Inspection on 09/01/08 for The Old Library

This inspection was carried out on 9th January 2008.

CSCI found this care home to be providing an Adequate 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 Old Library 22/01/09

The Old Library 31/01/07

The Old Library 01/02/06

The Old Library 22/06/05

The Old Library 10/03/05

The Old Library 16/08/04

The Old Library 26/03/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Old Library Isaac`s Hill Cleethorpes North East Lincs DN35 8JR Lead Inspector Mrs Kate Emmerson Key Unannounced Inspection 9th January 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 Old Library DS0000002908.V357682.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 Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Library Address Isaac`s Hill Cleethorpes North East Lincs DN35 8JR 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) 01472 601364 Mr Charles William Jackson Position Vacant Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2007 Brief Description of the Service: The Old library is a 30-bedded care home registered for older people. The accommodation is set in a Victorian style building, retaining much of its original features. It is set in the seaside town of Cleethorpes, with views of the main thoroughfare to the sea front. The homes ownership has remained stable for a number of years and many staff have been retained by the home, which has given a great deal of stability. The current acting manager has yet to be approved by the CSCI. There are eighteen single rooms and six shared rooms; one of the shared rooms has en-suite facilities. The home has two lounges and an adjoining dining area; all rooms are decorated and furnished to a good standard. There are bathroom and WC facilities located on each floor. The home has equipped itself with a variety of aids to accommodate the dependency of the people in the home. The fees for the home are £361 per week includes £16 per week third party top up. Additional charges include chiropody £9.00, hairdresser £5.00 - £23.00. The Old Library DS0000002908.V357682.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 1 star. This means that the people who use this service experience adequate quality outcomes. This inspection was unannounced and took place over one and a half days in January 2007. To find out how the home was run and if the people who lived there were pleased with the care they got the inspector spoke staff working in the home at the time of the inspection and people who lived in the home. An expert by experience, Margaret Ferry, also assisted in the inspection for three hours. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. She spoke to the majority of people who lived in the home and staff who were on duty. She took lunch with people and observed the care provided and activities on offer. Some of the records kept in the home were checked. This was to see how the people who lived in the home were being cared for, that staff were safe to work in the home, that they had been trained to their job safely. We also checked records to make sure that the home and the things used in it were safe and were checked regularly. The home was checked to see if it was kept clean and tidy. The home provided a very friendly atmosphere and people who lived in the home and visitors said they were generally happy with the care provided. The majority of requirements form the previous inspection had been met. What the service does well: The manager and her deputy had worked hard to make sure that the home continued to improve. However some staff will need to take more individual responsibility in the provision of a quality service particularly when management are not on duty if the service is to continue to improve. The manager visited people before they arrived at the home to see if their needs could be met and then a detailed care plan was developed so the staff knew what care the person needed. The home had made sure that when they The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 6 have identified that a resident may be at risk they write and carry out a plan of care to reduce the risk. People had the opportunity to read and discuss their care plan and had signed to evidence this. Medication practices were safe and staff had received training in this area. The home provided well-maintained accommodation and the home had been decorated through out in 2007. Complaints and protection of people living in the home was taken seriously and procedures and staff training had been improved since the last inspection. The manager had made sure that people living in the home would be safe with the staff employed in the home by obtaining criminal record checks and references before staff started work They had involved people in looking at the quality of care provided in the home and developed an action plan to show how they intended to address any areas for improvement. Results form surveys were made available to people on notice boards. What has improved since the last inspection? They had improved the way they write care plans to make sure that the care plans were more specific about the care people needed. They check regularly that people have not lost/gained too much weight so that their health is maintained. They have developed links with the local hospital to make sure that any issues relating to peoples diet can be quickly addressed. They made make sure that the medication that required refrigeration was now safely stored by purchasing a medication fridge that was kept securely. They also monitored the temperature of the fridge to make sure that medication was stored at the correct temperature. They have investigated complaints fully to ensure all issues are addressed and records of complaints were held. They had provided staff with training in the safeguarding adults and associated policies and procedures. They had made sure that new staff had a thorough induction to the home so they know the policies and procedures and the standards expected of them. They let people know the results of the quality review and any surveys undertaken in the home by displaying these on the notice board. The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 7 They made sure that people were not put at risk by ensuring fire doors were not wedged open. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Old Library DS0000002908.V357682.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 Old Library DS0000002908.V357682.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, 2, 3 and 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provided clear information about the services provided in the home and ensured that people’s needs could be met prior to admission. The home does not provide intermediate care. EVIDENCE: There was detailed information about the service provided in the home in the form of a service users guide and a statement of purpose. This was made available to people in the home and was sent to prospective residents on enquiry. The information had been updated since the last inspection. In the reception area there was information on advocacy services and solicitors and how to access records. There was also information regarding planned activities and how to make a complaint. The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 10 People stated that they had received adequate information about the home before they moved in. There was signed evidence in individual’s files of agreement to the contract/statement of terms and conditions. The home offered a trail period and people were encouraged to have a short visit to the home for a meal before they decided to stay in the home. A preadmission assessment of peoples needs was completed by one of the management team and this was signed and agreed by the resident. The home ensured that a care plan was completed prior to admission to the home and a staff member was assigned to meet the person on arrival to the home. The Old Library DS0000002908.V357682.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 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. There were detailed care programmes in place to support the care that was given in the home although lack of detailed evaluation meant that care plans were not always updated as needs changed. People were enabled to self-administer medication and the homes policies and procedures supported safe handling of medication. People did not always feel they were treated with respect and privacy was upheld. EVIDENCE: The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 12 Random selections of care plans were examined. The care programmes were detailed and focused on the individual’s abilities as well as areas in which they required assistance. There was evidence in the programmes that individual risk assessment was undertaken; risk assessments for moving/ handling, tissue viability, falls, nutrition, bed rails and general issues were in place. Daily diary records were well maintained and detailed. There was evidence that peoples health was monitored and professional advice sought for pressure area care and dietary needs. There was evidence that care plans had been discussed with people and the majority had signed to agree them. There were improvements in the care plans since the last inspection in that formats had been applied consistently, regular monthly evaluations had been completed and some formal reviews had been held. The manager had also provided detailed information for carers from NHS direct in each care plan where the person had a specific health problem. The manger had developed direct links with the dietician at the local hospital and referrals were made directly where issues were identified. Although the care plans were evaluated monthly these lacked detail about the persons health and wellbeing over the previous month and information in monitoring records such as weight charts had not always been taken into account. Where it had been identified that one person’s mental health had deteriorated referrals for medical advice had been made although care plan had not been developed to show how the person was to be supported. Incidents relating to the deterioration had been recorded but actions taken in response had not always been recorded. The manager was requested to look further at some of the incidents recorded and send a report to the Commission as to the action taken. The home had well developed procedures in place for the safe handling of medication, which included self-administration of medication and accredited training for the staff. One member of staff had been promoted to a senior position with responsibility to administer medication before accredited training had been completed. Records of receipt, administration and disposal were clearly maintained although the controlled drugs records were untidy and formats inconsistently applied this could increase the risk of errors. However there were no controlled drugs prescribed or stored in the home at the time of the inspection. The home had not obtained written confirmation of the dose required where warfarin was prescribed, this is recommended. Risk assessments were completed for people who wished to self medicate. Secure storage had been provided for refrigerated medication since the last inspection. The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 13 The induction programme covered people’s rights to privacy and dignity. To encourage privacy and dignity to be respected terms of address were indicated on the care programmes, a telephone was available for use in private, personal mail was handed directly and unopened to the person to whom it was addressed, unless otherwise agreed and privacy locks had been provided on private accommodation and toilets/bathrooms. However people said that some times they did not feel they were treated with respect by the staff and that privacy was respected. One person commented to the expert by experience that some staff sometimes left slippers out of reach and put clothes on the floor and didn’t pick them up. It was also said that often carers would enter a shower room unannounced to collect something from a cupboard in the room. A resident in a wheel chair reported asking to be taken to the toilet and being told to ‘go in the pad.’ People were also being taken to a very odorous toilet by staff even though there was another toilet close by. This does not promote respect and dignity for the people living in the home. Observation of staff during the inspection identified that they were patient and courteous at all times. The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 14 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 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 felt they were able to exercise control and choice over their lives although the home offered limited choices in some areas. The way some meals and the environment were presented meant peoples health and safety and comfort were not fully promoted. EVIDENCE: The inspector was assisted by the expert by experience to look at these standards. The home had a policy on choice and advocacy in place. In the reception area there was information about local advocacy services and solicitors and how to access records. There was also information regarding planned activities and how to make a complaint. Activities on offer were planned and people were informed of the activities in a newsletter and the plan was displayed in the lounge. The home had a social The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 15 committee to raise funds for activities. A residents meeting was held every three months. The meeting was organised and chaired by a resident’s relative. There was evidence in notes taken that people felt free to express their opinions in this meeting. The expert by experience observed that the regular weekly activities were generally repeated week on week, for example video afternoon, games, bingo (twice) or art and craft. A reminiscence session and a music session had also been offered in January. The expert by experience observed that there was a poor response from people to the day’s activity, which was art. She observed that the carer offering the activity took some colouring books, plus a picture with paints attached from a cupboard, put them on the dining table, and called, “does any one want to do some art?”. She observed just one resident take up the offer. The carer then left having not tried to engage with or encourage any of the other residents to be involved in an activity of their choice. This means that the home offered a limited variety of activities and the staff were not proactive in enabling or encouraging people to be actively involved in stimulating activities of their choice. People told the expert by experience that they could raise and retire when they wished, and a cup of tea and breakfast in bed was available. The people who lived in the home could chose where to sit and had the opportunity t watch the television programmes of their choice or listen to music. The meals were provided on a four-week rotating menu although the meal served on the day was not the meal on the menu and the cook confirmed that menus were not being consistently followed. The cook stated that there were two choices at lunchtime although there was little evidence of this in records and the expert by experience was not offered a choice and did not observe anybody being offered or receiving a choice. Choices were available at breakfast and teatime. Staff stated that alternatives were available at lunchtime but choices were not offered as a matter of course. People said each meal was a ‘surprise’. This means that people have limited choice at lunch times in what they want to eat. The expert by experience took lunch at the home. She found the meal to of chicken and vegetables quite bland but observed that most people enjoyed the meal. She observed staff encourage people to eat and be as independent as possible and juice was freely available. Liquidised /soft diet were now presented so that different elements of the meal could be offered separately to people so that they may enjoy the different tastes and textures. The expert by experience raised some concerns having observed that meals were taken to rooms uncovered, tables in rooms had not been cleaned; plates The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 16 were very hot and one person burned their fingers on touching the plate. This means that that peoples health and welfare may be put at risk. Staff left their coats and bags on the table in the main dining area this did not provide for a pleasant environment for people to take their meals. The kitchen was very clean and tidy and all associated records for the safe handling of food were maintained. The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 17 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home ensured that the people were made aware of the complaints procedure and had the opportunity to raise issues. The home had processes in place to protect people from abuse. EVIDENCE: The home had a policy and procedure for management of complaints. The manager made sure that people were aware of the complaints procedures by displaying the procedures. Meetings from residents meetings showed that people felt comfortable raising issues. The records of the three complaints received by the home since the last inspection was examined. Records had improved and now showed that full investigation of complaints was completed. The Commission had received two complaints relating to the same issues, these were referred to the Local Authority Safeguarding team. Their investigation showed the complaints to be unsubstantiated. The staff had access to a copy of the multi agency safe guarding adult’s policy and procedures; the home had also developed their own detailed safeguarding The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 18 policy, which linked in with this document. There were policies on restraint, dealing with aggression, whistle blowing and managing finances in place. All the staff had accessed safeguarding adult training with the Local Authority. The manager stated that training was also given to new staff within induction training. The recruitment procedures in the home offered protection to people living in the home. The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 19 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 and 26 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. The home provided a very comfortable and homely environment. It was generally clean and tidy and well maintained but odour was not well controlled in some areas. The home and gardens were accessible to all individuals accommodated. EVIDENCE: The home was located in a very central area, close all the local amenities and sea front. The home had three floors that were accessed via stairs or passenger lift. The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 20 The general condition of the furnishings and decoration was of a good standard; redecoration and refurbishment was ongoing. Records showed that the home had been redecorated throughout in 2007. All areas seen as part of this inspection were clean and tidy, including the grounds. There were two bedrooms that were odorous this was due to dirty stained divan beds. The manager stated that these had been replaced by the second day of the inspection. A ground floor toilet was exceptionally odorous yet staff continued to assist people to use this facility with no thought as to the comfort of people and with little motivation to take any action to improve the situation. The main lounge was also odorous and used as a dumping ground for staff bags and coats again with little thought as to the impact on the resident’s home. By the second day of the inspection the manager had made sure that night staff had completed their cleaning tasks correctly and the area was much cleaner and fresher on the second day of the inspection. The manager and the proprietor of the home were advised that they must make sure that odour control is improved as this is an outstanding requirement and an issue noted a safeguarding investigation. A letter provided by the proprietor indicated that the water system in the home was a pressurised system and hot water was not stored, minimising the risk of Legionella. The hot water temperatures in bathrooms were within acceptable limits on the day of inspection. Policies and procedures were in place for control of infection; this was covered in the induction-training programme for new staff. However staff must be more proactive in this area as they were observed transporting food to bedrooms uncovered and placing meals on dirty surfaces. Staff confirmed that they had adequate supplies of protective clothing. There was evidence in staff files that staff had completed training in infection control. The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 21 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 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. The staffing levels had not been correctly calculated leaving a deficit in staffing numbers. There may be gaps in staff training which could affect peoples health safety and welfare. The recruitment procedures had improved and were adequate for the protection of people living in the home. EVIDENCE: The home was registered for thirty residents and at the time of the inspection there were twenty-six people accommodated. Whilst the manager provided evidence that staffing levels in the home were assessed using guidelines set out by the Residential Forum not all the elements of the guidance had been correctly applied. This meant that, at the time of the inspection, not enough staff hours were being provided, down by approximately eight hour per day. Following the inspection the deputy manager was advised as to the correct staffing levels and she stated that this would be implemented. She was also advised to check the forum regularly as any change in numbers of people accommodated or in their dependency would affect the number of staff hours required. The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 22 Staff felt that they did not have sufficient time to assist with activities and were very busy at tea time when they assisting with the preparation of tea. They also found weekends very busy when the management team were not at work. There were the people who lived in the home raised no specific issues relating to staffing and all said that they enjoyed living at the home. The staff rota did not show when the deputy manager or the manager was in the home. This is required to evidence who is working the home at any one time. There was evidence from staff training records and staff discussions that the home had an active training programme, which included mandatory and service specific training such as moving and handling, fire safety, dementia awareness and arthritis awareness. It could not be determined accurately from the records available that all the staff had completed refresher training in mandatory areas such as moving and handling. Although there was some planning in provision of training, this was generally short term and did not identify how all staff would achieve refresher training in the next twelve months. The home was committed to staff receiving NVQ training and of 21 care staff employed 8 had achieved at least NVQ 2. The induction programme for the staff had improved since the last inspection. staff were completing skills for care induction training workbooks. The records show new staff initially spend three days with the deputy manager and then have three supernumerary days on the shift. There were also records to evidence that staff were supervised until a Criminal records bureau check Adequate checks were completed prior to employment of staff. POVA (Protection of Vulnerable Adults) 1st checks had been completed in all cases prior to employment but it is recommended that, other than in extreme circumstances, staff are not employed prior to the receipt of a full CRB (Criminal Records Bureau) check. The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 23 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, 36 and 38 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. An experienced but unregistered manager managed the home. The manager regularly monitored the quality of care in the home and processes were continuing to improve. Staff were not regularly supervised to ensure that policies and procedures were consistently applied. People’s financial interests were safeguarded. Health and safety was generally promoted and protected but all staff may not have received mandatory training. The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 24 EVIDENCE: The current manager Helen Line has been in post since July 2006. Helen had been the registered manager of the Old library and had continued to work in the home as cook since stepping down in 2003. Helen had still not made an application to the Commission to become the registered manager at the time of the inspection. A system of monitoring the quality of the care provided had been implemented. There was evidence of involvement in the process from people who lived in the home in surveys and meeting records. Action plans had been developed and results of surveys and action plans were displayed. Where issues were raised in residents meetings these sometimes took some time to resolve. The manager was advised to develop action plans following meetings to make sure that people were assured that issues would be addressed in a timely manner. There were policies and procedures in place for all areas of practise, which had been regularly reviewed. However there was no supervision plan in place to ensure that staff consistently worked to the homes policies and procedures. There were very clear records maintained by the administrator where the home was assisting people with their finances and receipts were held for transactions. There was no evidence of regular management audits and this is advised. Detailed fire and environmental risk assessments were in place and individual risk assessments were held in care plans. Maintenance records showed that equipment in the home was regularly safety checked and serviced. Although there was evidence of regular staff training and induction training, staff training records were not complete and did not evidence that all staff had received adequate mandatory training in areas such as moving and handling. Accident records were maintained and monthly log was completed to enable the manager to study the prevalence of accidents in the home. The majority of staff had received training in first aid. The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 25 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 1 X 2 The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The registered person must make sure that monthly evaluations identify changes in peoples needs and that where changes have occurred the care plans are up dated so they reflect all peoples care needs. This so that peoples needs continue to be met. The registered person must review records of incidents in care plans where people have had deterioration in their mental health and provide a report of findings including actions taken to the Commission. This is to make sure that people have been adequately protected. The registered person must protect people from burns from hot crockery and from cross infection when transporting and serving meals. The registered person must ensure that the home is kept free from offensive odours. The registered person must make sure that staffing levels are accurately calculated using DS0000002908.V357682.R01.S.doc Timescale for action 01/04/08 2 OP7 12(1)(a) 13(6) 01/04/08 3 OP15 13(4) 13(3) 01/04/08 4. 5 OP26 OP27 16(2)(k) 18(1)(a) 09/01/08 01/04/08 The Old Library Version 5.2 Page 27 6 OP30 18(1)(c) 7 OP36 18(2) the Residential Forum and implemented to make sure that people’s needs are met. The register person must provide 01/05/08 evidence that all staff have completed refresher training in mandatory areas. The registered person must 01/05/08 make sure that staff receive regular supervision. This is to make sure that policies and procedures are consistently implemented and continued staff development. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP9 OP9 OP10 OP11 Good Practice Recommendations The registered person should ensure that controlled drugs records are clearly and consistently maintained to reduce the risk of errors. The registered person should obtain written confirmation from the GP of the warfarin levels to be administered to reduce the risk of errors. The registered person should make sure that staff understand how to protect peoples privacy and dignity and monitor that peoples needs in this area are being met. The registered person should make sure that people are offered a varied activities programme of their choice and make sure that staff are proactive in arranging activities and enabling people to take part in activities. The registered person should make sure that people are offered a choice at lunchtime and that they are made aware of meals on offer. The registered person should ensure that the training plan identifies how all staff will receive refresher training in the next twelve months. The registered person should ensure that the manager completes the process with the Commission to become the DS0000002908.V357682.R01.S.doc Version 5.2 Page 28 5 OP15 6 7 OP30 OP31 The Old Library registered manager. The Old Library DS0000002908.V357682.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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