Inspection on 05/09/08 for The Firs

This inspection was carried out on 5th September 2008.

CSCI found this care home to be providing an Poor service.

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 18/03/08

The Firs 14/03/07

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 27/11/2008.

CARE HOMES FOR OLDER PEOPLE The Firs 186c Dodworth Road Barnsley South Yorkshire S70 6PD Lead Inspector Jayne White Key Unannounced Inspection 5th September 2008 09:30 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.V371133.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.V371133.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 F/P 01226 249623 None Mr Azar Younis Manager post vacant Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places The Firs DS0000018252.V371133.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th March 2008 Brief Description of the Service: The Firs is a care home providing personal care and accommodation for up to 33 older people. The home is on the same site as its sister home, Dorothy House. Dorothy House is registered separately and not covered by this inspection report. The home is owned by 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. There are three lounge areas. One is a separate small lounge, one a small lounge leading off the dining room and the other a conservatory. There is a lawned area and a small car parking area to the front. Information of the services and facilities the home offers, including the home’s statement of purpose and service user guide, including the CSCI inspection report is available in the entrance hall to the home and people’s bedrooms. The owner identified the fee as £341.50. Additional charges are 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.V371133.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means that the people who use this service experience poor quality outcomes. Jayne White, link inspector, Chris Taylor, inspector from the enforcement team and Steve Baker, pharmacy inspector visited the home on the 5 September 2008 between 09:30 and 18:00 without giving them any notice. The service is part of our enforcement strategy. This meant that during the visit we took copies of information to support our judgements in making statutory requirement notices. Before the visit we took into consideration other information the Commission for Social Care Inspection (CSCI) had received. This included: • • • Information contained in notifications from the home about any deaths, illnesses and other events, which affected the health and well being of people living there. Ault safeguarding investigations. Surveys that were sent to people living at the home, asking them about the home. Seven were returned (70 ). During the visit we spoke with the owner, the newly appointed manager, people that lived there, staff, looked round parts of the building and read some records. We would like to thank the people, staff and the owner for their time and cooperation throughout the inspection process. What the service does well: On the whole, people said they ‘were happy living here’ and that the staff were ‘very good’. They described how they were able to make choices and decisions about their life style, where this was possible and that on the whole, social and recreational activities available met their expectations. In general, staff were kind and courteous to people, which meant people felt they were treated with respect and dignity. Staff followed best practice when offering and giving medicines to people. This helped to maintain their health and well being by encouraging them to accept and take their medicines as prescribed. The Firs DS0000018252.V371133.R01.S.doc Version 5.2 Page 6 People and their representatives were able to express their concerns and had access to a complaints procedure. What has improved since the last inspection? What they could do better: Make sure that the manager has the recommended qualifications and experience to manage a care home, to aid the management and administration of the home and improve quality assurance systems to identify where improvements were needed. Assess and identify risks associated with people’s medical conditions and assessed needs, so that actions to maintain their health and assist them in an emergency can be taken. This is a breach of regulations therefore a statutory requirement notice has been issued, to make sure the service complies with their regulatory duties. Improving the medication storage and handling systems together with allocating sufficient trained staff time to medicines handling and recording would help to ensure the home always had the correct medicines available to use at the time they are needed. This is a breach of regulations therefore a statutory requirement notice has been issued, to make sure the service complies with their regulatory duties. Be more proactive in planning and improving the environment for people, so that they have a safe and well maintained living environment. Ensure people are kept safe by recruitment properly and training people in all aspects of the work they need to do. The Firs DS0000018252.V371133.R01.S.doc Version 5.2 Page 7 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.V371133.R01.S.doc Version 5.2 Page 8 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.V371133.R01.S.doc Version 5.2 Page 9 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): We did not look at any outcome areas in this section. These outcome areas were not assessed as there had been no recent admissions. This was as a result of a safeguarding investigation, when the owner had agreed to suspend admissions pending the outcome of the investigation. EVIDENCE: See above The Firs DS0000018252.V371133.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): The outcome areas for standards 7, 8, 9 & 10 were inspected. People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care that people received was based on their individual needs, but the lack of risk assessments in respect of their assessed care needs left people very vulnerable. There were aspects of upholding the principles of respect, dignity and privacy of people that needed to be improved. EVIDENCE: On the whole, when we spoke to people they were happy with the way that most staff looked after them and respected their dignity. One example they gave was staff calling them by the name they preferred. On the whole, when we observed staff working there was clear and respectful communication between people and staff and staff treated people in a kind manner. However, we did see staff speaking to one another when moving people and not including the person in the conversation. Staff therefore, need to make efforts to include people in conversation and day-to-day life. Also, at The Firs DS0000018252.V371133.R01.S.doc Version 5.2 Page 11 meal times, speaking to people as if they were in a dinner hall at school when asking what they would like or if they wanted any more. We provided this information to the owner and manager. We looked at seven care plans. The content and quality of these had improved significantly since the last visit and did demonstrate in a number of areas how people’s health and personal care were to be met. However, there were some health care needs where there were inconsistencies in the identified action and intervention that was recorded in the risk assessment and what we saw. For example, aids to support people’s pressure areas not being in place and weighing of people when it had been identified on their nutritional risk assessment to do so. This could result in the deterioration of peoples’ health. There were significant shortfalls that left people vulnerable to risks associated with their medical conditions. This was because risk assessments had not been carried out for them, which meant staff did not have guidance on how to support a person should those risks be presented. Examples included, people with epilepsy and diabetes. This supports the findings of an adult safeguarding investigation. In addition, when we spoke to staff they were not aware there were people living in the home with epilepsy. This meant the risks that might be presented, such as a seizure could be mistaken as something else. Because this is a breach of regulations, statutory requirement notices are being issued, to make sure the service complies with their regulatory duties. Where risks had been assessed there was sometimes insufficient information to be able to check that the action identified was sufficient to safeguard people. An example was the type and size of slings to be used when moving people in a hoist. We identified this to the owner and manager. People had access to health care services. Where people were unable to access local services they were supported by visits to the home by health care professionals. There was evidence in the care plan of health care treatment and intervention and a record of general health care information. There were some gaps in information, but when we spoke with staff they were able to give a verbal update. Medication storage conditions were very cramped and the store room was dirty and very untidy. We found a loose tablet on the floor carpet, which was dirty & sticky. The medication trolley tops and open shelves were cluttered with paperwork, dressings, plastic bags & aprons. There were no hand washing facilities in the room and conditions for storing district nurse clinical supplies were unhygienic. We found a shard of broken glass on one shelf next to dressing packs and food supplements. The inside of the medication fridge was dirty and a container of anaesthetic gel could not be accessed or opened as it was frozen onto the ice box. We found an open container of medication awaiting disposal on the floor of the very untidy staff room, which was accessible to all staff. No medication disposal records were kept. Controlled The Firs DS0000018252.V371133.R01.S.doc Version 5.2 Page 12 drugs were not stored according to current safe custody regulations and errors had been made in recording the use of controlled drugs. The recommended process for recording the receipt, use and disposal of controlled drugs were not being followed, which increases the risk of loss or diversion of this group of medicines. There was evidence that some staff had begun to receive further training in safe handling of medicines but no in-house assessments of authorised staff were taking place. No management checks of medication handling and recording arrangements had been made. The home’s medication policy & procedure documents was not in line with current professional guidance. We observed the deputy manager giving medicines to people living in the home. Good techniques and practices were used and people were happy to take their medicines when asked to do so. We were told that no-one in the home looked after their own medication. The standard of medication record keeping in the home must be improved. For instance, it wasn’t clear from the records whether some people had received all their medicines correctly or whether some people had their prescribed creams or inhalers at all. There was inconsistency in handwritten entries and in changes made to medication. The quantity supplied, the date of entry, the signature of the person making the entry and a witness signature where possible should be included in all hand written entries. Details of the person authorising any changes should also be included. This makes sure that there is an accurate record of any changes or new medicines as recommended in the previous inspection report. There is inconsistency in the recording of the quantity of medication supplied and the date received. The quantity of medication brought forward from one monthly cycle to another is not consistently recorded, despite earlier recommendations. This means it is difficult to have a complete record of medication within the home and to check if medication is being administered correctly. Checks made of the predicted amount of medicines remaining showed that the entries made on the MAR charts may not always be accurate. Because of the failures to meet regulations in respect of medication, statutory requirement notices are being issued, to make sure the service complies with their regulatory duties. The Firs DS0000018252.V371133.R01.S.doc Version 5.2 Page 13 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. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People described how they were able to make choices and decisions about their life style, where this was possible and on the whole, social and recreational activities available met people’s expectations. EVIDENCE: When we entered the home there was a pleasant ambience in the lounges. The majority of people were sat in the lounges, some were ‘watching the world go by’, some were reading and there were some that spent time sleeping. People were given the opportunity to take part in a variety of activities. When we spoke to the owner he said he had employed a person to do social activities with people. During the inspection we saw them playing bingo with a group of people. This was the activity that was advertised to take place on a Friday in the hallway. The Firs DS0000018252.V371133.R01.S.doc Version 5.2 Page 14 When we spoke to people, a number said they preferred to spend time alone. One said, “I stay in my room, but never get bored”. For those people who were cared for in their room, music was left playing for them to listen to. Surveys told us people were satisfied with the activities provided. When we looked at care plans they did not identify people had been consulted about what activities might be carried out with them to engage them in meaningful daytime activities of their own choice, interests and capabilities to enhance their well-being. When we spoke to people they described how they maintained links with their family and friends and that their families could visit ‘at anytime’. The dining room was welcoming, being bright and clean. The menu for the day was displayed outside the kitchen, so people knew what the meal would be. One person knew about the notice board but said, “I can’t read it, I’m registered blind. No-one tells me what it is, I just wait and see. At tea time they come and ask you what you’d like”. An idea might be to put individual menus on tables for people who might have difficulty seeing the notice board. We saw the lunchtime meal being served. It was leisurely and relaxed time for people, staff were patient and helpful and allowed people time to finish their meal comfortably. We saw that meals were well presented. Carers and the cook were attentive to people, offering them different choices and asking if they would like some more. When we spoke to the cook and staff they did have a good understanding of peoples’ dietary needs. On the whole, people said they liked the meals that were served. Comments included, “if they gave you better food they’d have to put the prices up and then they wouldn’t get people – ruled by market forces”, “I’ve had better” and “I get enough to eat”. The Firs DS0000018252.V371133.R01.S.doc Version 5.2 Page 15 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. People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People and their representatives were able to express their concerns and had access to a complaints procedure. There were adult safeguarding policies and procedures in place that promoted the protection of people from harm, but an adult safeguarding investigation had highlighted other failures, which had placed people at risk. EVIDENCE: On the whole, when we spoke with people they said they were satisfied with the care they received and felt safe. People could access the complaints procedure because it was displayed on the notice board outside the dining room/lounge for them should they wish to make a complaint. It was clearly written, easy to understand and explained what the procedure was and how long the process would take. The manager was asked to update the procedure, because of the new working and contact arrangements within CSCI. This was outstanding from the last inspection and therefore a recommendation has been made. Surveys and discussions with people indicated people knew how to complain. The owner said no complaints had been received since the CSCI last visited. The Firs DS0000018252.V371133.R01.S.doc Version 5.2 Page 16 Although there were adult safeguarding policies and procedures in place that promoted the protection of people from harm or abuse, an adult safeguarding investigation had highlighted other failures, which had placed people at risk. This included poor record keeping, a lack of written evidence to support the information staff had said they carried out to support people with their health and personal cares and a lack of staff knowledge in respect of people’s medical conditions. Recommendations to improve this had been made by the adult safeguarding team. These included: • • appropriate documentation to accompany people to hospital. The care plans we looked at had this information. training/information sessions to be arranged for staff regarding Parkinson’s Disease or any other conditions that staff need awareness of prior to admission. The service had not acted on this information (refer to health and personal care and staffing). This indicates the service have not learnt from the outcomes of adult safeguarding referrals, which may continue to place people at risk. Voluntary suspension of admissions by Mr Younis (this has now been lifted but no admissions have been made to the home since this, hence why choice of home was not inspected). • The Firs DS0000018252.V371133.R01.S.doc Version 5.2 Page 17 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. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. On the whole, there was a clean, adequately maintained and comfortable environment for people to live, but there were a number of improvements that were needed. EVIDENCE: There was a selection of communal areas, which meant people had a choice of where to sit, meet with family, sit quietly or engage with other people that lived there. It also provided sufficient space for the number of people that used them. Access around the home was good. The owner told us he’d made some improvements to peoples’ living environment, which we could see. The improvements included refurbishment The Firs DS0000018252.V371133.R01.S.doc Version 5.2 Page 18 of some bedrooms and replacement of lounge chairs. This did improve the environment for people. The owner acknowledged work on the conservatory was needed. During the inspection there were three areas where rain was leaking in and the carpet was ill fitting and stained. On the whole, when we spoke to people they said they thought their home was comfortable. They said they had a comfortable bedroom, which they had personalised with pieces of their own furniture and possessions. Some people had en-suite facilities. However, we saw some bedrooms where continence aids had not been put away, which compromised the respect and dignity of the person. In addition, this was in bedrooms where people were cared for in their rooms, which did not make it a tidy environment for them to look at. We provided the manager with this information and also that one of the rooms in the bungalow was cold and they must keep it warm to the satisfaction of the person living there. When we looked round the home there were sufficient toilets for people that were appropriately located and easily accessible. We identified to the owner that the adaptations in some of the toilets needed attention as they were rusting and therefore an area that could spread infection. Also, clean towels were stored in bathroom areas. This is not good practice in preventing the spread of infection, as well as making the bathroom look institutional and like a storage area. The Firs DS0000018252.V371133.R01.S.doc Version 5.2 Page 19 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. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. To provide appropriate support for people and support the smooth running of the service staff recruitment must improve and staff needed further training. EVIDENCE: On the whole, when we spoke to people and looked at surveys it told us enough staff were available to meet their needs. We observed how staff worked during the visit. This told us there were good relationships between staff and people and they responded in a timely way when people needed assistance. The service were unable to demonstrate and verify there were sufficient staff on duty at all times to support the smooth running of the service, because the staff rota was not a reliable source. For example, the rota identified only one member of staff on duty on the day of inspection, when in actual fact there were three. For ancillary staff it was their contract hours on the rota and not the day or hours they worked. This contradicts information in the AQAA that shows the maintenance of rotas as something the service does well. The AQAA also told us approximately a third of staff had left in the last 12 months. The Firs DS0000018252.V371133.R01.S.doc Version 5.2 Page 20 The service had a recruitment procedure that included prospective employees completing an application form, obtaining two written references, documentation of a full employment history and a CRB and POVA first check. However, the process was not always followed in practice as when we looked at two staff files, they had commenced work prior to the service receiving references. The previous visit had recommended that staff did not commence work without two satisfactory references. As this continues to happen and is not sufficiently robust enough to protect people, a requirement has been made. In addition, one of the people had commenced work without written gaps in employment being explained. When we spoke to staff they told us they had received training, including tissue viability and record keeping. They had not received any training in specific medical conditions that the people they care for have (see health and personal care and complaints and protection). There was a training matrix that provided dates for training and identified when staff had attended the training. When we asked to look at documentation, for example, certificates to confirm the training, this could not always be found. The AQAA did not provide robust information about the number of staff holding NVQ Level 2 or above as the figures did not support the information provided. The AQAA stated no care staff were trained in safe food handling. This is unsafe as care staff do prepare and serve food for people. The Firs DS0000018252.V371133.R01.S.doc Version 5.2 Page 21 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 & 38 were inspected. People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A change of manager and the manager’s lack of recommended qualifications and experience had led to some failures in the care home being managed effectively and included the lack of effective quality assurance systems. EVIDENCE: A new manager appointed since the last visit, had left. Another manager had been appointed and was due to start work in her manager capacity on 08.09.08, but was available on the day of the visit. A discussion with her identified she had eleven years experience working in a care, held NVQ Level 3 in care and was enrolling on NVQ 4 Leadership and Management. She was The Firs DS0000018252.V371133.R01.S.doc Version 5.2 Page 22 currently undertaking medication training and said her mandatory training was not up to date. The office environment was disorganised and created a chaotic environment for the manager to work and where the owner found information difficult to locate when asked for. The owner provided a quality audit file. It had good audit tools within it, but there were a lot of blanks where audits had not taken place. Where an audit had taken place, with action identified, this had not been acted upon. For example, improving the storage area for medications and rearranging the staff room. Questionnaires for people that lived there had been carried out, but no action plan formulated. This was raised with the manager at the last inspection and a recommendation made. As they haven’t been acted on and improvements are needed, this has now been made a requirement. The provider had been required to submit a monthly report of his opinion of the quality of the service. The last one submitted was for a visit on 19.05.08. He did produce his report for visits on 26.07.08 and 29.08.08. The information on the report for August states the deputy manager would be working full time alongside three carers to make things work effectively. This was not happening. The owner said it was because a third of staff had left. The AQAA was not submitted as requested, prior to the inspection. This meant the CSCI had no information to plan and focus our inspection, which gave us further concerns about the service. We looked at the financial transactions made on behalf of two people that lived there. This included the date monies were deposited and returned, the purpose for which the money was used and a receipting mechanism. We looked at a sample of maintenance and service records. These were up to date and current to the services provided. The fire risk assessment had been reviewed in November 2007. We also checked to see if the service had appropriate checks in place so that staff had sufficient training in first aid to help people should an accident occur. The owner said staff were trained in emergency first aid, but hadn’t conducted a risk assessment to determine whether this would be sufficient. The Firs DS0000018252.V371133.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 2 The Firs DS0000018252.V371133.R01.S.doc Version 5.2 Page 24 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 OP8 Regulation 12 (1) (a) Requirement The action identified in the plan of care to meet people’s health and personal care must be carried out, so that people’s needs in respect of their health and welfare are met. So that unnecessary risks to the health and welfare of people are identified and as far as possible eliminated risk assessments must be carried out. This matter is being dealt with though CSCI enforcement processes. People must receive the medication they are prescribed, so that their health care needs as assessed by a health professional are met. Previous timescale of 18.06.08 not met. This matter is being dealt with though CSCI enforcement processes. To maintain people’s health and welfare and keep them safe suitable arrangements must be in place for the recording, handling, safekeeping, safe DS0000018252.V371133.R01.S.doc Timescale for action 07/11/08 2. OP7 OP8 13 (4) (c) 07/11/08 3. OP9 13 (2) 07/11/08 4. OP9 13 (2) 07/11/08 The Firs Version 5.2 Page 25 5. 6. OP18 OP7 OP8 OP28 OP30 OP19 18 (1) (c) (i) administration and disposal of medicines received into the care home. This matter is being dealt with though CSCI enforcement processes. So that people are not placed at risk of harm, staff must receive training in the medical conditions of people that live at the home. To make the conservatory a safe and comfortable environment for people to use, the leaking roof must be repaired. To make sure people are sufficiently safeguarded two references must be received prior to new employees commencing duty and there must be a satisfactory written explanation of any gaps in employment. The provider must submit a copy of his report on the conduct of the care home to the CSCI, including information about how he has responded to and met requirements and recommendations made by the Commission. This will mean the CSCI are in a position to monitor the action they take to improve the service. Previous timescale of 27/05/08 not met 05/03/09 23 (2) (b) 03/12/08 7. OP29 OP31 19 (1) (b) 05/09/08 8. OP33 24 (2) (c) 26 (5) (a) 05/09/08 The Firs DS0000018252.V371133.R01.S.doc Version 5.2 Page 26 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 OP9 OP12 OP14 OP16 OP27 OP28 OP30 OP28 OP30 OP31 Good Practice Recommendations A record of all medication should be maintained by recording the amount of stock carried forward from one month to another. The plan of care should demonstrate consultation with people about how their social and recreational needs are going to be met. This gives people an opportunity to discuss with the service their expectations in this respect. The complaints procedure should include up to date information of the name, address and telephone number of the Commission. To demonstrate and verify sufficient staff are on duty at all times, the staff rota should be kept up to date. To demonstrate and verify staff have attended training documentary evidence of any relevant qualifications and training should be in place. To make sure staff are up to date with current good practice in respect of safe food handling, care staff should receive training. So that people live in a home which is run and managed by a person who is fit to be in charge and able to carry out their responsibilities fully, the manager that is registered should hold NVQ level 4 in management and care or equivalent, have two years experience in a senior management capacity, demonstrate they have undertaken periodic training to update their knowledge, skills and competence and be familiar with conditions/diseases associated with old age. Quality assurance systems should be improved, so that an annual development plan can be established to improve the quality of the service provided and monitor compliance with regulatory duties. To assess whether staff are sufficiently trained to help people in the event of an accident, a risk assessment should be conducted to determine this. 3. 4. 5. 6. 7. 8. OP33 OP31 OP38 9. The Firs DS0000018252.V371133.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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.V371133.R01.S.doc Version 5.2 Page 28 - 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. 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