Inspection on 16/01/06 for The Keepings

This inspection was carried out on 16th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Keepings 14/04/10

The Keepings 23/01/09

The Keepings 20/09/06

The Keepings 29/03/05

The Keepings 02/07/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Keepings 12 Priory Road Dudley West Midlands DY1 4AD Lead Inspector Mr Jon Potts Unannounced Inspection 16th January 2006 13:40p 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 Keepings DS0000024961.V278995.R01.S.doc Version 5.1 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 Keepings DS0000024961.V278995.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Keepings Address 12 Priory Road Dudley West Midlands DY1 4AD 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) 01384 253560 01384 214726 Mr Gordon Nuttall Mrs Sheree Eleanor Blackham Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places The Keepings DS0000024961.V278995.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user identified in the variation report dated 6 September 2004 may be accommodated at the home in the category DE(E). This will remain until such time that the service users placement is terminated. 9/8/05 Date of last inspection Brief Description of the Service: The Keepings is a large converted and extended domestic property located within easy reach by foot of Dudley Town centre, and therefore close to all public amenities. There is car parking to the front of the property and on the main road. There is a large garden to the rear, this well established with a variety of plants and a large patio area adjacent (with a number of tables and chairs available). The home has 19 single and 2 shared rooms. Resident’s accommodation is on two floors, the upper floor accessed by a stair lift. The bedrooms are individually decorated and reflect differing resident’s tastes and personalities. Residents can bring in their own furniture if they wish dependent on space requirements and following discussion with the manager. The home has a number of bathrooms with assisted bathing facilities on each floor. There is a large lounge with patio doors leading to a ramp with handrails. The dining area is situated on the ground floor. Communal areas are decorated and furnished to a high standard. The home has undergone building works last year to increase the number of beds available from 17 to 23 as well as improving the available space in communal areas, this now complemented by a new conservatory. The home is run by a manager/joint provider who has line management responsibility for a deputy, a number of senior staff and then carers. There is also ancillary staff including cooks, domestics, handyman and administrator. In addition the other joint provider is available at the home for the majority of the week. The Keepings DS0000024961.V278995.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was commenced at 1.40pm and ended at 5.05pm. The inspection drew evidence from the following; some limited case tracking; sight of care records; discussion with residents; reading various documents/ records; and discussion with one joint provider/deputy manager. The residents and staff that assisted with this inspection are to be thanked for their time and forbearance. What the service does well: What has improved since the last inspection? What they could do better: There was only one area of outstanding concern from the last inspection this related to recruitment checks carried out on new staff. The provider must ensure that no staff are employed without an enhanced disclosure unless a suitable risk assessment is agreed with CSCI, and this only when references and a POVA 1st check has have been obtained. Other issues identified were as follows: there needs to be a documented risk assessment in place for any residents that self administer medication; the registered manager must be based at the home or designate another person for registration as manager; and an annual development plan needs to be developed. Training for staff in infection control and adult abuse should be continued. The Keepings DS0000024961.V278995.R01.S.doc Version 5.1 Page 6 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 Keepings DS0000024961.V278995.R01.S.doc Version 5.1 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 Keepings DS0000024961.V278995.R01.S.doc Version 5.1 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): 1,3,5 Prospective residents have the information they need to make an informed choice about where to live and no resident moves into the home without having their needs assessed, with assurance that these needs will be met. Prospective service users and their relatives are offered opportunity to visit the home pre-admission, this to sample the facilities on offer. EVIDENCE: The home was seen to have reviewed their statement of purpose and service user guide in accordance with the changes that have occurred in respect of the premises over the last 12 months. This document is available to new residents admitted to the home, with additional information given verbally on any trial visits. Whilst the home was stated by one resident to be offering trial visits it was positive to see that the homes quality assurance system has identified that a policy on this area is to be developed by the deputy manager. There was evidence from the residents case files seen that there was information provided by the admitting social worker (where they were locally authority funded), this built on by staff at the home carrying out their own The Keepings DS0000024961.V278995.R01.S.doc Version 5.1 Page 9 assessment of need. For those residents that had lived at the home for a length of time recent reviews had taken place. The information within the assessments were seen to have influenced the individual resident’s care plans. There was documented evidence seen of the management confirming that the home was able to meet a resident’s needs prior to their admission to the home. The Keepings DS0000024961.V278995.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 10 The residents’ needs in respect of their health, personal and social care needs are in the majority of instances well set out in their care plan. Residents felt that their privacy and dignity is respected by the staff at the home. EVIDENCE: Care plans were seen to be available for all those residents whose care was tracked, these seen to be accurate when discussed with the residents concerned and cross-checked with other documentation. All care plans were seen to be signed by the resident or their representative and there was information in respect of risk assessment of individual’s health needs including tissue viability and nutrition. The outcomes for medication as a whole were not assessed but it was found from discussion with one resident that whilst the home allowed and encouraged self administration of medication (in this instance inhalers) this matter was not risk assessed as should be the case. The Keepings DS0000024961.V278995.R01.S.doc Version 5.1 Page 11 Arrangements for the resident’s privacy were discussed with residents with positive feedback that indicated staff respected their space, right to privacy, dignity and independence. Examples cited by residents included staff allowing them to choose their own clothes, stop in their bedroom when wished, attend to their own needs as far as possible (dress, wash etc), allowing privacy when using bathroom or toilet and staff knocking doors before entering bedrooms (this seen by the inspector). The Keepings DS0000024961.V278995.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Residents are assisted and enabled to exercise choice and control over their lives. EVIDENCE: Discussion with some of the residents evidenced that they were able to make a number of choices on a day to day basis this from staying in their rooms, what clothing they wished to wear, administering their own medication and deciding on what level of independence they would wish. The residents are encouraged to have involvement in their own financial affairs, although from discussion with residents they chose to involve others (not the home) to support them in this area. It was evident from resident’s signatures on documents that they have had access to records about them. There was evidence of residents bring their personal possessions into the home as confirmed by them and seen by the inspector. The Keepings DS0000024961.V278995.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These outcomes were not assessed at the time of this inspection. EVIDENCE: Whilst not fully assessed it was noted that a number of staff have received training in adult abuse, with five staff remaining to be so trained. The Keepings DS0000024961.V278995.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 25 Residents live in a safe and well maintained environment with access to comfortable in door and out door facilities. EVIDENCE: The home, from a quick tour of the building, was seen to be well presented and well maintained with no hazards present. All areas seen were also clean. Whilst there was no documented programme for the continued maintenance of the premises it was evidence that the provider has continued to maintain and improve the building with the extension, redecoration and refurbishment of the property, this having continued with the addition of a new conservatory. All the furniture in the living area is of a good standard and there is ample space available over and above that required with the addition of the conservatory area. The residents did comment on the conservatory as a nice area to sit and have some privacy, as it is partly separated from the main lounge, well presented and provides a comfortable living environment. Suitable arrangements are in place to protect residents from hot water and surfaces. The Keepings DS0000024961.V278995.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 The provider has committed to increasing the staffing level at night so resident’s needs are met by the numbers and skill mix of staff. There are weaknesses in the homes recruitment practices that may impact on the safety of staff. The number of qualified care staff indicates that residents are in ‘safe hands’. EVIDENCE: Based on the dependency and number of residents accommodated at the time of the inspection there were sufficient day staff seen to be available, but there was concern that there was only one waking member of night staff (supported by an on call carer). The provider has now confirmed that these staffing levels have now changed and there is two waking staff available. For this reason there is no requirement placed upon the home in respect of this matter. With the increase in night staffing the home will be meeting standard 27. An audit of the recruitment checks for the one staff member employed at the home since the time of the last inspection showed that not all expected recruitment checks had been carried out prior to employment. Two references had been obtained about two weeks after the worker commenced employment and of greater concern was that the POVA check seen (post inspection) was dated the 16th January when employment commenced on the 24.11.05. No staff are to be employed until receipt of a suitable POVA check and if intending The Keepings DS0000024961.V278995.R01.S.doc Version 5.1 Page 16 to employ workers prior to receipt of a disclosure, the manager must ensure that a risk assessment identifying what control measures are in place (to reduce risk to residents from staff that are employed) is developed. This risk assessment must be shared with and agreed by the CSCI prior to the employment of these staff. The home has over 50 of care staff with an NVQ level 2/3 The Keepings DS0000024961.V278995.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 The residents benefit from a home that overall is well run. There is however a lack of clarity as to who is responsible on a day-to-day basis however. The home is run in the best interests of the residents, with continued development of tools to evidence this fact. Resident’s financial interests are safeguarded. EVIDENCE: The home has a registered manager although the rota for the week of the inspection did not show her attendance at the home on a regular basis. The home was however seen to be supported on a daily basis by one of the joint providers and the deputy manager, with outcomes overall indicating that the service was well managed despite the registered manager’s absence. The joint provider did state that the deputy manager may apply for registration, but was The Keepings DS0000024961.V278995.R01.S.doc Version 5.1 Page 18 advised that the registered manager or a manager who has applied for registration must be available at the home. The home has developed its quality assurance system since the last inspection, this based on a quality manual and audit tool with evidence drawn from comments from residents through a questionnaires. Whilst there was evidence of audits the findings from these should be drawn out into an annual development plan. The home was seen to have policies and procedures in respect of the safeguarding of residents valuables in place and will safe keep small amounts of resident’s monies, these documented by the home, although not spot checked at the time of this inspection. Residents have been provided with key coded safes within bedrooms for storage of any valuables. Some of the residents spoken to were satisfied that their possessions were safe at the home. The Keepings DS0000024961.V278995.R01.S.doc Version 5.1 Page 19 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 3 X 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 4 X X X X 3 X STAFFING Standard No Score 27 3 28 X 29 4 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X X The Keepings DS0000024961.V278995.R01.S.doc Version 5.1 Page 20 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 OP9 Regulation 13(2) Requirement Timescale for action 28/02/06 2 OP29 19 3 OP29 19 Where a resident self administers medication this choice must be risk assessed, this to be fully documented. References must be obtained 15/02/06 prior to employment of staff, one of which must be from the last social care employer (where applicable). POVA 1st checks must be carried 15/02/06 out on all staff prior to employment. If there are concerns in respect of compromised staffing levels due to staff vacancies, the provider may employ staff without an enhanced disclosure, but only if all other recruitment checks have been carried out (including Pova 1st) and a risk assessment is completed and agreed with the CSCI. Staff employed without a disclosure must work with an existing named and experienced staff member, this until their disclosure is received. This is a repeated requirement. All staff must be trained in DS0000024961.V278995.R01.S.doc 4 OP30 18 30/04/06 Page 21 The Keepings Version 5.1 5 OP31 10 6 OP33 24 infection control and adult abuse where not already in receipt of such training. The providers must confirm who 28/02/06 is to manage the home if the registered manager is not able to spend sufficient time on site to discharge her responsibilities within this role. There must be an annual 30/04/06 development plan for the home based on a systematic cycle of planning – action – review, reflecting aims and outcomes for service users. 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 OP12 OP19 Good Practice Recommendations The staff should better document the individual activities residents are involved with on a day to day basis A rolling programme of redecoration and refurbishment, that formalises the routine and on-going work the providers are carrying out to maintain and improve the home, should be devised. The Keepings DS0000024961.V278995.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Keepings DS0000024961.V278995.R01.S.doc Version 5.1 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. 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