Inspection on 15/01/08 for The Regency

This inspection was carried out on 15th January 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Regency 26/03/10

The Regency 10/07/09

The Regency 26/06/09

The Regency 15/07/08

The Regency 21/03/07

The Regency 14/03/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE The Regency Torrs Park Ilfracombe Devon EX34 8AZ Lead Inspector Graham Thomas Unannounced Inspection 09:15 15 , 30 and 31 January 2008 th th st 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.V344568.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 Regency DS0000065822.V344568.R01.S.doc Version 5.2 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 nmcarehomesltd@yahoo.co.uk 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.V344568.R01.S.doc Version 5.2 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). 21st March 2007 Date of last inspection Brief Description of the Service: The Regency is a care home providing accommodation and personal care for up to 20 people over the age of 65 years, who may have a diagnosis of dementia or mental disorder. The home is situated in the Devon seaside town of Ilfracombe. There is a short, steep walk from the High Street and local amenities Accommodation is provided on four floors. A ramp provides access to one floor and passenger lift to the remaining three. All the present accommodation is in single rooms. Information given to the Commission by the provider indicates the current range of fees is from £244 to £372 per week. Additional charges are made for chiropody and hairdressing. The Regency DS0000065822.V344568.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 0 star. This means that people who use this service experience poor quality outcomes Before we visited the home Ms. Martin completed and returned an Annual Quality Assurance Assessment form with information about The Regency. We also out surveys to people with an interest in the home. These were returned by six people living in the home, four relatives, three staff and two visiting professionals. We also reviewed information received about the home since the last key inspection Our inspection visit to The Regency commenced on 15th January. Unfortunately, this had to be suspended due to an outbreak of infectious illness amongst people living in the home. The visit therefore recommenced on 30th January. During the visit we spoke with four people living in the home individually and others in small groups. Two staff were interviewed and more detailed discussions were held with the senior member of staff on duty. We held a brief conversation with Mrs Martin about issues arising during the inspection. Staff were observed going about their work. What the service does well: What has improved since the last inspection? • • • • • Some areas have been redecorated and recarpetted The home has been rewired and a new call bell system installed There are regular health and safety audits Water temperature regulators have been fitted to more rooms An activities programme has been introduced. The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 6 • Laundry facilities have been moved to the basement and new equipment purchased. • Dangerous decking has been removed and the garden tidied. 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 Regency DS0000065822.V344568.R01.S.doc Version 5.2 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.V344568.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering a move to The Regency are given enough information about the home to make an informed choice. People considering such a move can feel confident that their needs will be known before they move in. EVIDENCE: A booklet of information about The Regency has been produced for people considering using its services. This booklet was available in the entrance foyer. The available information included details of staff and the services provided. The information provided by Ms. Martin in the Annual Quality Assurance Assessment stated that visits were arranged for people before they moved in to help them make an informed choice. This was confirmed by some of the people with whom we spoke. Copes of letters were seen on individual files confirming that the home would be able to meet the person’s needs The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 9 Six individual files were examined, including those of the people who had moved into the home most recently. A standard assessment form is used to find out what people need before they move in. The form provided information about people’s abilities in the activities of daily living. Assessment information had also been gathered from other sources such as social services and hospital/community health care teams. The Regency does not offer accommodation for intermediate care. The Regency DS0000065822.V344568.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People living at The Regency receive generally adequate care and support though this is compromised by low staffing levels. Care planning is not sufficiently consistent or focussed on the particular needs of the individual. Medication practices continue to pose a risk to people living in the home despite a previous requirement. EVIDENCE: Of the six people living in the home who returned surveys, four stated that they always received the care and support they needed. Two said that this was usually the case. Surveys we received from people living in the home and their relatives contained both positive and negative comments, For example, “The patients that we see always look happy, healthy and clean” “ Medical care is good. Hygienic care often suffers due to lack of staff” “Long waits for assistance with toilet needs are common” The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 11 “Personal hygiene is left to him. This used to be done by a staff member. Not enough staff now” Most interactions we saw between carers and people living in the home were characterised by genuine warmth and concern. People with whom we spoke all said that they could see the doctor whenever they needed and that they were generally happy with the medical care they received. Six individual care plans were examined. These contained records such as basic personal details, personal records sheets, monthly ‘tick list’ style assessments, nutritional assessments, risk assessments, personal histories, daily records and plans. Personal records sheets contained details such as eating habits, likes, dislikes and hobbies. Some elements of the plans showed evidence of regular review and monitoring. For example, one plan showed regular monitoring regarding pressure sores, nutrition and weight. Records entitled “Social and Economic History” provided useful information for carers about the personal history of the individual. This is particularly important in helping to preserve the personal identity of people with a diagnosis of dementia. However, significant details were missing from some plans and recording in others was incomplete. Individual plans did not contain a photograph of the person. In some, the basic details of the person’s contacts, family GP etc, were not complete and did not contain the information required by law. In one instance the only detail on the sheet was the person’s next of kin. Sheets were included for staff to sign when they had read the plans. These had not been completed by staff. Some care plans contained statements which had been ‘cut and pasted’ directly from other plans with only the name changed. This was most evident in one plan where the name had been changed but the gender of the person was incorrectly referred to throughout. This suggests that the plans were not designed to meet each individual’s needs. It was not evident that the plans were being followed. For example, some plans indicated that the person should be asked when they wanted to get up. However, when this was discussed with individuals, some said they had no choice, one stating that this was because “staff are so busy” Risk assessments showed evidence of review. However, in one instance an agreement for the use of bed rails had been signed by staff on behalf of the person who was unable to make this decision. This is poor practice as it does not afford the person sufficient protection from potential misuse of the equipment. We also noted that where bed rails were fitted there were no protective “bumper” cushions available. This increases the risk of accident and injury. The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 12 Some of the plans examined showed little evidence of planning to meet the person’s social needs. We examined the system for administering medicines. Medicines were stored in a secure trolley which was chained to the wall when not in use. Controlled drugs were held in separate secure storage. Medicines requiring cool storage were held in the kitchen refrigerator. This is not sufficiently secure. The temperature records concerning this refrigerator showed temperatures exceeding those required for the cool storage of medicines. This was the subject of an immediate requirement. Quantities of medication received into the home were clearly recorded in a record book. Records included a photograph of each person to reduce the risk of medication being wrongly administered. The records of medicines administered were generally up to date and in good order. A sample list of the signatures of staff administering medicines was available. This is important when queries arise about any medicine administered. On the second day of our rescheduled visit, we arrived as medicines were being administered. Medicines, including liquids, were being placed in plastic pots ready for administration. However, it was evident that this was not for immediate administration as the medicines were being prepared on the lower ground floor for people on the upper floors of the building. When we questioned this practice, the medicines were placed in the trolley and transported upstairs in the lift. This obviously presented the risk of medicines being muddled, lost or spilled out of their containers during transportation. This was the subject of a requirement made at the last key inspection. We observed staff talking with and supporting people. The conversations were generally helpful, supportive and respectful. People with whom we spoke during our visit felt that they were treated with respect and that their dignity was preserved. Locking arrangements to individual rooms and some shared facilities did not promote privacy and dignity. This is addressed in the “environment” section of this report. The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the Regency are able to exercise an adequate degree and choice and control over their lives. However, planning to meet people’s social needs is not sufficiently clear or individualised. EVIDENCE: Several questionnaires completed by people living in the home in August 2007 rated the activities in the home as “poor”. This was echoed in some comments received in surveys such as, “The basic needs for physical support are provided. However, there is a total lack of support for mental stimulation, no organised activities.” One member of the home’s care staff has been given the role of activities coordinator. A book was seen for staff with suggested activities such as hand massage, card games, chair exercises and board games. The activities coordinator also stated that she was establishing links with a local day service to improve social opportunities for people living in the home. Visits to a local hotel for cream teas are a regular event. There is also a monthly visiting entertainer. The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 14 As previously stated, individual plans contained information regarding concerning people’s individual hobbies and social interests. However, there was little evidence of planning to meet these individual social needs. The records we saw concerning activities showed low levels of participation. Staff were seen attempting to engage some people in activities. However, this did not seem well planned or necessarily suited to the needs of the individuals concerned. The activities offered did not necessarily reflect the individual interests or hobbies identified in individual plans. These were therefore based on what the service provided rather than individual choice and preference. Some evidence was seen of people exercising individual choice in other areas during our visit. This included matters of food and whether to spend time alone in their rooms. Our survey asked relatives whether the home helped them to keep in touch with their relative. Two stated “always”, one “sometimes” and one “never”. One commented, “Never too sure whether my own communications are received by (XX), she cannot remember” People living in the home with whom we spoke were satisfied with the arrangements for maintaining contact with their friends and families. All the feedback we received about the meals provided in the home was good. People living at The Regency stated, “Yes they are fine” and “Meals are always fantastic” We examined the kitchen, food stores, the home’s menus and spoke with the cook. The menus showed clear choices at each main meal. Choices were recorded on a list in the kitchen and there was a record of what people had actually eaten each day. The Cook prepares food for the evening meal which care staff are responsible for heating and/or serving. There was a plentiful supply of fresh vegetables an facilities for steaming these to preserve essential nutrients. We observed a mid-day meal being taken in the home’s dining room on the lower ground floor. This comprised of gammon and pineapple with vegetables followed by a blackberry and apple pie. This was eaten with obvious relish by most people. People were offered extra helpings. During the meal, discreet assistance was offered by staff to those who required it. The cook was aware of the particular dietary requirements of four people with diabetes and one who required a soft diet. The soft meals were being prepared The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 15 so that each part of the meal was separately liquidised to provide a variety of individual tastes and colours on the plate. The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 16 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): Standards 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Regency’s practices in responding to concerns is adequate. However, complaints policies are not sufficiently clear. Some staff are insufficiently clear about the home’s policies and procedures to protect people from financial abuse. EVIDENCE: A complaints procedure was on display in the home’s foyer and complaints forms. However, during the inspection visit we found three different versions of the complaints procedure in policies and records available to staff. This could lead to potential confusion. One of these was headed with the address of the Commission, implying that it was the Commission’s complaints procedure rather than the home’s own. In surveys returned to us by people living in the home all the people living there stated that they knew how to make a complaint though one commented that there was “no need to”. All stated that staff listened to and acted on what people said though one commented “But they are severely stressed by having too many tasks and too little time” The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 17 Most relatives who returned surveys felt that the home “always” or “usually responded appropriately to concerns. One stated that this was never the case and suggested that this was due to low staffing levels. A policy was seen concerning protecting vulnerable people from abuse. The staff with whom we spoke had a clear understanding of how to respond to suspicion of abuse or witnessing actual abuse. One member of staff was particularly well-versed in this area. Information was available to staff on local policies and procedures concerning this topic The home holds small amounts of cash for individuals. A sample of these were checked. There were records of all transactions and the amounts counted were correct. A staff member’s file contained an envelope labelled to indicate this was a “staff fund” This contained cash records of two monetary gifts given by two people living in the home to staff. One of these gifts was for £100.00. This was in direct contravention of the home’s policy relating to the receipt of gifts from people living in the home. The gifts were clearly recorded, the cash was all present and there was no suggestion of deceit or dishonesty. However it demonstrated a lack of awareness of the policy and a potential risk to individuals living in the home. The Registered Provider was made aware of this. In one instance an agreement for the use of bed rails had been signed by staff on behalf of the person who was unable to make this decision. This is poor practice as it does not afford the person sufficient protection from potential misuse of the equipment as a restraint. The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 18 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): Standards 19, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at The Regency are provided with an adequately clean and comfortable living environment. However, serious safety shortfalls regarding fire escape routes place people at significant risk. EVIDENCE: The Regency is a large and complex building situated in the Torrs Park area of Ilfracombe. A short, steep walk provides access to the high street and local amenities. The property has a large sloping garden at the rear to which access was being constructed at the time of our visit. There is on-street parking for visitors. All parts of the premises were inspected except for one bedroom. There are a lower ground, ground, first and second floors to which access is provided by a passenger lift. A separate, self-contained area of accommodation The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 19 is accessed via a ramp leading from the lower ground floor. The laundry is located in a basement area which has a separate access from the outside of the building. There is also an office and flat at this level which has its own entrance from inside the building. Until recently this was occupied by Ms. Martin. There are five bedrooms on the second floor, four on the first floor and eight in the self-contained area accessed from the lower ground floor. A further three are located at one end of the building on the lower ground floor. These bedrooms are accessed via the dining room and a small lounge. On the second floor there is a shared bathroom with a toilet. A room containing a disinfector unit is also located on this floor. A shared bathroom on the first floor contains a “Parker” bath suitable for assisted bathing. There is also a staff toilet and an office at this level. The main lounge is located on the ground floor where there are also toilet facilities. At the lower ground level there are the kitchen, food store, dining room and a small lounge that is used by smokers. The three bedrooms accessed through this lounge are served by a bathroom with toilet facilities. This also contains a “Parker” bath. An improvement plan has been produced to deal with shortfalls in the home’s environment. In various parts of the building improvements and refurbishment were evident. For example, fire-safe hold open devices had been fitted to doors. Some bedrooms had been redecorated and recarpetted and the home had been rewired. Unfortunately some rewiring of the call bell system had occurred after redecoration which meant that the décor was once again disturbed. At the time of our inspection visit, a patio area was being built at the rear of the property overlooking the large garden which had been improved. The laundry room had been moved to the basement and a chute had been installed so that laundry could be transferred directly from the lower ground floor. Furnishings in individual rooms and communal areas were generally comfortable and homely. This was particularly evident in the large main lounge which is a light, airy and comfortable room overlooking the garden. Whilst some parts of the premises were comfortable and well-decorated, others required considerable decorative attention. For example, the area near the ramp on the lower ground floor showed signs of penetrating damp. Wallpaper had been stripped off a large area exposing a damp wall with mould growth. Material was flaking from the ceiling of the bathroom on the second floor. In this room the end panel had been removed from the bath, exposing the pipework. The walls in various individual rooms had been written on with marker pens to indicate the planned position of call bell fittings. The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 20 On inspection the home was generally clean and odour free. However the underside of the toilet frame in the toilet on the second floor was found to be dirty and corroded. The carpet edge at the top of the ramp in the lower ground floor was loose which presented a trip hazard. Serious safety issues were noted with regard to the fire escape routes. These are outlines in the “Management” section of this report. Individual rooms all have hand washing facilities. These were supplied with liquid soap and paper towels. Some rooms were provided with facilities according to individual need such as pressure relieving mattresses. Bed rails were fitted in one room for which no protective “bumper” cushions were available. This increases the risk of accident or injury. Radiators in individual rooms had been covered. A sample of hand basins and baths we inspected were fitted with hot water regulators. Most bedrooms were fitted with mortice type locks. Many of these did not work. One room had a key which had been left on the inside of the door. This poses potential risk in an emergency since, if the door is locked and the key left in the door, the room is not accessible. Toilet / bathroom doors in the home had no privacy locks The Regency DS0000065822.V344568.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): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at The Regency are well protected by staff recruitment practices. However, there are insufficient staff to meet the needs of people living in the home. EVIDENCE: During our visit, many positive comments were received about the assistance given by individual staff. For example, “Staff here are great”, and “They will always listen” Staffing rotas were examined. On weekdays there are routinely three carers on duty between 8:00am and 5:00pm. Two staff provide waking cover at night. Throughout the weekends there are two carers on duty. At times one staff member is on waking night duty and Ms. Martin provides “back up” whilst based in the basement flat. The carers include the team leader and senior carers. A cook works between 10:00am and 2:30pm every day except Saturday. Cleaning staff work for four hours per day during the week and two hours per day at the weekends. A laundry assistant works for two hours on Saturday and Sunday. Staff confirmed that those on night duty were expected to complete The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 22 laundry tasks, prepare and serve breakfasts and administer the morning medication. The cook leaves the evening meal ready for final preparation and serving by staff on duty in the evening. Staff communicate by means of a “walkie-talkie” system. At the time of this inspection there were 17 people living in the home. At least three of these required assistance with transfers. At least one person required the assistance of two people. At the lunchtime meal we observed, five people were using wheelchairs. A significant proportion of this group experience varying degrees of confusion and memory loss and some were seen to become agitated and to wander during our visit. Our examination of staffing led us to believe that there were insufficient staff. The complexity and layout of the building means that staff may be expected to provide individual support and supervision to people on four separate levels divided into five distinct areas. At key times such as lunch periods, staff are involved in serving and assisting with lunch in the dining room, delivering meals to those in their rooms perhaps three floors above and managing medication. This is in addition to catering for particular individual needs for those who may be distressed, require the toilet and so on. In the evenings and at weekends the task of the final meal preparation, serving and the other tasks falls to two people. This means that one member of staff may be left for care, supervision and support while the other prepares the meal. At night, there may be only one staff member in the main house while the other is in the basement laundry which has a separate outside access. This might also apply in situations where only “back up” is available. These findings were confirmed by comments received from both people living in the home and their relatives, such as: “Long waits for assistance with toilet needs are common” “…(staff).. are severely stressed by having too many tasks and too little time” “Personal hygiene is left to (XX). This used to be done by a staff member. Not enough staff now” “Sufficient staffing I believe would facilitate in providing the levels of care rather than staff having to ‘fight fires’ continually” The rota also showed regular occasions during which only male staff were on duty at night. This means that people have no choice about the gender of the person providing personal care. A sample of three staff files was examined as well as staff training records. A sound recruitment procedure was evident including a formal application, employment history, criminal records checks and references. The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 23 Training records and discussion with staff showed that training is provided in keeping with national training standards. For example, new staff receive induction training based upon the latest “Skills for Care” induction standards. There was also evidence of an ongoing programme National Vocational Qualification training in care. It is planned that the Team Leader will undertake a Registered Managers Award. Some staff had not received training appropriate to their duties. For example, The file of a member of the cleaning staff showed no evidence of training in infection control or the use of hazardous substances. Night carers who prepare breakfasts have not all received training in food hygiene. The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 24 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): Standards 31,33,35, 37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although management monitoring systems are in place, issues have been identified which place the health safety and welfare of people in the home at serious risk. EVIDENCE: The service is provided by Norma Martin Care Homes Ltd. Ms. Martin, who is a registered Nurse, is the Registered Manager. She is assisted by a Team Leader and a personal assistant who provides administrative support. In June 2007 Ms. Martin commenced a National Vocational Qualification in June 2007. Until recently she lived on the premises in a basement flat but has now moved to separate accommodation. The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 25 Management communication systems include staff handovers and regular staff and management meetings. Minutes of these were seen. Evidence was seen of systems to monitor the quality of the service provided. This included residents questionnaires and audits of medication, care plan files and night shifts. At the time of our visit an analysis was being undertaken of accidents in the home. Records of the outcomes of these audits showed what action was taken following the audit. The small amounts of cash held on behalf of people living in the home were examined. Records relating to these amounts were up to date and in good order. There were, however concerns relating to practices concerning the receipt of gifts. These are noted in the “Complaints and Protection” section of this report. The home’s policies and procedures were examined. The policies were adapted from a standard commercially available pack. These showed evidence of recent review. However not all policy areas were clear. For example, there were three different versions of the complaints policy. Two versions were seen of a policy concerning pets. These directly contradicted each other. Health and safety issues were examined. Risk assessments had been produced both for individuals and the building. Staff files showed evidence of training in health and safety topics. However not all staff had received health and safety training relevant to their work. For example, cleaning staff had not all received training in infection control and the use of hazardous substances. Staff were seen wearing gloves and aprons for cleaning and personal care tasks. There was antibacterial gel available for the use of staff and visitors. One staff member was seen without either apron or gloves who had been providing personal care. The same staff member was seen soon afterwards helping in the kitchen. The kitchen area was clean and tidy and food in the refrigerator was covered and dated. A cleaning schedule record was well-maintained. Temperature records for the kitchen refrigerator showed repeated unsafe temperatures. Both food and medication were stored in this refrigerator. An immediate requirement was issued relating to this issue. A fault in the thermometer was identified before the inspection visit ended. Ms. Martin stated that a fire evacuation plan was being developed. Serious concerns arose in relation to the homes fire escape routes. The rear fire escape route into the garden was littered with building materials and other debris. On inspection, the fire exit door from the second floor was stiff to open and decaying. Debris from this door had fallen onto the fire escape immediately The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 26 outside, presenting a slip or trip hazard. The metal fire escape outside showed signs of corrosion on the footplates, the edges of which were flaking. Outside the fire exit door on the first floor there was a large gap between the stairway from above and the platform immediately outside. This was large enough to fall through. The gaps between the side railings were also. large enough to fall through. None of the fire doors was alarmed which meant that a confused person might wander onto the fire escape without staff knowing. In the light of our findings in relation to staffing, this posed a serious risk to the safety of people living in the home. These issues were the subject of an immediate requirement. A number of documents were seen to indicate routine maintenance was taking place of such facilities of the shaft lift and hoists. An ongoing development plan had been produced to upgrade and modify the premises. The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 X X X X X X 2 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X 2 1 The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 28 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 17(1) and (3) Requirement Care plan records must include the information required by the Care Homes Regulations 2001 and Schedule 3 of those regulations. Timescale for action 22/03/08 2 OP9 13(2) The registered person must 29/02/08 make arrangements for the safe recording, handling, storing and administration of medications in the care home to ensure that the health care needs of service users are met. (Previous timescale of 01/06/07 not met) In particular, medicines must not be placed in pots for administration later. Medicines requiring cool storage must be kept in a separate locked refrigerator at the correct temperature Immediate Requirement Notice issued Where a person does not have the capacity to consent to the use of bed rails, this must be DS0000065822.V344568.R01.S.doc 3 OP9 13(2) 06/02/08 4 OP18 13(6) and (7) 22/03/08 The Regency Version 5.2 Page 29 sought in accordance with the Mental Capacity Act and not provided by staff members. 5 OP18 13(6) The Registered Person must ensure that all staff understand and adhere to the home’s policies and procedures concerning the receipt of gifts from people living in the home. The registered Person must fit locks to individual room doors which are lockable from inside but accessible to staff in emergencies, unless indicated by risk assessment or the written request of the room’s occupant. The Registered Person must conduct a review of the staffing arrangements of the home during the day and night. This must take account of the needs of people living in the home, the size and layout of the building, the number, skills and gender of the staff. The results of this review must be supplied to the Commission. The purpose of this review will be to demonstrate that there are sufficient staff to meet the personal, health and social care needs of people living in the home 15/03/08 6 OP24 12(4)(a) and 13(4)(a) 31/10/08 7 OP27 18(1)(a) 30/04/08 8 OP38 13(4)(a) The carpet edge at the top of the 29/02/08 ramp leading from the lower ground floor must be taped down to prevent potential trips and falls Where bed side rails are fitted, protective “bumper” cushions must be available to reduce the risk of injury. All fire escape routes must be DS0000065822.V344568.R01.S.doc 9 OP38 13(4)(c) and 16(2)(c) 23(4)(b) 15/03/08 10 OP38 01/02/08 Page 30 The Regency Version 5.2 cleared of debris Immediate requirement notice issued 11 12 OP38 OP38 23(4)(b) 23(4)(b) Fire exit doors must open freely Immediate requirement notice issued An assessment of the safety of the metal fire escape must be conducted and an action plan produced to eliminate or remedy any unnecessary risks Immediate requirement notice issued Action must be taken to ensure the refrigerator maintains a temperature which accords with good practice guidance for food hygiene Immediate requirement notice issued (A fault in the thermometer was identified before the inspection visit ended.) 02/02/08 03/02/08 13 OP38 13(3) 06/02/08 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 OP7 Good Practice Recommendations All elements of care plans should be produced to reflect individual needs rather than being reproduced for several individuals. Care plans should provide more detail as to how individual social needs will be met Activities should be further developed to reflect known individual interests and hobbies as well as catering for the needs of people with memory loss. DS0000065822.V344568.R01.S.doc Version 5.2 Page 31 2 3 OP7 OP12 The Regency 4 OP16 There should be only one, clear complaints procedure available to all. It should be clear that this is the home’s own complaints procedure. Improvements to the environment should continue to ensure service users live in a comfortable, well maintained home. Staff should receive training which necessary to perform their duties. In particular, cleaning staff should receive training in infection control and the Control of Substances Hazardous to Health. Policies and procedures should be reviewed to ensure that they are clear, consistent and not duplicated with other conflicting policies. 5 OP19 6 OP30 7 OP37 The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Regency DS0000065822.V344568.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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