Inspection on 26/09/06 for The Paddocks

This inspection was carried out on 26th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Paddocks 11/03/09

The Paddocks 22/08/07

The Paddocks 20/03/07

The Paddocks 29/11/05

The Paddocks 03/05/05

The Paddocks 01/11/04

The Paddocks 15/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE The Paddocks 45 Cley Road Swaffham Norfolk PE37 7NP Lead Inspector Kim Patience Unannounced Inspection 26th September 2006 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 Paddocks DS0000027321.V314926.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 Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Paddocks Address 45 Cley Road Swaffham Norfolk PE37 7NP 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) 01760 723416 01760 722420 lincolncare1@aol.com Lincoln Care Homes Limited Mrs Elizabeth Keys Care Home 74 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (23), Old age, not falling within any other of places category (50) The Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The unit known as Sandpiper to accommodate 23 (DE(E) and 1 DE. The unit known as Kingfisher to accommodate 29 (OP). The unit known as Nightingale to accommodate 21 (OP). 29th November 2005 Date of last inspection Brief Description of the Service: The Paddocks is a residential home providing care for 74 elderly people. It is situated on Cley Road, and is within walking distance of the town centre of Swaffham. There are two parts to the home, the older part and an adjacent new wing. In addition to the main building there is a separate building which houses the administrative offices and laundry. The home is set in mature and attractive grounds. There is car parking at the rear of the home.Medical and nursing services are provided via the local G.P. service. The home has now been extended to provide care to 24 residents with dementia type illness. The Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted over two days and took approximately 12 hours to complete. The majority of the inspection focussed on Sandpiper unit, which accommodates people with dementia, who have higher dependency needs. During the inspection, a tour of all three units was conducted and records relating to residents in Sandpiper and Kingfisher were inspected. Records relating to staff were also inspected along with those relevant to the running of the business. Observations of interaction between staff and service users were made and some residents and staff were spoken with. Medication arrangements in Sandpiper were also inspected, following up on the 7 requirements made by the pharmacist inspector at the last inspection conducted in December 2005. The registered manager and the responsible individual were available for discussion and feedback at the close of the inspection. The heads of care in each unit, were also helpful in facilitating the inspection process. What the service does well: What has improved since the last inspection? Sandpiper has collected good person-centred information in relation to people with dementia and progress has been made since the last inspection. The Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 6 The development of Kingfisher unit is progressing well. What they could do better: The home must develop care plans that address peoples individual care needs. The home must develop an effective risk management strategy and complete risk assessments in respect of all risks. The home must introduce nutritional needs assessments. The home must ensure that resident files are kept in accordance with schedule 3 of the regulations. This relates to the need to include a photo of each resident in the care plans. Medication arrangements must be improved to ensure the safe administration of medicines at all times. The home must consider the issues of privacy and dignity and seek to resolve some of the concerns raised in the report. The home needs to develop the social care plans and demonstrate that they are meeting resident’s individual needs in this respect. The environment in Sandpiper must meet the needs of its residents and the home should consider changes to make the environment more enabling. The home must review the staffing levels, particularly in Sandpiper to ensure that resident’s holistic needs are met. Staff files must be maintained in accordance with the regulations and recruitment practice must be improved to ensure the protection of vulnerable people. The management must introduce a recognisable system for monitoring quality. The provider must conduct regulation 26 visits and provide the Commission with a copy of the regulation 26 report. The manager must ensure that all staff are provided with an adequate level of supervision. The home should produce a staff training plan. The Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Paddocks DS0000027321.V314926.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 Paddocks DS0000027321.V314926.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 The quality outcome in this area is good as the home can demonstrate that new residents are only admitted to the home once an assessment has been completed to determine that their needs can be met. EVIDENCE: The home has a policy and procedure on new admissions to the home. All prospective residents have their needs assessed prior to coming to live at the home and are given information about the services provided so they can make an informed decision as to whether the home is suitable. Prospective residents and their relatives are invited to view the accommodation as part of the decision making process. Service user surveys indicate that residents are provided with a contract and adequate information about the service prior to moving into the home. People coming to the home for short-term respite also have their needs assessed in the same way. The Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7-10 The quality outcome in this area is poor, as the home cannot demonstrate that people’s needs are met in full due to the lack of individual care plans and adequate risk assessments. Medication arrangements also raise concerns for the safety and welfare of residents. EVIDENCE: Care plans in Sandpiper and Kingfisher wings were assessed. The home develops more detailed information on new residents within 24 hrs of admission. The assessment of need contains good person-centred information on individuals noting preferences in all respects. For those people with dementia, information is gathered from relatives and friends building a picture of the person based on past experiences and their life history. The information in respect of people with dementia is good. A care plan summary is written to provide care assistants with clear succinct information about peoples needs. However, while the home has these systems in place and some good individual information it needs to work towards full care plans that address each individual need and how the care assistant should meet those needs taking into account the persons strengths and abilities. See requirements. In addition, the care plans need to be reviewed regularly to The Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 11 ensure that they are up to date and take into account any changes in need. See requirements. The last inspection identified some issues in respect of care plans and the review of information held. At this time work was in progress to build the care plans for residents in the dementia care unit and a recommendation was made that care plans should be reviewed. While progress has been made, there was still evidence that care plans needed to be developed further and reviewed regularly, therefore requirements have been made on this occasion. Residents records did not include a photo of the resident, while the home has a photo of the resident on the medication administration records, and this is seen as good practice, it is a requirement that a photo is included in the care plans, as not everyone has access to the medication administration records. See requirements. Along with improvements to the care plans, the home needs to develop the risk management process, particularly for those people with dementia. Risk assessments need to consider all risks associated with daily life. For instance, products that could be a hazard if consumed were seen in people’s rooms but no risk assessments had been completed. Another example is, one resident is very vocal and as a result is more susceptible to the risk of abuse from other residents but no risk assessment had been carried out. Ideally, care plans should identify areas of need and risk assessments should be written in relation to each aspect of care. See requirements A record of Medical contacts is maintained and copies of accident reports are kept on the residents file. A falls risk assessment tool is used where residents are prone to fall and weight is monitored where necessary. The home does not yet have a process for assessing peoples nutritional needs, however, following discussion with the manager this is soon to be introduced. It is a requirement that resident’s nutritional needs are assessed and action taken to meet these needs. Observations of mealtime showed that residents would benefit from an assessment, for instance one resident was finding it difficult to manage to eat independently, however, an assessment would have identified the need for any aids to support her. See requirements Those residents who are accommodated in the rooms upstairs in Sandpiper currently cannot access their rooms. This does not promote choice or provide residents with the opportunity for privacy and the home should start to develop an enabling environment and consider the benefits of assistive technology. See requirements The arrangements in place for the storage, receipt, administration and disposal of medicines were examined in Sandpiper unit to follow up issues raised during the inspection of 25/11/05 by the Pharmacist Inspector. The home has an adequate system in place for medicine administration. There are now resident-identifying photographs in place to assist in safe medicine administration. At the time of inspection, medicines were noted to be secure The Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 12 and keys were held by authorised members of staff. Recent medicine refrigerator temperature records indicated that medicines requiring refrigeration had been stored within the accepted temperature range. The manager said that since the pharmacy inspection members of staff administering insulin by sub-cutaneous injection had received training and that further training had been scheduled for 11/10/06. Medicine administration practice was observed during inspection. Concerns were raised that one member of staff handled medicines by hand without due consideration for safe hygiene practice. Another carer was observed to administer medicines in the dining room and good practice was seen. The registered person must take steps to review medicine administration practice at the home ensuring safe hygiene practice is adhered to at all times. See requirements. There were further concerns raised in relation to the home’s record-keeping practice. There were omissions in records for the receipt and administration of medicines including medicines prescribed with variable doses and where records indicated that medicines were not administered there was inadequate recording. For many medicines it was not possible to conduct audit trails of medicines. Therefore for these medicines records do not confirm that the medicines have been administered in line with prescribed instructions. The registered person must take steps to ensure full and accurate records for the receipt of medicines are kept at all times. In addition, the registered person must ensure that full and accurate records are completed for the administration of all medicines (including those prescribed with variable doses) and medicines not administered. There must be full audit trails in place for all medicines thereby demonstrating that medicines have been administered in line with prescribed instructions at all times. See requirements. It was noted that some medicines of a psychoactive (and sedative) nature prescribed on a PRN (as required) basis were being offered for administration on a routine basis. It was unclear if the administration of these medicines was clinically justified. At the time of the pharmacy inspection, the use of clear care planned guidance on the administration of such medicines was discussed and recommended. The home has not yet implemented this so this is again recommended as a means of ensuring such medicines are administered only when clinically appropriate. The Paddocks DS0000027321.V314926.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 The quality outcome in this area is adequate. However, the home cannot fully demonstrate that people’s individual social and emotional needs are being met and nutritional needs are being fully considered. EVIDENCE: The provision of activities and how social care needs are met, were assessed in Sandpiper. The home has lots of information relating to peoples life history from which they can build a programme of meaningful activities. This needs to be developed further to ensure that they are meeting people’s individual needs as opposed to the needs of the group. Social care plans contained very little information to guide care assistants and it is required that these be developed further. This is the third consecutive requirement to be made in respect of meeting people’s social needs. See requirements. The home has a programme of activities and records of activities and who participated are maintained. Activities range from group activities such as bingo and to individual reminiscence work. Each resident has a memory box that contains items that are meaningful to him or her. All staff are to be provided with training in reminiscence work in November. The lunch routine was observed. The dining room is incorporated in the lounge area where several tables were laid out for lunch. Residents were seated to eat The Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 14 at the tables and in other chairs in the lounge, indicating that people are given some choice about where they have their meals. Food is served from a hot trolley by the chef and only one main meal option is stated on the menu, but alternatives are offered where needed. Residents who were able to comment on the quality of the food stated that the food is usually good. Liquidised food was prepared in individual portions and nicely presented. A choice of drinks were offered in a variety of vessels, sherry was also being served at lunchtime to those who wished to have it. Finger foods were provided at intervals throughout the morning and appeared to be successful and this is good practice. As already mentioned in standard 7-10, nutritional needs assessments must be completed to ensure that people’s needs are being met in this respect. See requirements. The Paddocks DS0000027321.V314926.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The quality outcome in this area is poor, as the home cannot fully demonstrate that people are protected from harm due to concerns with recruitment practice and the risk management process. EVIDENCE: The home has a policy and a clear procedure for dealing with complaints and concerns. A copy of the complaints procedure is included in the service users guide along with a complaints form. Service user surveys indicate that people know how to make a complaint if they need to. The home has an adult protection policy and procedure that includes the whistle-blowing policy. Staff have been provided with some training on adult protection and further training is planned in November. Due to the concerns about unsafe recruitment practices (see standards 27-30) it cannot be said that the home fully protects people’s welfare. In addition, in Sandpiper a care assistant was observed to deal with a resident’s behaviour inappropriately and this raised concerns about how much staff understand about adult protection and the various forms of abuse. As mentioned in standards 7-10, the home also needs to ensure they have a robust risk management strategy in place so that staff have clear guidance about how people should be protected from harm. See requirements The Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The quality outcome in this area is adequate, however, the home cannot demonstrate that they provide an enabling environment that meets the needs of people with dementia and it was not possible to fully assess the environment in the other wings of the home due to the current building work and forthcoming refurbishment. EVIDENCE: A tour of the premises was completed in Sandpiper and Kingfisher. The assessment of the premises is based on Sandpiper, the unit allocated to people with dementia care needs. Sandpiper was found to be clean, tidy and odour free. Residents who were able to make comment in the survey stated that the home is generally clean and tidy. In the reception area of the unit photographs of residents engaged in various activities could be seen on display, in addition to artwork created by the residents. This is good practice and helps to promote a sense of belonging. The Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 17 There is one large lounge diner split into two separate areas, partially divided by a wall. In one area the television was on and in the other the radio was on. Noises from both areas were conflicting making it difficult to distinguish between the various sounds. This will inevitably add to the confusion already experienced by some people and the home must find a solution to this problem. See recommendations. The flooring and the layout in the lounge lacks a homely, domestic feel and the lino floor could increase the noise levels already mentioned. In addition, the office window looks out into the lounge, again, not a homely feature. However, there are plans to place a blind on the window to make its appearance more domestic. The home should introduce more signage and prompts to aid orientation, for instance there is no directional signage. Residents room doors show the name of the resident and the key worker, however, the signs are not clear and there is nothing else on the door to aid recognition and recall. Therefore, residents may not be able to identify their own room until they are inside and recognise their own personal items. The home should consider the effective use of colour and make the rooms more person-centred and individual. The home should also consider the use of assistive technology to make the environment more enabling and encourage independence and choice. See requirements The rooms on the first floor are currently not accessible to residents unless accompanied by a member of staff and this may restrict resident’s freedom and right to privacy. See requirements One communal toilet has a yellow door that is easily recognisable to residents and this is good practice. One of the communal bathrooms contained unmarked toiletries and this could indicate communal use, which again does not promote choice. Resident’s rooms contained products such as steradent tablets that could be a hazard to people’s safety, as mentioned in standards 7-10 risk assessments had not been completed and therefore the risk had not been identified. See requirements Kingfisher unit was entered, however, it was not possible to assess the environment due to the substantial building work taking place in the unit to create eight new bedrooms. Risk assessments had been carried out on the premises in light of the building work and the hazards that may be created. The Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 The quality outcome in this area is poor, as the home cannot fully demonstrate that staffing is adequate to protect the health and welfare of residents. EVIDENCE: The staffing levels in Sandpiper were assessed because residents accommodated there have higher levels of dependency. Copies of the staff rotas were provided and observations of how resident’s needs are being met were made. Analysis of the rotas showed that there are 4 care assistants on duty between 07.00-1300, 3 care assistants between 13.00-22.00, 2 care assistants between 22.00-07.00. In addition to these hours the unit has a head of care who works between 06.45-16.00, two days a week on care duties and 13 hours per week on management duties. The hours allocated to each unit head of care for management tasks does not appear to be sufficient given the number of residents and staff in each unit, each must generate the management tasks equivalent to a small care home. The unit is registered to accommodate 24 residents with dementia. Based on the information provided in the rota, the staffing levels are below that expected in a unit for this number of people with dementia type illness. Observations at key times, such as lunchtime, also support this view and this was raised with the manager during the inspection. In the afternoon of the inspection there was very little happening in the lounge and only one care assistant was available to support residents for some of the time. One resident appeared to need more attention than others and was heard to shout for much The Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 19 of the time, but was quiet when there was something to focus on, staff were not available in sufficient numbers to devote the attention needed. There is also the issue of restricted freedom for some residents, as mentioned in standard 19. If the staffing levels were adequate the home would be better able to promote independence in this respect, for instance, residents would have safe levels of supervision when walking around the home. Service user surveys also indicate that some people feel the staffing levels are not always sufficient. When discussed with the manager, she felt that the staffing levels were adequate, even though at times during the day only three members of staff are scheduled to work. In addition, at the time of the inspection the home did not have an activities coordinator and planned activities had been delegated to care staff. It is required that the home review the staffing levels with a view to increasing them to a sufficient number to fully meet peoples health and social care requirements. See requirements. The home currently has 72 of staff with an NVQ 2 or above which exceeds the target set in the standards. Training is provided throughout the year however; it was difficult for the home to demonstrate this without the plan and a central record of training undertaken. The manager stated that all mandatory training, such as fire safety, moving and handling and health and safety has been provided through a mix of internal and external training providers. Staff have been provided with in-house training in dementia care, delivered by the heads of care who have completed the Alzhiemers, yesterday, today and tomorrow. It is recommended that the head of care in Sandpiper be given the opportunity to undertake advanced training in the care of people with dementia. See recommendations. Each of the heads of care has completed the NVQ level 3 and it is hoped that they will progress to level 4. The home demonstrates a positive commitment to enhancing the knowledge and skills of the workforce, showing a good understanding of what is needed to achieve best outcomes for residents and improve the overall standard of care. Recruitment practice was assessed and some good practice could be seen in this area. The home has policies and procedures to support the recruitment process. All prospective employees are required to complete an application form and attend a face-to-face interview. Two members of staff, one being the manager conducts interviews and a record of the interview is kept. Two files relating to new staff were inspected and irregularities were found. A new care assistant had commenced employment without a POVA or CRB and with only one written reference. This is unsafe practice and does not promote The Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 20 protection of vulnerable people. The home must ensure that they are up to date with the conditions under which new staff can commence employment. See requirements The staff files also did not include photo ID of the member of staff and this is a requirement. See requirements. The Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36,38 The quality outcome in this area is poor, as the home cannot fully demonstrate that the overall management systems are in place to ensure a quality service that protects resident’s health and welfare. EVIDENCE: The home has a registered manager who has been in post since last November who is supported by one head of care in each of the three units and senior care workers. It is recommended that the registered manager and the head of care in Sandpiper undertake advanced training in the care of people with dementia. See recommendations. The home has made attempts to introduce a quality assurance system and have recently conducted a quality assurance survey with all major stakeholders. The results of the survey are not yet available and once collated and analysed the home must produce a report that is made available to all stakeholders involved and a copy sent to the Commission. The Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 22 Quality assurance was discussed with the manager and the director of the service. Both confirmed that a quality assurance system is yet to be developed in full and this is work in progress. It is required that the home has a recognisable quality assurance system in place before the next inspection as it is critical that the home is able to identify deficit in the service and take action to resolve these deficits through a process of continuous change and improvement. See requirements. In addition, it was identified that the provider has not so far submitted any monthly regulation 26 reports and this is a requirement. See requirements The provider has produced a business plan and agreed to provide the Commission with a copy. The provision of staff supervision was assessed and again it is reported that this is work in progress. The home has good systems in place for supervision, such as a supervision contract and a set format for recording supervision sessions. At present the manager is supervising the unit managers who in turn are supervising the senior staff. Once the senior staff are trained in supervision techniques they will take on the task of supervising the care staff. The home must progress this plan without delay as it is important that staff are properly supervised and that any issues with practice are dealt with. See requirements. In respect of health and safety, the home has policies and procedures in place. Staff are trained in aspects of health and safety, including moving and handling. The home has a maintenance man who ensures that general maintenance tasks are taken care of. Fire safety records and health and safety records were available for inspection, however, not looked at in any depth on this occasion. Although the manager confirmed that all checks are carried out in accordance with the standards. Some health and safety hazards have been identified in this report and must be addressed through the risk management process. The Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X 3 2 3 2 2 X STAFFING Standard No Score 27 1 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X X 2 X 2 The Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The registered persons must ensure that each resident has a written plan of how needs in respect of health and welfare should be met. This includes the regular review of those assessments and the further development of social care plans. The registered person must ensure that a robust risk assessment strategy is introduced, risks are identified and written plans are in place to minimise risk. The registered person must ensure that the nutritional needs of residents are assessed. The registered person must ensure that privacy and dignity is promoted at all times. The registered person must take steps to review medicine administration practice at the home ensuring safe hygiene practice is adhered to at all times Timescale for action 24/11/06 2. OP8 13(4)(a,b, c) 24/11/06 3 4 5 OP8 OP10 OP9 Schedule 3(m) 12(4)(a) 13.2 13.4 24/11/06 24/11/06 27/10/06 6 OP9 13.2, 17.1 The registered person must take (sched 3) steps to ensure full and accurate DS0000027321.V314926.R01.S.doc 27/10/06 The Paddocks Version 5.2 Page 25 records for the receipt of medicines are kept at all times – repeat requirement 7 OP9 13.2 13.4 17.1 (sched 3) The registered person must ensure that full and accurate records are completed for the administration of all medicines (including those prescribed with variable doses) and medicines not administered –repeat requirement The registered person must ensure there are full audit trails in place for all medicines thereby demonstrating that medicines have been administered in line with prescribed instructions at all times The registered person must ensure that the Sandpiper unit promotes independence and the wellbeing of people with dementia. The registered person must conduct a review of staffing levels in sandpiper unit to ensure that staff are in sufficient numbers to meet peoples holistic needs. The registered persons must ensure that recruitment practice promotes the protection of vulnerable people and that staff files are kept in accordance with the regulations. The registered person must ensure that all staff are provided with adequate supervision. The registered person must ensure that a recognisable quality assurance system is introduced and an annual report on the quality of the service is provided to all major stakeholders. DS0000027321.V314926.R01.S.doc 27/10/06 8 OP9 13.2 13.4 27/10/06 9 OP19 16(2) 24/11/06 10 OP27 18(a) 24/11/06 11 OP29 19 24/11/06 12 13 OP36 OP33 18(2) 24(1)(2) 24/11/06 31/01/07 The Paddocks Version 5.2 Page 26 14 OP33 26 The registered person must ensure that regulation 26 visits are conducted on a monthly basis and that the Commission is supplied with a report in this respect. 24/11/06 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 OP19 OP30 OP30 Refer to Standard Good Practice Recommendations It is recommended that the registered persons resolve the issues of conflicting noise in the lounge of Sandpiper. It is recommended that the registered persons develop an annual staff training plan to demonstrate an ongoing commitment to staff training and development. It is recommended that the registered person provides the opportunity for the registered manager and the unit manager of Sandpiper to undertake advanced training in dementia care. The Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Paddocks DS0000027321.V314926.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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