CARE HOMES FOR OLDER PEOPLE
The Regency Torrs Park Ilfracombe Devon EX34 8AZ Lead Inspector
Fiona Cartlidge Unannounced Inspection 14th March 2006 12:00 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 Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service The Regency Address Torrs Park Ilfracombe Devon EX34 8AZ 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) 01271 862369 01271 863012 Norma Martin Care Homes Limited Ms Norma Elfreda Martin Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (20), Old age, not falling within any other category (20) The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The Regency is registered as a care home able to provide care accommodation for up to 20 service users in the categories OP Old Age (20), DE (E) Dementia over 65 (20) and MD (E) Mental Disorder over 65 (20). 15th July 2005 Date of last inspection Brief Description of the Service: The Regency is a care home providing accommodation and personal care for 20 people over the age of 65 years, in the categories of old age, dementia and mental disorder. The Regency is an older type property providing accommodation on four floors, which has been adapted through the provision of a passenger lift and ramps. Currently all service users are accommodated in single rooms. The Regency changed ownership in February 2006 and is now owned and managed by Norma Martin Care Homes Limited. The home is situated in the Torrs Park area of Ilfracombe, Devon, a short steep walk from the High Street and beaches. The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over 3 hours and 50 minutes and was unannounced. A tour of the home took place when some bedrooms and the communal bathrooms and living rooms were viewed. Personal records held within the home on behalf of 2 residents were inspected. The inspector spoke with 9 residents, 2 staff members, and the Registered Manager/provider. Written information about the services, facilities and staffing arrangements was also considered as part of the inspection process. This was the home’s first inspection since it changed ownership in February. What the service does well: What has improved since the last inspection?
The home has only recently changed ownership. The new registered provider shows a commitment towards continuing the business and continually improving the services and facilities in the best interests of those living and working in the home.
The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 6 Formal and informal communication systems are in place through regular meetings, staff handovers and daily contact. Quality assurance programmes are being introduced and are based on the views of those people using the service. 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 Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5, Some information provided in the statement of purpose and Service users guide has not been fully completed, this may be misleading. The homes own contract/terms and conditions of residency has not been provided to all new residents or those who were in residence before the home changed hands. The admission process is safe. People are provided with the opportunity to visit the home before making a decision about an admission. EVIDENCE: The inspector examined the homes statement of purpose and Service users guide found situated in the entrance hall. The documents are informative and written in plain English however some information regarding the number and qualifications of staff had not been fully completed. The inspector examined the personal records held within the home on behalf of 2 of the residents and when shown the contract was provided with the 3rd party contract, which is provided by the Social Services department responsible for contracting the care; a copy of the homes own contract was
The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 9 shown to the inspector. The document contained specific information about the personal accommodation provided for the resident i.e. type of room and specific identity of room i.e. its number/location. The document also contained information on how to make a complaint. Including a statement about how complaints about the home can be made to the Commission for Social Care Inspection (CSCI) at any time/stage. The provider indicated that these contracts were for use when self-funding residents are admitted to the home. The records of a recently admitted resident contained evidence that a full and detailed assessment had been performed on the resident prior to their admission and that this information was used to enable a decision about how the individuals needs will be met. One of the records of the recently admitted resident provided evidence that the provider/manager had visited the prospective resident in their previous setting to perform a needs assessment and the prospective resident had visited the home before making a decision about their admission and had viewed the facilities and had the opportunity of meeting existing residents as well as a number of the staff team. The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10 Residents have a clear documented plan of care. The health care needs of residents are regularly reviewed and action is taken to meet those needs. EVIDENCE: The inspector examined the personal records held on behalf of 2 residents; there were documented assessments which provided information about skin integrity, moving and handling, safety - including risk of falls, nutritional screening and 1 contained information about social needs. The information generates the plans of care, which provide the basis for the care to be delivered. The care plans were clear and easy to understand and had been regularly reviewed, daily records indicated the actual care given and significant events were documented. . Records are maintained for all visits to the home by social or health care professionals, all residents are registered with a GP. Documents provided evidence that as well as visits from General Practitioners, district nurses also visit.
The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 11 One care plan indicated a preferred choice of gender of their carer, where possible this is adhered to but the home currently employs only 1 male carer all intimate personal care is provided by him. The inspector observed that when personal care was being provided this was done behind closed doors, the staff spoke to residents in a polite manner and were witnessed to knock on the doors to private accommodation before entering. The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 Social activities are organised and provide stimulation and interest for some residents on most days. Meals are nutritious and balanced offering a healthy and varied diet for residents. The arrangements for residents to receive visitors are good. EVIDENCE: The inspector examined the personal records held on behalf of two residents, for one who had been resident for a number of years there was a document titled ‘social and economic history’ which included a good level of information about past occupations, experiences, hobbies and interests. A social activity sheet for the same resident had no entries since 16th January. Some residents were seen socialising in the lounge or watching television others were spending time in their rooms. The registered provider plans to provide a two monthly magazine to residents, which will include information about organised activities it is hoped in the summer months to provide outings, but the provider said that during periods of cold weather they plan to bring entertainment into the home. Residents spoken with were happy with the quality of the food provided; on the day of inspection lunch was served, residents were offered sausages with a mixture of vegetables and roast or mashed potatoes the main meal was
The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 13 followed by chocolate pudding. Some residents ate their meals whilst sat in the lounge/diner at tables; one requiring assistance was given this in a smaller lounge, which is used by other residents to sit in and smoke. This is not appropriate and a healthier environment needs to be used to ensure the resident can be assisted in an appropriate supportive manner. Some residents ate their lunch in their own accommodation. Records seen provided evidence that resident’s weights are regularly monitored. The people living in the home told the inspector they were happy with the visiting arrangements, and one resident was independently off to the town. The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 14 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 Residents’ complaints will be listened to and acted on. Residents are protected. EVIDENCE: The home has a complaints procedure, which is included in the service user guide the information is inclusive of details on how to contact the Commission for Social Care. The inspector observed good interaction between the manager/provider and residents, with residents obviously feeling comfortable discussing issues about their care and services provided in an open and honest manner. The manger showed a commitment to listening to concerns as part of a continual improvement plan. The inspector found information for staff to follow if alerted to incidents or allegations of abuse, which defined their responsibilities in the role of protection of vulnerable adults and included other agencies who should be contacted. The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 15 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,25,26 A number of areas in the home require attention in order to provide a homely and safe environment for residents. EVIDENCE: The property is old and has ongoing maintenance needs. Work was being undertaken to clear the overgrown and non-accessible garden at the time of this inspection. The décor in some bedrooms and bathrooms looks tired, old and worn. Two bedrooms had inadequate water supply the inspector was informed that new header tanks were to be fitted in the roof the following day to ensure adequate water pressure to these rooms. Some of the furniture in the bedrooms is old and broken and requires replacing one wardrobe had been moved out of a bedroom on to the landing because it had been in danger of falling over and hurting the resident and or staff it was noted that this resident had their clothes in draws on the floor in their room.
The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 16 A programme of routine maintenance and renewal has not yet been produced the inspector was shown a record of on going maintenance which has been carried out on a ‘need to be done basis’ such as replacement of light bulbs. Residents spoken with were generally happy with the environment and bedrooms were personalised. All bedrooms are connected to the home’s alarm call system but there was no cord in several resident’s bedrooms and another resident was unable to reach the call bell when in bed. The inspector was told that quotes to up grade/replace the system have been sought by the new owner. Currently only one bath has a thermostatic mixer to ensure safe water temperatures. The inspector was told the owner has fitted other valves to wash basins there was no documented risk assessment of hot water temperatures. The inspector feels the risk of scalding is high due to some residents’ limited capacity. One en suite WC has recently been with a door a number of others still have only a curtain to divide them from the bedroom area, the access to some En suite WC’s is not wide enough to be accessed by people with walking aids or wheelchairs. The home was clean but there was a smell of cigarette smoke on one floor used by residents to socialise and dine and which also has the kitchen on it. On this floor there is one small lounge off the dining room used by residents to smoke as well as a small staff room where staff smoke. One resident who does not smoke was being assisted with their meal in the residents smoking lounge. Some fire doors have been fitted with ‘safe hold open devices but at the time of the inspection two bedroom doors on the top floor had been held open with wooden/plastic wedges. Documents provided evidence that one resident had complained that there bedroom was cold and the manager/provider told the inspector that a number of room thermometers and 6 small portable heaters had been purchased, these were seen in bedrooms at the time of the inspection. The inspector noted there were supplies of protective gloves around the building, but some bedrooms lacked suitable hand washing facilities for staff. The laundry has recently been fitted with hand washing facilities however exposed pipes showed a build up of dust and debris providing a warm and moist environment for bacterial growth and contamination. The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 17 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,30 The deployment and number of staff available at night may not be sufficient to meet the needs of the residents. Staff training requires development to ensure that staff have the skills to meet the residents’ needs. EVIDENCE: The inspector was provided with the staff off duty rota covering the week of the inspection. This showed that 4 care staff were on duty in the morning with one more providing assistance at lunch time, 3 in the afternoon, 2 in the evening and only one at night with the manager/provider being on call in the building, but the staff member having to access a phone on the lower floor to summon her assistance. The duty rota provided evidence that some care staff work exceedingly long hours i.e. from 8.30 pm through to 13.00hrs the following day and in one instance from 08.30 to 13.30 then 17.00 hours through to 08.30 hrs the following day. There were 18 residents in the home at the time of the inspection situated on 4 different floors in the building; in addition to care staff there were 2 domestic staff on duty in the morning and a chef. The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 18 Staff files were not inspected on this occasion however there was documentary evidence that the registered provider/manager is undertaking Criminal Record Bureaux checks (CRB’s) on all existing staff. 7 of the 11 care staff employed at the home have obtained a National Vocational Qualification (NVQ) in care. The new manager/provider is currently performing an individual and team training needs analysis to aid in arranging a training plan to be designed that will ensure the staff individually and collectively have the knowledge and skills to care for the range of needs of the residents. All staff have recently been provided with codes of conduct booklets. 4 staff are booked to attend an external training/update on care of people with diabetes and it is planned this information will be disseminated to all other staff via internal training sessions. The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 19 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): 31,32,33,37,38 Resident’s will benefit from the open and clear management approach taken in this home. The homes new provider/manager is introducing systems that include leadership and direction for staff. Residents will benefit from influencing the way the home is run. EVIDENCE: The registered provider is also currently the registered manager of the home, Norma Martin is an experienced Registered Nurse who until recently worked as a district nursing sister in London. The Commission expects the registered Manager to obtain a National Vocational Qualification (or equivalent) in Management.
The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 20 There are clear lines of accountability and the management team has specific responsibilities Normas’ daughter is a share holder and plans to visit the home unannounced on a monthly basis. 2 visits have been undertaken since the home changed ownership and a report of findings compiled. This report is copied to the commission and forms part of the internal quality assessment process. In addition all residents have been provided with service satisfaction questionnaires and actions have been taken or planned to meet any issues identified, e.g. larger portions at meal times and improved activity/leisure opportunities. The homes quality assurance processes are based on continual evaluation, an open policy on feedback and complaints, regular meetings between management and residents and staff. Minutes of meetings are recorded and copies of recent meetings were seen at this inspection. All of the records seen during the inspection had been reviewed and were up to date and in good order and records held on behalf of residents are confidential and secure. Policies and procedures are not in place for all areas required. The registered provider/manager has introduced 2 policies regarding employees terms and conditions and is exploring external suppliers of policies and procedures which she will need to personalise for use in the home. The fire precautions logbook indicated that the fire alarm has not been tested weekly or emergency lights monthly. There was documentary evidence that professionals had checked all fire equipment in January 2006 and a certificate confirming this was found displayed in the entrance hall. A full environmental risk assessment needs to be completed with a plan formalised to minimise any identified risks. The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 21 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 2 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 2 X X X X 2 2 STAFFING Standard No Score 27 2 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X X X 3 1 The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? N/A The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 23 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 OP19 Regulation 23 (2)(b) Requirement A programme of routine maintenance and renewal of the fabric and decoration of the premises must be produced and implemented with records kept. A separate communal space must be provided for residents who smoke, residents who do not smoke should not be placed in areas where residents do smoke unless they actively request to do so. A risk assessment must be performed on all hot water outlets and where a risk is identified design solutions must be put in place to reduce the risk. All hot water outlets that provide water for full body submersion (baths) must be fitted with pre set valves of a type unaffected by changes in water pressure and which fail safe devices are fitted locally to provide water close to 43 degrees centigrade. Hand washing facilities must be available for staff in all areas where they assist with personal care and may come into contact with body fluids. Systems must be put in place to prevent the build up and deposits of dust and debris in the laundry. There should be 2 waking staff available in the home at night because of the number of and needs of service users and lay out of the home. Timescale for action 01/05/06 2 OP20 23(2)(h) 01/06/06 3 OP25 13(4) 01/05/06 4 OP26 13 (3) 01/05/06 5 OP27 18(a) 01/06/06 The Regency 6 OP38 23 DS0000065822.V286289.R01.S.doc Version 5.1 Page 24 The registered manager must 01/05/06 ensure that risk assessments are carried out for all safe working practise topics and that 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 OP1 Good Practice Recommendations The statement of purpose and service users guide must be up dated to include all information relating to staffing qualifications and experience and numbers of staff available. The homes own terms and conditions of residency/contract should be provided to all existing and new residents. An activities programme should be organised with input from residents. Information about activities should be circulated to all residents in formats suited to their capacities to ensure they are able to make a choice about whether or not to join in. An activities programme should be organised with input from residents. Information about activities should be circulated to all residents in formats suited to their capacities to ensure they are able to make a choice about whether or not to join in. Staff should not work more than 12 hour shifts. All staff should have an individual staff training profile and a development programme, which ensures they receive at least 3 days paid training/year. The registered manger should obtain a qualification , at level 4 NVQ in management or equivalent. The registered manager should provide a written statement of the policy, organisation and arrangements for maintaining safe working practise. In line with all matters listed in Standard 38.2, 38.3 and 38.4. Staff must not work more than 12 hour shifts. 2 3 OP2 OP12 4 OP15 5 6 7 8 OP27 OP30 OP31 OP38 The Regency DS0000065822.V286289.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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