Inspection on 01/11/06 for The Lawns Residential Care Home

This inspection was carried out on 1st November 2006.

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 Lawns Residential Care Home 22/08/07

The Lawns Residential Care Home 23/06/06

The Lawns Residential Care Home 08/12/05

The Lawns Residential Care Home 19/05/05

The Lawns Residential Care Home 11/10/04

The Lawns Residential Care Home 11/05/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE The Lawns Residential Care Home 1-2 Kensington Gardens Monkseaton Whitley Bay Tyne & Wear NE25 8AR Lead Inspector Glynis Gaffney Key Unannounced Inspection 01, 02 and 03 November 2006 14:30 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 DS0000000308.V302999.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. DS0000000308.V302999.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Lawns Residential Care Home Address 1-2 Kensington Gardens Monkseaton Whitley Bay Tyne & Wear NE25 8AR 0191 2530291 0191 253 7248 No Email 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) Mr Trevor Nesbit Mrs Sylvia Tidmas Care Home 28 Category(ies) of Dementia - over 65 years of age (8), Learning registration, with number disability over 65 years of age (1), Old age, not of places falling within any other category (19) DS0000000308.V302999.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2006 Brief Description of the Service: The Lawns is situated on Monkseatons high street. The Home provides residential care for 28 older people, of whom up to eight may have dementia care needs. Nursing care is not provided. It is a large, older style, detached building and has been adapted to meet the needs of older people. It is a threestorey building and a lift provides access to all floors. There are 26 single bedrooms, one of which has an en-suite facility. There is one double bedroom. There is a kitchen, a large lounge, a smaller lounge, a dining room and a laundry. There are toilets and assisted bathing facilities on each floor. At the front and side of the Home, there are pleasant and attractively landscaped gardens. There is a secluded patio garden to the rear. Bus routes, pubs and local shops are all within easy walking distance. The current scale of charges for a place at the Lawns ranges from £361 to £365. Additional charges are made for hairdressing, aromatherapy and chiropody. A copy of the Commission’s most recent inspection report, and the Home’s Statement of Purpose and Service user Guide, were available for visitors to read. DS0000000308.V302999.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, took place over 8 hours and involved one inspector. A range of evidence has been used to support the judgements reached in this report, including interviews conducted with the Home’s Manager, members of her staff team and residents. The premises were also inspected, as were a sample of care records, policies, and procedures. At the time of writing this report, no survey questionnaires had been returned by residents, their families or professionals who visit the Home. What the service does well: What has improved since the last inspection? DS0000000308.V302999.R01.S.doc Version 5.2 Page 6 The Manager had updated the Home’s Service User Guide since the last inspection. It was attractively presented, had been written in plain English and was easy to understand. New equipment to help staff safely move and transfer residents had been purchased. New call points and leads had been purchased for residents’ bedrooms. New smoke and heat detectors had been fitted and the Home’s Fire Risk Assessment had been revised to take account of the new Fire Regulations. All staff had been made aware of the new legislation. Improvements had been made to the Home’s heating systems. Thermostatic valves had been fitted on all baths and sinks. Various items of soft furnishings had been purchased. The new care plan system had been used with newly admitted residents. What they could do better: Ensure that the Home’s Service User Guide includes the required information to enable residents to make an informed choice about whether to accept a placement at the Lawns. Consideration should be given to making the Service User Guide available in alternative formats and languages. Ensure that residents’ care plans cover the required areas. Residents should be provided with opportunities to read and sign the records kept about them. This will help ensure that staff are clear about how residents’ needs are to be met. Ensure that residents’ risk assessments include information about potential risks identified by their Care Manager. Moving and handling risk assessments should cover residents’ needs for support with bathing. This will help to ensure that residents are protected from potential harm. Ensure that the kitchen is maintained in a clean and hygienic condition at all times. Monitoring checks should be carried out to ensure that hygiene standards are being maintained. This will help ensure that residents do not contract infectious diseases that may lead to ill health. Ensure that all staff have completed training in the protection of vulnerable adults. This will help ensure that residents are protected from the potential threat of harm or abuse. DS0000000308.V302999.R01.S.doc Version 5.2 Page 7 Ensure that the premise related concerns referred to in this report are addressed. This will help ensure that residents live in a well-maintained environment. Ensure that staff records contain the required information. This will help ensure that residents are protected from staff that are considered unsuitable to work with vulnerable adults. Ensure that staff regularly update their training in key areas. This will help ensure that residents are cared for by competent and skilled staff. Ensure that the Manager obtains a Level 4 National Vocational Qualification in Care. This will help ensure that the Lawns is managed by a person who has the necessary skills and knowledge to run the Home in the best interests of residents. Ensure that a written report is prepared following visits carried out by the Provider to monitor the quality of care provided at the Home. This will help ensure that residents are receiving a quality service that meets their assessed needs. Prepare an Annual Development Plan for the Home. This will help ensure that residents are able to see that there is a written programme that sets out how the Home’s furnishings, fittings and fabric of the building are to be renewed, repaired and improved. Ensure that the quality of care and support provided at the Home continues to be reviewed at least once a year involving residents, their families, staff and visitors to the Home. This will help ensure that any concerns identified about the way in which the Home is run are identified and addressed. 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. DS0000000308.V302999.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 DS0000000308.V302999.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): 1 and 3. Standard 6 was not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information contained in the Service User Guide was not satisfactory. This meant that prospective residents might not have been provided with all of the information they needed to make an informed choice about whether to live at the Home. Satisfactory arrangements had been put in place ensuring that prospective residents’ assessed needs could be met within the Home. DS0000000308.V302999.R01.S.doc Version 5.2 Page 10 EVIDENCE: The Service User Guide had been amended following a requirement set in the last inspection. The Guide contained most of the required information, was written in plain English and easy to understand. But, not all of the necessary information had been included. Other than in large print, the Home’s Guide was not available in alternative formats or languages. The records of two residents were examined in detail. The Home had obtained copies of their Care Management assessments and care plans. There was written evidence that prospective residents’ needs had been assessed by the Home before admission. The Manager said that she always took account of the information provided by Care Management to see if the Home was able to meet a prospective resident’s needs. DS0000000308.V302999.R01.S.doc Version 5.2 Page 11 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): 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. Care plans did not adequately cover all aspects of residents’ health, personal and social care needs. This could result in staff not being clear about how to meet residents’ needs. Residents’ health care needs were well met ensuring that they were able to lead healthy and pain free lives. Staff were seen to provide personal support in such a way as to promote and protect residents’ rights to privacy, dignity and independence. EVIDENCE: Individual plans of care were in place for each resident and covered most aspects of their health, personal and social care needs. Care plans covering residents’ needs for support with their medication, finances and health care DS0000000308.V302999.R01.S.doc Version 5.2 Page 12 needs were not in place. Also, in one resident’s care record there was no guidance about how to meet their dementia care needs. A range of preventative risk assessments had been completed for each resident in the following areas: management of skin care needs; nutrition; falls prevention and continence care. But, the following concerns were also identified: • • • The nutritional risk assessment for one resident did not include important information detailed in the Care Manager’s assessment and care plan; The moving and handling risk assessment for one resident did not assess their needs in relation to the support they needed with bathing; Risk assessments had not always been reviewed at the frequency set out by the Home. Although the Manager confirmed that residents’ care plans were reviewed on a monthly basis, there was no evidence that this had happened in one of the care records examined. Six monthly placement reviews had been completed for each resident. There was evidence that a recently admitted resident had signed some of the risk assessments completed by the Home. A Key Worker system was in operation and residents interviewed were satisfied with their Key Workers. Residents’ records were securely stored. Assessments of residents’ levels of dependency had been completed. None of the care plans examined had been signed by the resident, or their representative, confirming their agreement with the contents. The Manager had recently made arrangements for checks of the quality of information held in residents’ care records to be carried out on a regular basis. Residents confirmed that their health care needs were well met. Weight checks had been carried out on a monthly basis. Staff interviewed told the Inspector that they had access to the equipment they needed to meet residents’ continence and skin care needs. Hand wash facilities were not available in the area within which medication was stored and administered. However, staff had been provided with anti-bacterial hand wash. Advice had been obtained from the local Infection Control Nurse about this matter. Identification photos had been placed on residents’ Medication Administration Records. The medication trolley was clean and maintained in an orderly manner. A Controlled Drugs Register had been used to record the administration of Controlled Drugs. Although the medication records were generally well completed, staff had not signed and dated a resident’s medication record to confirm that an item of medication had been discontinued. Staff were observed providing personal care to residents in a kind, considerate and helpful manner. Residents interviewed confirmed that staff respected their privacy and treated them in a dignified manner. But, sensitive information about residents’ bathing choices and needs had been left on top of the drugs trolley that was located in the dining room. DS0000000308.V302999.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): 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. There was a good range of social activities provided in the Home and this meant residents had opportunities for stimulation through leisure and recreational activities. Residents were supported to maintain contact with their families and friends and visitors were made to feel welcome. The meals in this Home were good offering residents both choice and variety. Meals were served by staff who were willing to provide whatever assistance was required. EVIDENCE: The Home operated a key worker system that enabled staff to develop supportive relationships with residents. Information about activities and events taking place at the Lawns was displayed around the Home and at the DS0000000308.V302999.R01.S.doc Version 5.2 Page 14 front entrance for visitors. An activities organiser employed for 16 hours per week had developed a programme of social activities ranging from talking about the past to parties celebrating special events. The activities programme for one week included – a bingo session; a Halloween event; an arts and craft session; a musical performance; cards and dominoes; games and a fireworks party. A hairdresser visited the Home on a weekly basis and an aroma therapist every fortnight to offer relaxation sessions. An exercise and dance motivator also visited the Home regularly. A mobile library provided residents with access to new reading material. The Home also had a selection of its own books. Information about residents’ previous and current interests and hobbies was available in their care records. Care plans addressing residents’ social care needs were in place. Residents interviewed said that they were happy with the social activities provided. Residents spoken with said that the Manager and her staff team always made families and friends feel welcome. A relative told the Inspector that visitors could be seen in private or join residents in the lounge and dining areas. There was a policy outlining the Home’s approach to enabling residents to maintain contact with family and friends. There were no restrictions placed upon visitors. Wherever possible it is the Home’s policy to support residents to maintain control of their own financial affairs. The Manager confirmed that safekeeping facilities, and day-to-day support with managing personal monies and valuables, would be provided if a need to do so was identified. Residents said that they had been supported to bring their own personal possessions with them when they moved into the Home. The Home had a rotating four-week menu cycle. The menus contained the required information with the exception of the timing of meals. Details of the meals available for each day had been placed on a whiteboard in the main reception area. Choices were offered at all main meal times and a hot food choice was provided at the teatime meal. The lunchtime meal appeared to be enjoyed by all residents who participated in the meal. Staff were on hand to provide residents with support throughout the mealtime despite the temporary dining arrangements that had been put in place following the breakdown of the lift. The Manager said that for a short period of time, residents had to take their meals in the lounge areas whilst the lift was being repaired. DS0000000308.V302999.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): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A satisfactory complaints procedure was available. Residents felt that their views and opinions were listened to. This is important in ensuring that any concerns or complaints received will be treated seriously and handled appropriately. Satisfactory arrangements were in place to protect residents from the threat of potential harm and abuse. But, not all staff had received training in the protection of vulnerable adults. This could mean that staff might not have the skills and knowledge required to protect residents from potential harm or abuse. EVIDENCE: A Complaints Procedure was available that included details of how to make a complaint, who the complaint would be handled by and the Home’s timescales for completing investigations. Residents spoken with said that they had been made aware of the Homes Complaints Procedure and would be happy to raise matters of concern with any member of staff. The Commission had received DS0000000308.V302999.R01.S.doc Version 5.2 Page 16 one anonymous complaint that the Provider had been asked to investigate. The Provider’s findings were not available at the time of the inspection. An Adult Protection Policy was in place that provided guidance on what action should be taken to protect residents from potential harm. The Home had submitted its Adult Protection Policy to the local Safeguarding Team for comment. During the period since the last inspection, neither the Home nor the Commission had received any allegations that residents had been subject to abuse. Some staff had not received training in the protection of vulnerable adults. Arrangements had been made by the Manager to provide staff with this training. DS0000000308.V302999.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): 19, 20, 22, 24, 25 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The Home’s decoration, furnishings and fittings were of a good standard providing residents with comfortable surroundings within which they could relax and feel safe. But, the kitchen was in an unhygienic condition and this had the potential to place residents’ well being and good health at risk. Residents had access to most of the equipment they needed to maintain their independence. This meant that residents could choose to live independent lifestyles and only use staff support when absolutely necessary. DS0000000308.V302999.R01.S.doc Version 5.2 Page 18 EVIDENCE: The Home had been fitted with a range of aids and equipment to meet the care needs of the residents accommodated. Single room accommodation was provided throughout. En-suite facilities were available in one bedroom. Residents said that they were very pleased with the standard of their bedroom accommodation. The laundry was tidy, organised and clean. The grounds were tidy and attractively landscaped. Residents had access to the front and side gardens by way of a ramp leading from the main lounge area. The toilets and bathrooms were clean, tidy and hygienic. Toilets were situated near residents’ bedrooms and the lounge and dining areas. Normally, residents would have had level access to all parts of the building, with the exception of a step leading down into one of the bathrooms. But the lift, which enabled residents to access bedrooms and other facilities on the first and second floors, was out of order. As a result, a small number of residents were being cared for and, having to sleep in, the Home’s dining room. Action had been taken by the Provider to rectify this situation. There was a ramp at the front of the building, and a selection of aids and adaptations, such as grab rails and hoisting equipment, were located throughout the Home. Call points were available in each bedroom and within the communal areas. Radiators were guarded and fitted with thermostatic controls. There was no unguarded pipe work. Suitable locks had been fitted to bedroom doors enabling residents to protect their privacy. Staff were able to gain access in the event of an emergency. Lockable storage was available in all bedrooms. But, a number of concerns were identified as follows: 1. The kitchen: • • • • • • • Items of crockery were chipped and stained; The sink, food bin, fridges and the freezer were grimy and unhygienic; The floor, cooker and cooker hood, microwave and deep fat fryer were unclean and had not been satisfactorily cleaned by kitchen staff at the end of their shift; There were opened items of foodstuffs in the freezer which had not been properly sealed or dated; Some of the food storage cupboards were so untidy that stock control would have been very difficult. The cupboards were also unclean; Wall tiles and light switches were grimy and unhygienic looking; The kitchen fan was grimy with grease and dust. DS0000000308.V302999.R01.S.doc Version 5.2 Page 19 It was also of concern that catering staff had signed records to say that the kitchen had been cleaned when it had not. Also, this problem had not been identified and rectified by senior staff; The Manager took action to resolve the above concerns within 12 hours of the inspection commencing. 2. Bedroom Accommodation: Bedroom 14 - the paint on the commode framework was chipped and marked; Bedroom 9 – the room had an unpleasant odour; Bedroom 1a – the carpet had a worn appearance and was fraying in places. But, the Manager confirmed that a new carpet had been fitted within the last 12 months. 3. First floor bathroom – the ceiling had water damage in one corner. DS0000000308.V302999.R01.S.doc Version 5.2 Page 20 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): 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. There were sufficient numbers of staff on duty to ensure that residents’ needs were satisfactorily met. The arrangements for ensuring new staff receive their qualifying induction training and for updating staff training in the required areas were not satisfactory. This meant that staff might not have the knowledge and skills required to care for residents in a safe and competent manner. The information contained in some of the staff records was not satisfactory. This had the potential to place residents at risk of harm. EVIDENCE: The staff rotas contained the required information with the exception of staff designations. There were no care staff aged under 18, or senior staff aged less than 21. Staffing levels had not been reduced since the last inspection of the Home. The Manager confirmed that the numbers of staff on each shift were sufficient to meet the needs of residents living at the Home. No concerns about staffing levels were identified. DS0000000308.V302999.R01.S.doc Version 5.2 Page 21 An examination of the Home’s training records confirmed that over 75 of the care team had obtained a relevant care based qualification. However, a number of staff had not received refresher training in key areas such as – moving and handling, first aid, basic food hygiene and infection control. Arrangements had been made for all staff to attend training in these areas. The sample of staff files checked contained the required information with the following exceptions: • • • Confirmation that staff had received a copy of the General Social Care Council’s Code of Conduct for Employees; A full employment history and an identification photograph; An individual development plan. A Recruitment and Selection Policy was available. A member of staff appointed in July 2006 said that they had not yet received qualifying induction training. DS0000000308.V302999.R01.S.doc Version 5.2 Page 22 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): 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. Satisfactory arrangements were not in place to review the quality of care and services provided at the Home. This could mean that residents, their families and staff are not provided with opportunities to comment on how the Home is run and what action needs to be taken to improve its performance. The Manager had taken suitable steps to protect and promote the health and safety of both residents and staff. DS0000000308.V302999.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Registered Manager had relevant and substantial experience in caring for older people within a residential care setting. She had obtained the required management qualification. Mrs Tidmass was in the process of undertaking a Level 4 National Vocational in Care at the time of the inspection. An annual development plan had not been prepared and, although a professional quality assurance package had been purchased by the Home earlier in the year, only a small section of the document had been completed. A quality assurance report for 2006 was not available. Although the Provider’s representative had visited the Home to monitor the quality of care provided, a report had not been prepared covering the required areas. A record of accidents occurring within the Home had been kept. The Home’s Fire Log contained evidence that the required fire prevention checks had been conducted. There was an up to date fire risk assessment. A clinical waste contract was in place and a range of workplace risk assessments had been completed. Some of the risk assessments had not been signed and dated. There was a maintenance contract for the lift and a policy had been prepared providing staff with guidance on what to do in the event of the lift breaking down. Staff were observed using the dinner trolley to prop open the fire door leading into the kitchen from the dining room. DS0000000308.V302999.R01.S.doc Version 5.2 Page 24 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 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 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 2 DS0000000308.V302999.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5 Requirement The Registered Manager must ensure that the Home’s Service User Guide: • Provides a clear explanation of what services are provided to residents with ‘early onset dementia’; Includes a summary of residents’ views of the Home; Timescale for action 01/04/07 • (Previous timescale of 01/11/06 not met.) • • Includes a summary of staffs’ experience; Includes information about how the Home will meet the needs of residents with different cultural and ethnic backgrounds. 01/04/07 2. OP7 15 The Manager must ensure that: • Each residents care plan sets out in detail the action to be taken by care staff to DS0000000308.V302999.R01.S.doc Version 5.2 Page 26 • • ensure that all aspects of residents’ health, personal and social care needs are met, including their need for assistance with medication and managing their finances; Residents, or their representatives, are provided with an opportunity to read and sign their care plans; Care records contain signed evidence that residents have been given a copy of the Home’s Statement of Purpose, Service User Guide, latest inspection report and Complaints Procedure. (Previous timescales of 01/06/06 and 01/11/06 not met.) • • • Residents’ care plans are reviewed on a monthly basis; Care plans clearly describe residents’ needs for support and assistance; Care plan interventions take account of needs identified in the Home’s care records. (Previous timescale of 01/11/06 not met.) 3. OP8 13(4) 15 The Registered Manager must ensure that: • Important information about residents’ needs as detailed in their Care Management assessments and care plans is referred to in any risk assessment Version 5.2 Page 27 01/04/07 DS0000000308.V302999.R01.S.doc • completed by the Home; Moving and handling risk assessments cover residents’ needs for support with bathing. 01/01/07 4. OP18 13(6) The Registered Manager must ensure that all staff have received training in the protection of vulnerable adults. (The timescale for complying with this requirement had not expired at the time of the inspection.) The Registered Manager must ensure that: • The food bin, sink, floor, cooker, microwave and deep fat fryer are cleaned by kitchen staff at the end of each shift; The Home’s fridges, freezer, wall tiles, cooker hood and light switches are cleaned on a regular basis and daily cleaning is undertaken as necessary; Chipped and stained crockery is replaced; Foodstuffs kept in the freezer are sealed and dated; Food storage cupboards are kept tidy to enable effective stock control and rotation to take place. The cupboards must also be kept clean; The kitchen fan is kept clean and 5. OP19 16(2) 01/01/07 • • • • • DS0000000308.V302999.R01.S.doc Version 5.2 Page 28 grease and dust free. The Registered Manager must also put arrangements in place to monitor the condition of the kitchen and the standard of work carried out by kitchen staff. 6. OP19 23(2) The Registered Provider and Manager must ensure that: • Bedroom 14 - the commode frame is repainted or the commode is replaced; Bedroom 9 – action is taken to eliminate the unpleasant odour; Bedroom 1a – the carpet is replaced; First floor bathroom – the ceiling is redecorated. 01/04/07 01/04/07 • • • 7. OP29 18(2) The Registered Manager must ensure that: • The Company has obtained a full employment history for each member of staff; (Previous timescale of 01/11/06 not met.) • There is written evidence that all staff have been issued with a copy of the General Social Care Council’s Code of Practice; An identification photograph is included in the records for each member of staff. 01/04/07 • 8 OP30 18(2) The Registered Manager must ensure that: • An Individual Development Plan has been completed DS0000000308.V302999.R01.S.doc Version 5.2 Page 29 • for each member of staff; All new staff complete the Skills for Care Induction within the first six weeks of their employment. (Previous timescale of 01/11/06 not met.) 9. OP31 9 The Registered Manager must obtain a relevant care qualification. The Registered Manager must undertake a review of the quality of care and services provided at the Home. The views of residents, their families, staff and professional visitors to the Home, must be obtained as part of the review process. A copy of the review must be made available to residents and the Commission. (The timescale for complying with this requirement had not expired at the time of the inspection.) The Registered Provider must ensure that he, or his representative, visits the Home at least once a month unannounced to: • Interview residents, their representatives and staff working at the Home to form an opinion of the standard of care being provided; Inspect the premises and its records, including the complaints record. 01/01/08 10. OP33 24 & 26 01/01/07 • The Registered Provider must prepare a written report on the DS0000000308.V302999.R01.S.doc Version 5.2 Page 30 conduct of the Home and supply the Commission with a copy. 11. OP33 24 The Registered Manager must prepare an annual development plan following completion of the Home’s first quality audit cycle. A copy of the report must be forwarded to the Commission. (The timescale for complying with this requirement had not expired at the time of the inspection.) 12 OP38 13(4) The Registered Manager must ensure that: • Staff update their training in the following key areas: First Aid; Basic Food Hygiene; Moving Handling; Infection Control; 01/01/07 01/01/07 (The timescale for complying with this requirement had not expired at the time of the inspection.) • All workplace risk assessments are signed and dated. DS0000000308.V302999.R01.S.doc Version 5.2 Page 31 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 OP8 Good Practice Recommendations The Registered Manager should ensure that in-house risk assessments are reviewed at the frequency set out in the risk assessment. The Registered Manager should ensure that information about residents’ bathing needs and preferences is treated in a confidential manner. The Registered Manager should: • Seek advice from the Home’s fire officer about the possibility of installing suitable equipment, to allow the fire door leading from the kitchen into the dining area, to be propped open during key times of the day such as meal times; Complete the good practice Infection Control checklist issued by the Department of Health. 2. OP10 3. OP38 • DS0000000308.V302999.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 DS0000000308.V302999.R01.S.doc Version 5.2 Page 33 - 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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