving and handling practices. There continued to be omissions within the plan of care for pressure area care and residents who had pressure areas had not been notified to CSCI. Nutritional risk assessments were in place, but again the plan of care did not demonstrate the action taken as a result of the assessment. In one instance there was no evidence to demonstrate the reason why a resident was on a ‘fat free diet’ and monitoring of this. Systems for the monitoring of accidents had potentially been improved. Details of the accidents were being filed in the residents’ plans of care, however, this demonstrated omissions where two accident reports could not be found. A system had been implemented for the monitoring of accidents that did not require medical intervention. Again although this is good practice, the system was not implemented consistently and could place residents at harm if their condition is not monitored. A pharmacy inspector undertook the inspection of medication systems and concluded: The medication policy/procedure had been updated since the last visit to include the procedure to follow when recording non-administration. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 14 Record Keeping: • A list of staff authorised to administer medicines and examples of their signatures is kept in the MAR folder as recommended at the last pharmacist inspection. This allows identification of who was involved in administration if a query or problem occurred. The recording of medicine administration has improved since the last pharmacist inspection. There were missing entries for the recording of administration of patches to treat angina and for a new medication issued by the local hospital. Handwritten entries were good. The use of codes for recording the reason medication was not administered was consistent. The quantity of medicines received and the date of receipt are recorded on the MAR chart. This is an example of good practice, as it makes sure there is an accurate record. Changes to MAR entries such as a new dose were missing a signature and date of change. To make sure there is an accurate record the date, a signature and second signature where possible should be included. The MAR dividers in the folder were untidy. Some were missing the name of the resident. There was nothing on the MAR to indicate those residents who selfadminister. To make sure that the chart accurately records all administration it should be clearly written if a resident self-administers. There was no record in the care plans for these residents to show that a risk assessment had been done to make sure it was safe for them to administer their own medication. There were a number of entries for administration that had a signature not listed on the staff list. The staff list should be regularly updated to include new staff members authorised to administer medicines. There is a good system in place for the recoding of returned medication. • • • • • • • • • Administration: The lunchtime round was observed. Medicines were administered in an appropriate manner. Patients were asked quietly if they needed their medicines, this helped to maintain their confidentiality and dignity. An audit of current stock and records showed that some medication had been given but not recorded. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 15 Controlled Drugs: • • • The controlled drugs cabinet is suitable for use. A new register has been bought since the last inspection, which meets the requirements. Medicines returned to the pharmacy are recorded in the register. There was some confusion over the recording of balances. The quantity remaining in the cabinet was one less than the balance. The inspector was informed that this figure was the quantity before administration. However to make sure there is an accurate record the quantity remaining after administration should be recorded. Storage: • The medication room on the day of the visit was warm. The room has no ventilation. The maximum temperature recommended by most manufacturers for the storage of medicines is 25 degrees. The inspector advised the manager to get a thermometer to regularly check the temperature of the room. The medication room was much tidier than the last pharmacy inspection. There was more room to move which makes access to medication especially between rounds easier. The fridge temperatures are checked and recorded twice a day. The fridge was self-defrosting during the inspection and when the door was opened water ran out over the box of dressings below. If this happens regularly the home must make sure that there is no medication stored below the fridge. A pack of dipyridamole supplied from a local hospital was open and in use. This medication has a maximum of 6 weeks use from opening but no date of opening had been recorded. To make sure medication is safe to use staff must be aware of medication with short dates of use once opened and record opening dates when appropriate. There was a large amount of lancets and strips belonging to a someone who is no longer a resident. All medication and medical devices must be returned to the pharmacy if no longer in use. To reduce waste regular checks of the stock of such products should be done before ordering prescriptions. • • • • Training: The manager informed the inspector that a number of training courses had been provided to staff. The manager had organised an in house training package including a DVD presentation. The pharmacy had agreed to provide training and visit the home every 3 months. The staff had also attended a course provided by a local college. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 16 All residents spoken with said that they felt well cared for, staff treated them with respect and they were able to spend time in their room if they wished. Staff were observed approaching residents in a respectful manner and respecting individual preferences. Good relationships between staff and residents were evident. There were areas where the privacy and dignity of residents was respected, for example, knocking on residents’ doors before entering and closing toilet doors when in use. Staff were able to describe the measures they took to maintain the privacy and dignity of residents’. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 17 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 12, 13, 14 & 15 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. On the whole discussions with residents’ and their advocates described how they were helped to exercise choice and control over their lives and how the lifestyle within the home met their preferences, interests and needs. Residents maintained contact with family and friends and members of the local community as they wished. The food in the home was of good quality, well presented and on the whole met the dietary needs of residents. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 18 EVIDENCE: Residents’ spoken with described how they could choose to spend their day and confirmed that they could choose what time to get up and go to bed within reason, accepting the constraints as part of group living. Residents who were able entertained themselves with reading, crosswords and word searches. A wipe board in the corridor identified activities that had taken place in January and February 2007 and included a manicure and arm massage, clothes party and singer. These were still advertised so the assumption is made that either there have been no further activities or if they have taken place residents have not been told about them. A pianist was playing on the day of the visit, which residents were enjoying. Resident meetings had been implemented. The manager and provider must proactively implement the outcomes of those meetings or explain why they would not be possible. Current reasoning, for example, no monies or insufficient staff are not reasons to continue not implementing the outcomes, otherwise, the resident meetings are not a proactive way of encouraging residents to offer their opinion of the service and how it could be improved. Current shortfalls identified from those meetings are trips out. It was discussed with the manager and owner that the cost of this did not necessarily have to be at the providers expense, but could be an additional charge, however, this would need to be clear within residents contract/terms and conditions with the home. In addition, it was discussed that it was not necessary to include all residents in an activity that only one resident may want to do, for example, bingo. It might be that this is facilitated by an outing once a month, accompanied by a member of staff to a local bingo hall to meet that resident’s social care needs, but, as with all social care needs, they need to be demonstrated how they are going to be met in the plan of care. Personal items and furniture were brought into the home by residents to personalise their rooms. Residents confirmed that they maintained links with their family and friends and that they could visit “at anytime”. Relatives and observations during the day confirmed this. The dining room was very welcoming, being bright and clean. The menu for the day was displayed outside the kitchen. Meals were advertised as breakfast 8:30, lunch 12:30, tea 16:30 and two supper times of 19:00 – 20:00 and 22:00 – 22:30. The lunchtime meal was observed with carers and kitchen staff being attentive to residents with choices offered and provided. Lunch was well presented and consisted of gammon or chicken, potatoe mash, carrots and cauliflower. Dessert provided a choice of pear and almond flan, custard tart, yoghurt and fruit. All were freshly prepared and served by the cook on duty who was aware of special diets and likes and dislikes. When the meals were served they were unhurried and residents’ were given sufficient time to eat. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 19 One resident described how staff were good at encouraging people to eat and drink. They said meals were sufficient and you can have more if you ask. One relative said encouraging residents to drink had improved over the past year. They said residents were offered pieces of fruit and good meals were offered. They said dad always enjoyed his meals. Another said the food was excellent. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 20 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 16 & 18 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives were confident their complaints would be listened to and acted upon. There was an adult protection procedure, staff had received protection of vulnerable adults training and staff could describe action they would take to ensure residents were protected from harm or abuse. EVIDENCE: The complaints procedure ensured that residents and/or their advocates were aware of how to make a complaint and who would deal with them. Residents said they were satisfied with the care provided and had no complaints. No complaints had been made since the last inspection. The home had Barnsley Metropolitan Borough Council’s multi agency procedures for protection of vulnerable adults in place that promoted the protection of residents from harm or abuse. Discussions with staff confirmed they had received training in the protection of vulnerable adults, which provided them with the knowledge to identify and report any allegations or incidents of abuse to residents. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 19 & 26 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. On the whole, the living environment was in the main well maintained, clean and safe. EVIDENCE: Residents’ that were spoken with said they thought the home was comfortable and were pleased with their living environment. On the whole the home was clean and tidy, which promoted a comfortable and homely environment. The home was decorated in a comfortable and welcoming manner including homely touches of pictures and ornaments. Furnishings and furniture were of a good standard. Apart from one bedroom area no The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 22 unpleasant odours were noticeable. Residents had access to all indoor and outdoor facilities. Since the last inspection the conservatory carpet had been cleaned, however, a couple of areas had again started to pucker. The manager and provider were informed and that this needed continued monitoring to ensure the risk of tripping/falls to residents was minimised. Areas that required addressing to ensure a safe well-maintained environment was provided for residents were: 1. The windows in the bungalow part of the building were displaying evidence of age and rotting and replacement needed to be included in a refurbishment programme. 2. A broken toilet chair was stored in a bathroom. 3. An audit of bins for the disposal of paper towels was required as a bin was not available in all toilet areas, some of the bins were rusty and could cause foot injuries and there were bins without lids, which is not pleasant to observe and does not aid the control of infection. 4. The doors for bedrooms, toilets and bathrooms were not easily distinguishable and if they were, the information was displayed too high for some residents to see. 5. Some pull cords were dirty and were a source of cross contamination and therefore required cleaning. 6. In the identified bedroom there was a smell of urine and the carpet was frayed in the thoroughfare to the en-suite. Laundry facilities were sited away from food preparation and storage areas. Hand washing facilities were provided. Staff were able to describe the measures they took to control the spread of infection. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 27, 28, 29 & 30 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs were met by the numbers and skill mix of staff. Staff were trained to equip them with the knowledge and skills for their roles within the home, to enable them to care for residents in a safe way. Residents were not wholly protected by the home’s recruitment policy and practices. EVIDENCE: Good relationships between staff and residents were evident. Residents stated that they were satisfied with the level of care they received and that staff knew how to care for them. One resident described how they watched staff attitude with those residents who weren’t able to help themselves. Their conclusion was staff were very good. A relative said staff were friendly and do their best. Another said staff were excellent, understanding, first class and couldn’t be any better. The observation of staff responding to assistance as required was good. Discussions with residents and observation of care practice between staff and residents confirmed there was sufficient staff to meet their needs. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 24 The manager’s hours when she was working as manager were not identified on the staff rota. Rotas for the weeks commencing 05.03.07, 12.03.07, 19.03.07 & 26.03.07 were examined. The actual month was not identified on the rota, which if having cause to address the rota at a later date would cause problem. On the whole the staff on duty on a morning and afternoon consisted of a deputy/senior and two members of care staff. At night two care staff were on duty. Currently there were 22 residents and therefore minimum staffing levels were being provided. Ancillary staff at the home included a cook, kitchen domestic, cleaner, a laundry person and handyman. This contributed to ensuring standards relating to food, meals and nutrition were fully met and the home was on the whole maintained in a clean and hygienic state. The rota confirmed staff were now getting regular days off and not routinely working double shifts. The number of care staff that held NVQ Level 2 in Care was not ascertained as the manager had not submitted the pre-inspection questionnaire that would have contained that information, despite her saying she would return this at a meeting with the provider and herself on 02.02.07. Staff that were spoken with demonstrated they had undertaken a range of training including protection of vulnerable adults, health and safety, moving and handling, fire training, food hygiene, first aid and infection control. Newly appointed members of staff received induction to the home and worked three days supernumerary until they were conversant with the policies/procedures adopted by the home. Formal training had been received in previous employment. Two staff files were inspected. A thorough recruitment procedure was not wholly established as the information in respect of requesting a POVA first check prior to one member of staff commencing employment and that the outcome was satisfactory was not demonstrated. In addition there was no evidence of a full CRB being received for one of those members of staff and the staff record did not identify how and by whom they were being supervised until a full CRB was received. In addition, two references identified areas of concern and there was no evidence that this had been addressed/considered as part of the recruitment process and/or monitoring processes had been implemented to ensure suitability of employment. Certificates to demonstrate qualifications and training of staff were in place. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 31, 33, 35, 36 & 38 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspection process did not demonstrate the manager proactively fulfilled all her responsibilities. Although the manager/provider had implemented quality assurance and monitoring systems, these were in their infancy and time is required before a judgement can be made about the effectiveness of the process. Residents’ financial interests were safeguarded. Staff were not appropriately supervised. On the whole the health, safety and welfare of residents and staff were promoted and protected. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 26 EVIDENCE: Residents and relatives spoke highly of the management and staff team, however, proactive action by the manager to ensure compliance with regulations and standards has not been demonstrated in the last twelve months. Discussions with residents, relatives and staff identified the manager cared about the residents and was familiar with their needs. The manager stated she had commenced a quality assurance and monitoring system involving stakeholders of the service but had not yet collated the information to provide a report of the action to be taken to improve the service. The provider had provided a more consistent report of his opinion of the quality of the service, however, this could be in more detail and relate more to the meeting of requirements, regulations and NMS and action that he has taken to address the shortfalls within the manager’s responsibilities. An up to date insurance certificate was in place. The record of monies held on behalf of a resident was maintained with the balance and monies correlating. The description of where the money came ‘in’ and ‘out’ from was adequate and the exchange of finances were verified by two signatories. Receipting mechanisms were in place for monies that were spent. There were safe facilities to store the monies. Discussions with staff identified they were not receiving appropriate supervision. The home did have a health and safety policy. There were appropriate measures in place to ensure the security of the premises and prevent intruders. Hazardous products were safely stored. When the building was inspected no fire exits were blocked. A fire risk assessment dated 22.11.06 was in place. A record was now being maintained of weekly checks of the emergency lighting and monthly checks of the fire extinguishers. Staff records demonstrated fire training was up to date but not all staff had been present on a fire drill. This could place residents and members of staff at risk of harm if staff members are not up to date and familiar with practices should there be an actual fire. In addition all fire drills were being carried out at 11:00am. This does not facilitate a fire happening at different times of the day and the risks that this may pose, including different staff groups that may be on duty. The pre inspection questionnaire had not been provided to the CSCI and therefore documentation to confirm servicing and maintenance of services and appliances was not established. There had been an improvement in the notification of incidents to the CSCI since the last inspection, however, residents with pressure areas had not bee reported. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 27 There was sufficient equipment and aids and adaptations provided to meet the needs of the residents and good moving and handling techniques were observed. Regular documented checks were being made of water temperatures and were satisfactory. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 28 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 2 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 1 X 2 The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 29 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. Standard OP1 OP31 OP2 OP31 Regulation 5 Requirement Timescale for action 31/05/07 31/05/07 3 OP7 OP3 4. 5. 6. 7. OP7 OP7 OP8 OP7 OP8 OP9 The service user guide must include all the items required by the regulation. 5 & 17 The contract/terms and conditions for each individual resident must include all the information required. 14 & 15 The plan of care must demonstrate how each assessed need is going to be met, including social care needs. 15 A history profile of the resident must be included in the plan of care. 12, 13, 15 The plan of care must detail how & 17 carers will meet the pressure area care needs of residents. 12, 13, 15 The plan of care must identify & 17 how the nutritional needs of residents will be met. 13 (2) Records. Each time medication is administered to a service user it must be recorded on the MAR. If medication is not administered the reason why should be clearly stated on the MAR. Previous timescale of 03/10/06 & 09/01/07 not DS0000018252.V320641.R01.S.doc 31/05/07 31/05/07 31/05/07 31/05/07 31/03/07 The Firs Version 5.2 Page 30 8. OP9 12 9. 10. 11. 12. OP12 OP2 OP19 15 & 16 23 23 23 OP19 OP19 13. 14. OP19 OP19 23 23 met There must be a system in place that identifies the date when medication must be discarded. Previous timescale of 03/10/06 & 09/01/07 not met Facilitate the social care needs of individual residents, making a charge if necessary. The windows in the bungalow part of the building must be replaced. The broken chair in the toilet must be removed. An audit must be conducted of bins for the disposal of paper towels and replaced where necessary. Pull cords must be cleaned. The carpet in the identified bedroom must be replaced. Until this has been completed the carpet must be cleaned on a regular basis. Staff must not commence employment unless receipt of a satisfactory POVA first check can be demonstrated. Where a member of staff commences employment prior to a full CRB being received, but demonstrating a satisfactory POVA first check, a member of staff who is appropriately qualified and experienced must be appointed to supervise the new worker pending receipt of the outstanding CRB. So far as is possible, the appointed member of staff must be on duty at the same time as the new worker. A formal, verifiable quality assurance system must be demonstrated. DS0000018252.V320641.R01.S.doc 31/03/07 31/05/07 31/08/07 31/05/07 31/05/07 31/05/07 31/08/07 15. OP29 OP31 17 & 19 31/05/07 16. OP29 OP31 17 & 19 31/05/07 17. OP33 OP31 24 31/05/07 The Firs Version 5.2 Page 31 18. OP36 OP31 OP38 18 19. 37 Staff must be appropriately supervised. Previous timescale of 03/10/06 not met. Notification of residents with pressure areas as required by the regulation must be submitted to the CSCI. 31/05/07 31/05/07 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. Refer to Standard OP3 OP7 OP38 OP7 OP9 OP9 OP9 OP9 OP9 OP9 OP9 OP19 OP27 OP29 Good Practice Recommendations The assessment must contain an assessment of all the items in 3.3 of the NMS. Ensure consistency is maintained in the implementation of the 72 hour monitoring observation record where an accident does not result in immediate medical intervention. Implement an index within care plans to aid the location of information. The temperature of the medicines room should be checked to make sure it does not exceed 25 degrees. The quantity of controlled drug remaining after administration should be recorded in the register. MAR charts should clearly state if the resident administers their medication. Changes to MAR entries must contain a signature and witness signature and a date when the change was authorised. The list of staff authorised to administer medication must be updated. Medication and medical devices no longer in use should be returned to the pharmacy for disposal. A risk assessment should be made of those residents wishing to self-administer. Signage on toilet, bathroom and bedroom doors, pictures and mirrors should be placed lower down. All the manager’s working hours should be identified on the staff rota. The staff file should demonstrate that where concerns DS0000018252.V320641.R01.S.doc Version 5.2 Page 32 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. The Firs 14. OP33 have been raised in a reference that this has been addressed/considered as part of the recruitment process. That the regulation 26 contains more detail to demonstrate compliance with regulations and NMS, together with demonstrating requirements and recommendations that have been met. The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Firs DS0000018252.V320641.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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