Inspection on 19/10/05 for The Firs

This inspection was carried out on 19th October 2005.

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 14/03/07

The Firs 06/04/06

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 Unannounced Inspection 19th October 2005 08:30 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.V254796.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. The Firs DS0000018252.V254796.R01.S.doc Version 5.0 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 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.V254796.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th July 2005 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 Dorothy House, although both are registered separately. A variation has been submitted to register Dorothy House and The Firs as one site but registration to do this has not yet been approved. The Firs has a lawned area and a small car parking area to the front. The garden area was accessible to residents. The Firs DS0000018252.V254796.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 between the hours of 8:30 and 14:15. Opportunity was taken to make a partial inspection of the premises, inspect a sample of records, observe care practices and talk to residents, staff and the manager. The majority of residents and staff were seen during the inspection and the inspector spoke in more detail to three members of staff on duty about their knowledge, skills and experiences of working at the home and five residents about their views on aspects of living at the home. The inspector wishes to thank the residents and staff for their time and co-operation throughout the inspection process. What the service does well: What has improved since the last inspection? Staff were undergoing medication training. This had resulted in improved practice in the recording of medication received in the home and medication being administered in accordance with instructions. Care was now taken with how staff dealt with and ironed residents’ laundry. The staff rota now included all the information required and was much clearer. The Firs DS0000018252.V254796.R01.S.doc Version 5.0 Page 6 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. The Firs DS0000018252.V254796.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 The Firs DS0000018252.V254796.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): The outcomes for standards 1 and 2 were inspected. The statement of purpose and service user guide did not contain the required information for potential residents to make an informed choice about the facilities and services the home provides. Residents’ had a contract in place between themselves, the placing authority and the home. It did not identify the terms and conditions with the home for the resident. EVIDENCE: The statement of purpose and service user guide were submitted to the CSCI prior to the inspection. They did not contain all the requirements of the regulations. A completed pro forma of the areas still missing was given to the manager. One resident’s file was inspected in regard to a written contract/statement of terms and conditions. A contract was in place but it did not identify the terms and conditions with the home for the resident. The Firs DS0000018252.V254796.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): The outcomes for standards 7, 8, 9 & 10 were inspected. Residents’ health, personal and social care needs were not adequately set out in the individual plan of care although there was evidence that health professionals were involved to meet health care needs. Residents’ were protected by the homes policies and procedures for dealing with medicines. Residents’ were satisfied with the care they received and no adverse comments were made in regard to staff maintaining their privacy and dignity, however, in the inspector’s opinion the dignity of residents’ was compromised as one of the settees in the lounge area was covered with a plastic sheet and blanket. EVIDENCE: Residents spoken with spoke positively about their personal care needs being met. Individual care plans were in place, however, they did not contain up to date and relevant information including all the information required by the regulations and standards. An example was no nutritional assessment. There was evidence care plans were reviewed to reflect residents changing care needs but of the two partially inspected one had not been reviewed for seven months, the other 10 months. The Firs DS0000018252.V254796.R01.S.doc Version 5.0 Page 10 There was a review sheet showing more recent reviews but what of wasn’t clear. At the last inspection staff identified training in care planning and recording had not been received. On this inspection they confirmed it had been arranged. Also one of the recording systems was of a tick sheet type and this can only work if detail on the care plan is sufficiently detailed and well documented, which it was not. A representative from the home and the resident and/or their advocate did still not verify records of personal possessions brought into the home by residents’. The recording, administration and storage of medication was inspected on a sample basis. Medication was appropriately stored and medication instructions identified on the MAR sheet correlated with the medication administered. Staff were currently undertaking medication training. Staff were able to describe the measures they took to maintain the privacy and dignity of residents’. The inspector observed a settee in the lounge area that was covered with a plastic sheet and blanket. This did not preserve the dignity of the residents’. There was a telephone in the home for residents’ to use. This was in the hallway of the home and therefore would be unable to be used in private. The Firs DS0000018252.V254796.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): The outcomes for standard 12, 13 & 14 were inspected. Residents living at the home said the daily routines within the home allowed for them to make their own choices. Residents were encouraged to make informed decisions with regard to their daily lives and maintain contact with their family, friends and the local community as they wished. EVIDENCE: Comments made by residents about their lifestyle at the home included ‘nobody tells us what to do – we do what we want, more or less’, ‘I love reading and they get large print books from the library’, ‘everything is perfection’, ‘I can adapt to different environments so have found it ok’, ‘I like to do my own thing, I don’t like joining in activities and trips and I can do that’, ‘I still write’ and ‘routine suits me – I like doing crosswords and watching quizzes on TV’. One thing two residents did say was ‘a cup of tea in the morning before breakfast would be nice’. Residents were observed to be spending time in the lounges, whilst others had chosen to spend their time in the privacy of their bedroom. Residents were motivated on the day of the inspection as it was the day the hairdresser came. Residents confirmed that they maintained links with their family and friends and that they could visit “at anytime”. The Firs DS0000018252.V254796.R01.S.doc Version 5.0 Page 12 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): The outcome for standard 16 was inspected. The complaints procedure was displayed in the entrance to the home and clearly identified the procedure to be followed should anyone wish to make a complaint. 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. Two residents said ‘a cup of tea before breakfast in the morning would be nice’. Complaints were recorded in a bound book. No complaints had been made since the last inspection. The Firs DS0000018252.V254796.R01.S.doc Version 5.0 Page 13 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): The outcome for standard 26 was inspected. On the whole the main living environment at the home was clean and odour free. Attention was required in the laundry to promote cleanliness and control of infection. EVIDENCE: The building was free from offensive odours. Laundry facilities were sited away from food preparation and storage areas. Hand washing facilities were provided. The flooring to the laundry floor posed a tripping and cleanliness risk as it was ill fitted. The sanitizer for clinical waste identified the homes own procedure was not being followed regarding the disposal of clinical waste as faeces was on the lid and bag. One member of care staff confirmed they had, had training in infection control. The laundress and domestic had not but had only recently been employed. They were able to describe measure they took to control the spread of infection. One tablecloth was clean but stained and marked. A discussion about staff responsibility for disposing of furnishings that were no longer fit for purpose was held with the manager. The Firs DS0000018252.V254796.R01.S.doc Version 5.0 Page 14 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): The outcomes for standards 27 and 29 were inspected Agreed staffing levels were met and discussions with residents confirmed there were sufficient staff to meet their needs. The recruitment procedure was not sufficiently robust enough to protect the safety and welfare of residents’. EVIDENCE: The staff rota for the week of the inspection demonstrated that minimum staffing levels were met and discussions with residents confirmed there were sufficient staff to meet their needs. The manager confirmed she had not implemented a Recruitment and Equal Opportunities Policy/Procedure. Two staff files were inspected, one on a sample basis. One of the files demonstrated a member of staff had commenced work prior to a POVA first check being issued. Information of criminal convictions under the Rehabilitation of Offenders Act 1974 and any cautions by the member of staff was not demonstrated. This is an unsafe practice and may not protect the safety and welfare of residents. There were also omissions in the health declaration and staff information. The Firs DS0000018252.V254796.R01.S.doc Version 5.0 Page 15 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): The outcomes for standard 31, 33, 34, 35, 36, 37 and 38 were Although the manager had implemented some systems to promote her ability to manage the home in a more robust and effective manner, a more proactive role in quality assurance and staff supervision would enhance this. The financial procedures used by the home were sufficient to safeguarded residents financial interests. Resident’s rights and best interests could be placed at risk by the homes failure to maintain all records adequately. To ensure the safety and welfare of residents and staff attention is required to the servicing and safe storage of equipment within the home. EVIDENCE: The manager confirmed a quality assurance policy/procedure had not been implemented although the owner of the home had now started to complete regulation 26 visits so that they are informed of the service provided. The Firs DS0000018252.V254796.R01.S.doc Version 5.0 Page 16 Also staff meetings had been implemented. It must be noted, however, that residents’ that were spoken with during the day expressed satisfaction with the service. The manager could demonstrate personal allowances were paid to residents, however, the audit trail was time consuming and the inspector suggested a more appropriate method of recording this. The record of monies held on behalf of a resident was maintained with the balance and monies correlating. The description of where the monies came ‘in’ and ‘out’ from was adequate and the exchange of finances were verified by two signatories. There were safe facilities to store the monies. A business and financial plan was not in place. The manager confirmed individual supervision of staff had not been implemented although again pro formas had been put in place. A sample of records that the home is required to keep have been commented upon throughout the report and requirements made. Records were securely stored. When the building was checked no fire exits were blocked and the fire extinguishers seen had been serviced. Documentation had been provided to the CSCI to confirm servicing of the fire alarm and emergency lighting were in place. There were appropriate measures in place to ensure the security of the premises and prevent intruders. Window restraints had been fitted to windows in communal areas to prevent falls. One window restraint was broken. The manager stated servicing of the gas cooker had taken place and work was required, the portable appliances were being serviced on 24 October 2005, the servicing for the central heating had not been completed and the company who had completed the servicing of the fire alarm and emergency lighting said fixed wiring had been completed at the same time but this was not demonstrated on the servicing documents. The safety and welfare of residents was found not to be consistently promoted in that residents were going into the kitchen because the door was open, all bathrooms were being used for storage of equipment and creams, toiletries, disinfectant and razors were found in bedroom areas. The Firs DS0000018252.V254796.R01.S.doc Version 5.0 Page 17 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 1 2 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x x x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 1 2 2 1 2 2 The Firs DS0000018252.V254796.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4, 5 & 17 Requirement Timescale for action 19/12/05 2 OP7 15, 16 & 17 3 OP7 OP8 15, 16 & 17 4 OP7 15, 16 & 17 A copy of the statement of purpose and service user guide, that includes all the requirements of the regulations must be submitted to the CSCI. Required since 1 April 2002. The care plan must reflect the 31/12/05 health, personal and social care needs to be provided for the resident. The plan must be reviewed at least monthly and reflect any change in need if necessary. The care plan must contain a 31/12/05 nutritional risk assessment of the resident. Previous timescales of 31 May 2004, 31 October 2004, 31 March 2005 and 30 September 2005 not met. Both the person completing the 31/12/05 documentation and the resident and/or their advocate must sign records of residents’ furniture and personal possessions brought into the home. Previous timescales of 31 March 2005 and 30 September 2005 not met. DS0000018252.V254796.R01.S.doc Version 5.0 The Firs Page 19 5 6 7 8 9 OP10 OP26 OP26 OP26 OP29 12 13 13 16 17 10 OP29 19 & 17 11 OP29 18 12 13 OP29 OP29 19 & 17 19 & 17 14 OP33 24 Plastic sheeting and blankets must not be placed on settees. The flooring in the laundry must be refitted/replaced. To control the spread of infection all equipment must be kept clean. When furnishings are not fit for purpose they must be disposed of. The staff file must demonstrate the position the member of staff holds at the care home, the work to be performed by them and the number of hours for which they are employed each week. Previous timescales of 31 May 2004, 31 October 2004 and 31 March 2005 not met. A health declaration demonstrating that the person is physically and mentally fit to work at the care home must be implemented. A copy must be submitted to the CSCI. Previous timescales of 31 May 2004, 31 October 2004 and 30 September 2005 not met. The Code of Conduct and Practice set by the GSCC must be implemented. Required since 1 April 2002. Staff must not commence work at the home unless a POVA first check has been issued. The recruitment files of staff must include a signed declaration by the member of staff of any criminal convictions under the Rehabilitation of Offenders Act 1974 and any cautions. A formal, verifiable quality assurance method must be implemented to enable residents to contribute to the way the service is delivered and a copy submitted to the CSCI. DS0000018252.V254796.R01.S.doc 31/12/05 28/02/06 31/12/05 31/12/05 31/12/05 19/12/05 31/12/05 31/12/05 31/12/05 19/12/05 The Firs Version 5.0 Page 20 15 OP34 26 16 OP36 18 17 OP37 17 18 OP38 13 19 OP38 13 20 OP38 13 21 OP38 13 22 OP38 13 Required since 1 April 2002. A copy of the business and financial plan must be submitted to the CSCI. Required since 1 April 2002. A staff supervision policy/procedure must be implemented. Required since 1 April 2002. All records required by the regulations must be in place, up to date and accurate. (These have been identified throughout the report). A copy of the service agreement for the gas cooker and repairs/replacements where required must be submitted to the CSCI. Previous timescales of 31 May 2004, 31 October 2004 and 30 September 2005 not met. All electrical equipment brought into the home must have a protable appliance test. Confirmation this has been completed must be submitted to the CSCI. Previous timescales of 31 May 2004, 31 October 2004, 31 March 2005 and 30 September 2005 not met. A copy of the fixed wiring certificate must be submitted to the CSCI. Previous timescales of 31 May 2004, 31 Octoner 2004 and 30 September 2005 not met. A copy of the service agreement for the central heating system must be submitted to the CSCI. Previous timescales of 31 May 2004, 31 October 2004 and 30 September 2005 not met. The door leading into the kitchen from the lounge must be kept locked when the area is unsupervised. DS0000018252.V254796.R01.S.doc 19/12/05 31/12/05 31/12/05 19/12/05 19/12/05 19/12/05 19/12/05 31/12/05 The Firs Version 5.0 Page 21 23 OP38 13 24 25 OP38 OP38 13 13 & 23 Previous timescale of 30 September 2005 not met. An audit of all window restraints must be made and where they are broken repaired. Previous timescale of 30 September 2005 not met. Creams, toiletries, disinfectant and razors must be securely stored. Bathrooms must not be used as storage areas. 31/12/05 31/12/05 31/12/05 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 Refer to Standard 2 29 35 Good Practice Recommendations The terms and conditions of a residents’ stay with the home should be included with the contract. A Recruitment and Equal Opportunities Policy/Procedure should be implemented at the home. That an individual record with receipts should be kept for personal allowances paid to residents. The Firs DS0000018252.V254796.R01.S.doc Version 5.0 Page 22 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 © 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.V254796.R01.S.doc Version 5.0 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!