Inspection on 23/05/07 for The Firs

This inspection was carried out on 23rd May 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 12/06/08

The Firs 25/05/06

The Firs 09/02/05

The Firs 10/09/04

The Firs 05/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Firs, The 90 Glasshouse Hill Codnor Ripley Derbyshire Derbyshire DE5 9QT Lead Inspector Helen Macukiewicz Key Unannounced Inspection 23rd May 2007 09:10 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 Firs, The DS0000002116.V340084.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. Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Firs, The Address 90 Glasshouse Hill Codnor Ripley Derbyshire Derbyshire DE5 9QT 01773 743810 01773 571531 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) www.ashmere.co.uk Ashmere Care Group Mr Gerald Poxton, Mrs Sandra R Poxton, Mrs Ann Theresa Poxton, Dr Michael G Poxton, Mr David A Poxton Mrs Pamela Mary Wood Care Home 42 Category(ies) of Dementia (12), Dementia - over 65 years of age registration, with number (12), Old age, not falling within any other of places category (30), Physical disability (2) Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Ashmere Care Group is registered to provide at The Firs Nursing Home personal care with nursing for service users of both sexes whose primary needs fall within the following categories:Old age not falling within any other category (OP) (30) Physical Disabilities aged 50 years and over (PD) (2) 2. Dementia aged 55 years and over (DE) DE(E) 12 The maximum number of service users to be accommodated within The Firs Nursing Home is 42 25th May 2006 Date of last inspection Brief Description of the Service: The Firs is situated in the village of Codnor. It is a converted house with extensions. The Home provides 30 beds for older people needing nursing care. There are 24 single rooms, some with en suite facilities, and an additional 3 shared rooms. There is provision for 2 people with physical disabilities, aged 50 years or over, included within the 30. There is also a 12 bed extra care unit which was completed on 2006. This provides 12 en-suite bedrooms, and separate lounge/dining facilities. There are landscaped gardens to all sides of the home. There is a bus service to local towns operating along the main road at the end of the car park belonging to the Home. The weekly fees range between £380.00 and £615.00 per week depending on additional assessed needs. The fees do not include chiropody, hairdressing, magazines/newspapers, transport/taxis and some toiletries. The Manager provided this information in her pre-inspection questionnaire. The Manager informs people about the availability of the Inspection reports by providing a copy in the main foyer. Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection was unannounced and lasted 8 hours during one day. Eleven pre-inspection questionnaires were received from people living in the home. This represents about a third of the total number of people. Most had been completed with the assistance of a relative. Findings from these questionnaires are included in this report. The Manager had provided written information about the home and this was used in the planning of this inspection. Computer held records of all contact between the Home and the Commission for Social Care Inspection since the last Inspection were also referred to in the planning of this visit. During this Inspection discussion with people who use the service and their relatives took place. Time was spent in discussion with the Manager and staff. Four residents care files were looked at in detail and their care was examined to see how well records reflect care practices within the home. Relevant records belonging to the home were also examined such as complaints and policy documents. A brief tour of the home took place including some bedrooms. An interim unannounced Inspection took place on 8 August 2006. The purpose of this visit was to follow up on the requirements made at the previous inspection on 25 May 2006. The outcome of the August Inspection is not available as a public document but should be available from the Firs. Reference to the Inspection and any requirements will be made in this report where necessary. What the service does well: Residents and their relatives feel the level of information provided about the home prior to admission is good. One comment from a pre-inspection questionnaire was ‘the information about the home was very helpful’. The recording of care needs in residents care files is comprehensive and staff are making concerted efforts to ensure continual improvements in this area. There are clear and comprehensive records of complaints received and feedback to the Commission for Social Care Inspection from Social Services during 2006 was that staff in the home had handled an adult protection matter well. Residents and relatives spoke positively about staff during the inspection. A comment taken from a pre-inspection questionnaire is ‘staff have always acted positively in terms of listening and acting upon what I say’. Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 summary of this inspection report can be made available in other formats on request. Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 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 Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, and 3. Standard 6 does not apply; the home does not offer intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who may use the service and their advocates have the information they need to choose a home that will meet their needs. EVIDENCE: There was a copy of the statement of purpose available in the office. This is a comprehensive document. The home is registered to provide nursing services for both general and dementia care. However, the extra care unit is primarily staffed and run to meet residential care needs only. This is not explicit in the current statement of purpose. Relatives spoken to during the inspection felt they had been given plenty of information about the home before their relative had been admitted. They had been given the opportunity to visit prior to making a decision about whether Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 9 their relative would come to live at the Firs. Although none of the relatives knew about the Commission for Social Care Inspection they felt the information told them enough about the home to ensure they knew what to expect when their relative arrived. In a pre-inspection questionnaire one person said ‘the information about the home was very helpful’. About 60 of people who completed pre-inspection questionnaires said they had received a contract stating terms and conditions. Care files viewed during the Inspection also documented that a contract had been issued. There was evidence of a pre-admission assessment in all of the care files seen to enable staff in the home to establish whether they can meet the needs of the person. Generally these were comprehensive although some information about the person’s social care needs was missing and some needed more baseline information about people’s usual habits/routines. The assessment form prompted the assessor to cover all areas of need although the section regarding the person’s marital status did not cover same sex relationships. All files contained a care managers’ assessment where appropriate. Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 10 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): Standards 7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are involved in the planning of their care and have their health needs largely met, although errors in the management of medicines means their well being is not fully safeguarded. EVIDENCE: All care files had a plan of care that had been drawn up with agreement from the resident or their relatives acting on their behalf. There was evidence that care plans are reviewed and updated with the exception of one occasion where a wound care plan and change to medication had not been added to the plan of care. However, there was evidence to support that care in this area had been given. Care files contained risk assessment in the areas of falls, nutrition, prevention of pressure sores and moving and handling. There was evidence that these had Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 11 been reviewed. There was evidence of assessment of continence needs and nutritional needs. Care plans detailed visits form the chiropodist and G.P. as well as liaison with Occupational therapy services and Physiotherapist. One visitor confirmed that their relative had been provided with new spectacles since they had been admitted to the home. About 75 of responses to the pre-inspection questionnaires stated there is always medical support available and the remainder stated that this is usually the case. One pre-inspection questionnaire contained the comment ‘overall, care very good’. There was evidence of specialist medical equipment around the home and one visitor said that their relative had a new specialist mattress. Medication charts for four people whose care files were examined were seen. Some contained gaps where staff should have signed for medicines given. In the extra care unit the number of medicines being brought into the home were not always recorded and amendments to medication records were not fully dated and signed. Also, one medication was incorrectly stored in a person’s bedroom. The prescription label on one bottle of medication did not match the MAR sheet. The designated storage area for medicines in both the main home and the extra care unit were warm, despite the fact that a fan has been installed in the main home storage area. The temperature should be 25°C or below to safely store some medications, the wall thermometer in the main home storage area registered 27-28°C. This was a requirement of the last 2 Inspections that has only been partly met. Residents’ need for privacy is met by the home. All residents and relatives consulted felt that there is enough privacy within the home. Visitors can see their relatives in their bedrooms if they want. Residents felt they had enough privacy when staff undertook personal care. They also confirmed that staff knock to request permission before entering their bedrooms. There was evidence that residents had been offered a key for their bedroom doors in the care files. One Visitor said that their relative was ‘looked after better than I did at home’. One area where residents and relatives felt their need for respect was not upheld was in the planning and undertaking of building works within bedrooms. Residents and relatives felt there was not enough consultation regarding changes to their bedrooms, and any decorating that has arisen as a result, although they were happy with the improvements and ultimate outcome of alterations. The dignity of one resident is compromised by the fact they are residing in a room with linoleum flooring where there is no genuine need for this. This flooring is not in keeping with a homely environment. The consultation regarding this move, from a carpeted room, is not documented in their plan of care. Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 12 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): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their lifestyle. Recreational activities largely meet individuals’ expectations. EVIDENCE: Findings in the pre-inspection questionnaires were that 27 of people felt there were usually activities for them to participate in, 55 said this was sometimes the case and 18 said they are never able to participate in these. In the manager’s pre-inspection questionnaire, she recorded that in house events organised include an accordionist, organist and exercises. Three trips out were advertised on the lounge wall. One trip took place on the day of the inspection and all people living in the extra care unit went out. One relative confirmed that activities do usually take place. Residents who were consulted on the day of the inspection said there is enough to do in the daytime. In the extra care unit staff had used a ‘life diary’ to record the person’s social care needs and to gather some past life history, which was an example of good practice. Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 13 Care records referenced individual rising/retiring habits, and documentation referenced the need for respect and person centered care. Visitors said that staff treat their relative with respect and take care when assisting with personal appearance. Relatives said they could visit anytime and were made to feel welcome in the home. Some residents are taken to the local pub; this is mainly in the extra care unit. Relatives confirmed that personal possessions were brought in from home to decorate their rooms. One comment received in the pre-inspection questionnaires was ‘can’t get up in a morning as early as I would wish’. However, all residents who were consulted during the inspection said they have a lot of choice over how they spend their day and they can choose what time to get up, and return to their rooms. They have freedom of movement around the home within safety limitations. All responses to the pre-inspection questionnaire confirmed that staff listen to people and act upon what they say. One comment received was ‘staff have always acted positively in terms of listening and acting upon what I say’. Some residents have personalised their bedrooms with fridges, televisions and have telephones installed, and spend their time there. Relatives and residents said they could make telephone calls anytime. 10 of people responding to the pre-inspection questionnaire said they always enjoy the food. 54 said this is usually the case, 27 said this is sometimes the case and one declined an answer. During the inspection all residents said the food is satisfactory. A brief tour of the kitchen took place; this was clean and tidy, with plenty of supplies. There was a change to the set menu being prepared on the day of the inspection, although a choice of 2 options was still offered. The cook said this was to meet the individual preferences of the residents living in the home. The manager said that the menus are standardised across all Ashmere Care group of homes, but that consultation with residents in the Firs does occur when planning these. A likes and dislikes food sheet was evident in one of the residents’ care file. Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live in the home are safeguarded and protected from abuse, although gaps in procedure and documentation leave them vulnerable. People’s rights to make a complaint are upheld through the homes’ complaints procedure. EVIDENCE: All residents and relatives consulted during the visit said they would be able to raise issues in the home, and felt confident in doing so. The pre-inspection questionnaire identified that just under half of those who responded would not know how to formally raise a concern. No residents or relative knew they could contact the Commission for Social Care Inspection, although the contact details had been given with the complaints information, provided on admission. There have been 3 complaints received by the home since the last Inspection. The complaints file contained good documentation of the action the home had taken to resolve these issues. There has been one adult protection issue since the last Inspection. This has been resolved. Social Services contacted the Commission for Social Care Inspection following this issue to say how well the matter had been handled by the home. There are policies on handling aggression and staff training on this has occurred and more is planned. Some staff have received adult protection training and there are more dates planned for those who are yet to attend. Both local and district wide policies Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 15 are kept in the home. Not all staff have signed to confirm they have read the local policy. The local policy did not include the following information:• • • • Recognition that other people besides staff can be abusers Timescales for when to inform Social Services and the Commission for Social Care Inspection The need to notify the Commission for Social Care Inspection The need to ensure a joint decision with outside agencies is made about who will investigate issues and the role of strategy meetings Staff do not use restraint techniques in their care of residents, although the homes’ policy on restraint indicates there may be circumstances where it is necessary to use restraint. Unless there is a proper restraint policy and training programme this policy should be reviewed. Equipment such as cot sides and alarm mats are used. These could be seen as providing a degree of restriction to movement. In such cases, staff ask residents/relatives to complete a consent form and this was documented in care files seen. The use of a keypad door system in the extra care unit could also be perceived as restricting resident’s rights to freedom of movement and there is no current consent obtained for this. Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home is effective in ensuring residents privacy, dignity and freedom of movement is upheld. However, poor standards of cleanliness and furnishings affect the quality of life for people in the main building. EVIDENCE: The physical layout of the home meets with the statement of purpose. The newly completed extra-care unit provides an excellent standard of accommodation, which is in contrast to the main home, where redecoration and refurbishment have not taken place as regularly as required. Paintwork in places is damaged, wallpaper in need of repair and carpets in some bedrooms and the lounge are stained or in need of replacement. The floor covering in the corridor toilet leading to the smoking area is coming away Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 17 at the edges making cleaning problematic. Some chairs in the main lounge are worn and stained. Bathroom 2 contained cans of paint, boxes and wood, which meant this could not be used safely by residents. Comments from residents/relatives in the pre-inspection questionnaire included, ‘very scruffy, lounge particularly, carpet absolutely disgusting’ and ‘there has been occasions where it has been necessary to complain about the general state and tidiness of the bathroom’. One relative consulted during the Inspection said that they had recently had to request cleaning of a bedroom. There were areas of that bedroom that still required cleaning during this inspection visit. Internal quality monitoring reports also highlighted that redecoration and recarpeting is required and that areas of the home required cleaning. Most communal parts of the home were clean, with the exception of high areas, which required dusting and the lounge carpet that was dirty. Bedrooms were less clean, carpets were stained and individual pieces of furniture such as bed tables were dirty. There were allocated cleaning hours stated on the staffing rota, these should allow for a minimum of 5 cleaning hours per day. The Manager has recognised this as an area for development and described ways in which she has attempted to improve the cleanliness of the home. There is adequate staffing and equipment in the laundry area. Equipment allows for appropriate cleaning of soiled items. There is a programme in place to provide more en-suite facilities in bedrooms. Some redecoration has occurred since the last Inspection. Residents are able to bring in personal possessions from home to make their bedrooms more homely. The garden area has been landscaped and provides pleasant and safe areas for residents to use. The staff call and fire alarm systems have been replaced in the last 12 months. Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home have their needs met by competent and suitably qualified staff although gaps in staffing and recruitment systems mean their well being is not fully safeguarded. EVIDENCE: Staffing rotas and comments from relatives and residents suggested there are sufficient numbers of staff to provide care. In completed pre-inspection questionnaires, 27 said there are always staff around when needed, 64 said this is usually the case and 9 said this is sometimes the case. Residents consulted on the day of Inspection said staff are always prompt at answering the staff call system. There were times during the afternoon when staffing was not provided in the main lounge, during this time some residents were requiring reassurance and others drinks or snacks. One resident was found in their bedroom in a state of undress and requiring help. There are a high proportion of residents with mental health related illnesses. Staff had not all received training on how to communicate with this client group. Just over 50 of care staff are qualified to NVQ (National Vocational Qualification) level II or above. There was documentation in place to support Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 19 that staff undergo a thorough training programme when they commence employment. Four staff recruitment files were examined to see how well the recruitment procedures safeguard residents. These generally contained the required checks with the exception of the following:• • 2 written references were missing from one file. The applicant provided reasons why they had left former employment, rather than this information being pursued by the employer, so it could not be established if reasons for leaving employment involved protection of vulnerable adult issues. There was no record that staff had checked original certificates of qualifications for authenticity. Former employment dates were not recorded as a six-figure date so gaps in employment could not be fully established. There was no record of interview. • • • There was evidence in staff files that they had received an induction, which included asking them to sign to confirm they had read key policy documents. Staff confirmed they had received training in areas such as moving and handling, fire safety and safe handling of chemical cleaning agents. The manager’s pre-inspection questionnaire detailed an extensive list of training that staff have received in the past year including nutrition, continence, safe handling of medicines and wound care. The manager of the dementia care unit had good training records for staff, which enabled her to identify areas of training required at a glance. About 50 of staff require health and safety training, the manager said this was booked for October 2007. Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed effectively although health and safety hazards create unnecessary risks to the welfare of residents. EVIDENCE: The Registered Manager and Deputy are suitably qualified and experienced to manage the service. Both regularly attend training to keep professionally updated. There are clear lines of accountability within the home. There is a senior member of care staff who manages the residential dementia unit; the overall Manager for the Home provides oversight of this unit although this oversight had not been effective in recognising omissions in recording of medication, or Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 21 consolidating areas of good practice across both units, in terms of care documentation. The home’s management were able to show documentation of monthly quality audits. Some areas for improvement were identified on these such as replacement of the lounge carpet. Documentation did not state who is responsible for pursuing actions required, and did not provide timescales for when jobs needed to be completed. Therefore it was difficult to establish how effective monitoring is in terms of achieving prompt action when issues are raised. Forms used to monitor standards under Regulation 26 of the Care Homes Regulations 2001 did not include space for consultation with service users, their representatives and staff. Management said they would be undertaking an annual quality review at the end of the year. Management confirmed that no money is kept at the home on behalf of residents. Residents care files contained a bedroom risk assessment. A health and safety policy was contained in the policy file and the pre-inspection questionnaire completed by the manager recorded that staff have received training in health and safety. Most parts of the home were free from hazards to the safety of residents with the exception of the following areas:• • • In the area designated for smoking, cigarette butts had been discarded in a waste paper basket containing flammable items. The laundry room contained cleaning solutions with a hazard warning notice, this room is unlocked and therefore these products are accessible to residents. Bathroom 2 contained cans of paint, boxes and wood. This presented a fire hazard as there is no fire detection in that room. It was unsafe due to trip hazards and paint. This room was unlocked and unsupervised during the Inspection and there were residents accommodated in the neighbouring bedrooms. The Manager was asked to ensure all products were removed from bathroom 2 at the time of this Inspection. A sample of service records for equipment used by the home showed that all equipment is maintained appropriately. Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 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 2 17 X 18 2 2 X X X X X X 2 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 3 X 2 X 3 X x 2 Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15(1)(2)( b) 13(2) Requirement Any changes in care must be updated into the plan of care to ensure residents are safeguarded. • MAR (Medication Administration Record) charts must not contain unexplained gaps. • In the extra care unit, the number of medicines being brought into the home must always be recorded and amendments to medication records fully dated and signed. Medication must be correctly stored. Medication must not be left in resident’s bedrooms unless this is consistent with agreed guidelines contained within a selfmedication policy. Prescription labels on bottles of medication must match the information recorded on the MAR Version 5.2 Page 24 Timescale for action 31/07/07 2. OP9 31/07/07 • • Firs, The DS0000002116.V340084.R01.S.doc sheet. • The designated storage area for medicines in both the main home and the extra care unit must be within safe temperature guidelines of below 25°C so that medicines are correctly stored. To support that residents have received the medication they require, and that systems for the receipt and storage of medicines safeguards their wellbeing. The final point was a requirement of the last 2 Inspections that has not been met. The feelings and wishes of 31/07/07 residents and their advocates must be respected in the planning of any alterations to the premises, which they live in. The physical environment must not compromise the dignity of residents. There must be documentation to support full consultation and agreement when a move to a room where flooring is not as homely as previous accommodation occurs. 4. OP18 13(6) The homes’ adult protection policy must include the following information:• • Recognition that other people besides staff can be abusers Timescales for when to inform Social Services and the Commission for Social Care Inspection The need to notify the Version 5.2 Page 25 3. OP10 12(4)(a) 31/07/07 • Firs, The DS0000002116.V340084.R01.S.doc • Commission for Social Care Inspection The need to ensure a joint decision with outside agencies is made about who will investigate issues and the role of strategy meetings To ensure residents are safeguarded against abuse. 5. OP19 16(2)(c) The Home must provide residents with a good standard of furnishings. The lounge carpet and damaged chairs must be replaced. The Home must provide residents with clean and reasonably decorated accommodation. There must be adequate numbers of staff on duty in the afternoon to ensure residents requiring reassurance, assistance, drinks or snacks have their needs met. Obtain all information and documents listed in the amended Schedule 2 of the Care Homes Regulations in respect of staff working in the Home to ensure residents are safeguarded. 30/09/07 6. OP26 23(2)(d) 31/08/07 7. OP27 18(1)(a) 31/07/07 8. OP29 19 Schedule 2 31/07/07 9. OP33 26 10. OP38 The process used to monitor 31/07/07 standards under Regulation 26 of the Care Homes Regulations 2001 must allow for consultation with service users, their representatives and staff. 13(4)(a)(c There must be adequate facilities 31/07/07 ) for the safe disposal of cigarettes. A risk assessment of the storage of chemicals in the laundry room must occur and any actions required taken. Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 26 Bathroom 2 must be made safe. To ensure residents live in a safe environment. 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 OP1 Good Practice Recommendations The Home’s Statement of Purpose should provide more specific details about the purpose and function of the extra care unit, which is primarily staffed and run to meet residential care needs only. Information about the person’s social care and more baseline information about people’s usual habits/routines should be recorded on the pre-admission assessment to ensure the home is aware of all the needs to be met. The assessment form should cover same sex relationships in the marital status section to support equal opportunities and the needs of all people within society. 3. OP5 The Home’s contract with residents should mention that residents are able to move in on a trial basis. (This recommendation was not assessed on this occasion) Any equipment that caries a degree of restraint should only be used when agreement has been reached with relevant parties such as relatives and care managers. Where possible, an appropriate specialist assessment should be obtained. Reasons for use of such equipment should be clearly recorded. (This was a previous recommendation and was not assessed on this occasion) Residents using baths should have easy access to the Home’s emergency call system. (This was a previous recommendation and has not yet been fully addressed.) 2. OP3 4. OP8 5. OP10 Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 27 6. OP14 7. OP15 The Home’s written policy on residents’ and staff members’ access to personal records should make mention of access to ‘third-party correspondence’. (This was a previous recommendation was not assessed on this occasion) Records of food provided for residents should be in sufficient detail to determine that each resident’s diet is satisfactory. (This is a previous recommendation was not assessed on this occasion) Residents and their advocates should know how to contact the Commission for Social Care Inspection, through communication of the Homes’ complaint procedure. All staff should sign to support they have read the local adult protection policy. Unless there is a proper restraint policy and training programme, the policy on managing challenging behaviour should be reviewed. Use of a keypad door system in the extra care unit could also be perceived as restricting resident’s rights to freedom of movement and therefore consent of residents/advocates should be obtained for this. 8. 9. OP16 OP18 10. OP24 Further adjustable beds should be provided for residents receiving nursing care. (This is a previous recommendation was not assessed on this occasion) The ‘Safe Disposal of Clinical Waste’ policy should state how soiled items should be transported to sluice rooms. It should also refer to filling the clinical waste bags to no more than ¾ full. (This was a previous recommendation and was not assessed on this occasion) Staff should all receive training on how to communicate with residents with mental health related illnesses. 11. OP26 12. OP30 Firs, The DS0000002116.V340084.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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