Inspection on 25/07/07 for The Shrubbery

This inspection was carried out on 25th July 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Shrubbery 15/09/09

The Shrubbery 22/09/08

The Shrubbery 25/04/06

The Shrubbery 23/06/05

The Shrubbery 06/04/05

The Shrubbery 06/01/05

The Shrubbery 21/04/04

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

CARE HOMES FOR OLDER PEOPLE The Shrubbery 33 Woodgreen Road Wednesbury West Midlands WS10 9QS Lead Inspector Mr Jon Potts Unannounced Inspection 25th July 2007 2:40pm 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 Shrubbery DS0000004831.V340740.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 Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Shrubbery Address 33 Woodgreen Road Wednesbury West Midlands WS10 9QS 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) 0121 556 8899 F/P0121 556 8899 Mr Avtar Singh Sandhu Mrs Amarjit Kaur Sandhu Bobbi Kaur Kakkad Care Home 15 Category(ies) of Dementia - over 65 years of age (15) registration, with number of places The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing levels are to be maintained at the following minimum levels for: (1) Between 10 - 15 residents (with dementia) A minimum of four staff during peak periods (peak periods being 8am - 1pm and 4pm - 8 and 9pm with three at all other times with the exception of nights where a minimum of two would be acceptable. This is to allow for one staff based in each area of the home throughout the day. This is a minimum and increased dependency may dictate that the staffing levels are increased appropriately. (2) For any lower levels of occupancy the registered provider must consult and agree changes to staffing with CSCI To ensure that there is appropriate and continued dementia care training for staff in accordance with the assessed needs of the accommodated residents. This is so to enable the home to meet resident’s needs and it’s statement of purpose. 25th April 2006 2. Date of last inspection Brief Description of the Service: The home is situated on a main route between Wednesbury and the M6 and is easy to access by public transport and car. The facilities offered by Wednesbury town centre are also in easy reach. The house itself is a mature detached residence set in its own grounds and well screened from the road with ample off road car parking. The house has three floors, all accessible by lift. There are many pleasing period features that have been retained that add character and ambience to the home. The ground floor consists of two lounges, a quiet room, a dining room, one bedroom, bathroom, toilets and service areas (kitchen, laundry etc). The other two floors contain bedrooms, toilets and bath/shower rooms. The home has a range of adaptations that include bath hoists, grab rails, raised toilet seats, call system, although the home is not seen as suitable for a persons who are permanent wheelchair users. The home is staffed by care assistants, a cook and cleaner under the supervision of the manager or Responsible Individual . Information about the home is made available through a statement of purpose and service user guide which is given to prospective service users and also available in the foyer of the home. Information can also be verbally obtained from the manager or provider. The current scale of charges is from £405.00 to £436.00. The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection focused primarily on the homes performance against key national minimum standards and was carried out over two and a half days. Evidence was drawn from a variety of sources but involved tracking the care of a number of residents, which included discussion with residents. All care records relating to these residents were examined as well as a number of other records including those pertaining to staff and management. The inspector also had discussion with staff on duty, and the Responsible Individual . There was also pre inspection information used that included an annual quality assurance assessment and a number of questionnaires completed by residents and relatives. The Responsible Individual , staff and especially residents are to be thanked for their assistance with this inspection. What the service does well: What has improved since the last inspection? The home has addressed all the requirements from the last inspection in part or in full. The areas where there was noticeable improvement include the following, some of these areas in response to past requirements: - There has been redecoration of a significant part of the home, this presenting a lighter and cleaner environment for residents. The improved lighting in areas of the home has helped this. The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 6 - The involvement of relatives in pre admission assessments and care plans is better. - Some of the recording in respect of medical administration records has improved in terms of clear directions for administration. - Meal provision has improved - Staff presented as having a better awareness of safeguarding residents and procedures in respect of this area have improved. - The home now has over 50 of staff qualified in NVQ 2, this seemingly impacting on the quality of the care provided to residents. 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 Shrubbery DS0000004831.V340740.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 Shrubbery DS0000004831.V340740.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): 1,2,3,4 & 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective users of the service and their representatives have the information needed to choose a home, which will meet their needs. They have their needs assessed and a contract which clearly tells them about the service they will receive. EVIDENCE: The management of the home understands the importance of making sufficient information available to prospective residents during the period when they are trying to choose a Care Home. There is statement of purpose and service users guide that is made available to prospective residents at the point of initial assessment, this stated to be given whilst staff are available to answer any potential queries. Whilst the information pack available is not currently accompanied with images the provider showed the inspector a computer based presentation that they were developing that could be taken out to assessments The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 9 on a laptop, this so that discussion as to the service the home provided could be accompanied by a visual presentation that showed what the home was like. It was envisaged that this would be ready for use in the near future. The homes Statement of Purpose, this specific to the individual home, and the resident group cared for, clearly sets out the objectives and philosophy of the service, with this information summarised in the home’s Service user Guide. The guide details what the prospective individual can expect and gives a clear account of the services provided, quality of the accommodation, qualifications and experience of staff, how to make a complaint and reference to CSCI inspection reports. Whilst it was stated that all new admissions are given a copy of the Guide, copies of the same are also available in the reception area of the home for any visitors or residents to read. The provider is considering ways in which information may be presented so as to meet the capacity of residents. 80 of relatives that responded to CSCI questionnaire agreed that the home provided enough information pre – admission to assist with their decision-making, with 100 of residents admitted stated this was the case. Admissions are not made to the home without the manager (this position currently covered by the Responsible Individual ) and other staff visiting the prospective resident to carry out a full needs assessment, this for local authority funded or self funded residents. The assessment is carried out with the individual and where applicable their representative. Assessments forms are completed and information gained agreed as accurate with the resident/representative. Where the individual is funded through care management arrangements the service usually insists on receiving a summary of the assessment, although it was stated that these are not always available. There was evidence that in some instances care plans have been obtained, this sometimes from other services that are working with the individual at the time. The Responsible Individual stated that admissions to the home only take place if he is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident, and sees a robust assessment framework as key to establishing if this is the case. The management team may consider the application together with other staff, where all information is shared and views, opinions, and comments would be considered. Prospective individuals are invited to visit the home pre admission and there is sufficient staff available to allow time to assist residents to settle in. New residents are provided with a Statement of Terms and Conditions that sets out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the individual. This document is fairly clear but is currently only available as a written document. The provider stated that he would actively encourage residents to raise comments with him, and comments from the residents indicated they were aware of who managed the home and indicated that they are approachable. The Shrubbery DS0000004831.V340740.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): 7,8,9 & 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual assessed needs, although recording of how these are to be meet needs to be better. There are practices in respect of medication management that present some risks to residents. Residents say in most instances that the principles of respect, dignity and privacy are put into practice by staff. EVIDENCE: Whilst the homes approach to assessment was generally good there was concern that the quality of care plans does not reflect the former. The Responsible Individual stated that he had concerns as to the quality of care plans and as a result was in the process of changing these to a different format. Difficulties have arisen in respect of the newer formats not always been completed. Out of three case files one had a care plan, one had a plan that consisted of a one-line statement and the third had a blank format. A fourth care plan was examined for evidence of the home having a robust care The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 11 plan in place in terms of diabetic care and whilst this was present it needed to be more robust, possibly with reference to the homes policies/procedures on this issue. Whilst there was some evidence of residents or their representatives been consulted as to care plans in place the overall findings indicate that the home’s audit system for care plans is not effective at present. The Responsible Individual did have some awareness of these issues and based on the proposals made had considered how this issue was to be addressed. It is critical that staff are however aware of the changes and how care plans should be completed as they have responsibility as key workers for update of these documents in the long term. Risk assessments were in place in respect of falls, nutrition, tissue viability, moving residents and a number of other areas relevant to individuals, these seen to be updated on a regular basis. There was evidence that this acknowledged limitations placed on residents although agreements were almost all with relatives, not the resident themselves. There needs to be time spent considering the implications of the mental capacity of residents through risk assessment and their ability to take on board their own decision making. Discussion with residents did reflect that choices documented were generally ones they agreed with, although there were some exceptions to this, notably in respect of holding bedroom door keys. Some directives in the risk assessments were not in accord with actual practice (frequency of night checks for some residents as an example these in this instance more frequent that the resident wished according to the homes assessment). There was documented evidence that residents have timely access to healthcare and remedial services, this supported by comments from residents. People who use services have the aids and equipment they need and these are well maintained to support both residents and staff in daily living. There was once again some concern as to the quality of documentation as bathing records were inaccurate (i.e. residents stated they were provided with baths/showers in accordance with their preferences, this not reflected in records) and there was little evidence of staff monitoring resident’s weights on a regular basis. Staff are encouraged to access training in health care matters and are encouraged and given time to attend training sessions on specialist areas of work (examples include dementia, continence and skin care). The aims and objectives of the home reinforce the importance of treating individuals with respect and dignity and in discussion with residents they confirmed that staff did so. Staff spoken to were also aware of how to promote a residents privacy and dignity, citing valid examples of how they would do so. The staff understand the need to comply with the administration, safekeeping and disposal of medication and those involved in administration have received accredited training although there were instances where the medication systems did not always follow good or safe practice guidelines as detailed within the home’s policy: The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 12 - Prescribed creams when administered were not recorded on medication administration records (MARS) and where there was a resident administering their own cream there was no risk assessment, nor facility in their room to secure the cream safely when not in use. - There was some limited evidence of gaps in MARs sheets where medication was not signed out. - The last contracted pharmacy visit to the home stated that eye drops need storing in the fridge; despite this some were stored in the homes medication trolley. - There were some tablets not in use from January 2007 that had not been returned to the pharmacy. - Management of controlled drugs in terms of storage needs to be better (i.e. stored in a separate double locked compartment. - The Responsible Individual was advise to keep an up to date copy of the homes current medication procedure in the homes MARs folder for ease of reference for staff. The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use services are able to make choices about their life style, and are supported by the home to develop their life skills. Social, educational, cultural and recreational activities generally meet individual’s expectations although some feel they could be better. The residents have access to meals that are in keeping with their preferences and dietary needs. EVIDENCE: Residents spoken to in respect of their daily routines were clear that the service allowed them flexibility to follow their own wished daily pattern in respect of when they get up in the morning, what they did throughout the day and when they decided to go to bed. Residents also said that they were allowed to be independent wherever possible with staff encouraging them to chose their own clothing, dress and wash themselves etc. The home offers a range of activities to residents and all those residents spoken to say they were never bored. The records showed that the staff have tried to encapsulate individuals chosen daily routines in writing and residents confirmed the accuracy of these, as well as those activities documented as their preferences The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 14 in their case files. There was evidence that residents are supported to pursue individual interests such as going to church and other community activities with the assistance of friends or relatives. There was comment from some residents and relatives that suggested activities could be improved, this acknowledged by the Responsible Individual who felt that this was an area where he wished the home to develop with more activities that encouraged mobility and movement. In addition it was suggested that the provision of activities targeted to dementia care and specifically aiming to improve mental stimulation should be considered. The home has identified individual’s communication needs within assessments and strategies to assist staff and residents to communicate were documented and accurate based on discussion with residents. The home actively supports the residents to have contact with significant others and has a visiting policy that does not impose any daytime restriction on visiting times, although consideration is given to security issues during unsocial hours, this only applicable to relatives not known to staff however. There was clear evidence that any known restrictions are documented. 80 of relatives stated in response to CSCI questionnaires that the home was good at keeping them up to date although there was some limited comment as to the home not having any formal process for updating relatives. The home has recently revised its menus and these offer residents a varied a nutritional range of meals, with the ones on offer on the days of the inspection in accord with the displayed menu. Whilst the menu consisted of traditional English foods residents spoke of other cultural dietary options been available on a regular basis, these not documented on meal choice records however. Residents spoken to stated they were happy with the meals available with comments such as “food very good, have a choice and it’s easy to digest” & “ food is good and happy with it”. Observation of the serving of the midday meal showed that care was taken to ensure that residents were given portions in accordance with their preferences with the cook serving the meals. The pace at which the meals was served was relaxed with staff taking their time and ensuring residents had the assistance needed to enjoy their meal. There was comment from one resident that there could be more availability of fruit juices, and discussion indicated that the making of the same using the residents recipe could be a enjoyable activity for residents that would also encourage a healthy option. The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 & 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and have access to a robust, effective complaints procedure, and are protected from abuse. EVIDENCE: Based on comments from residents at the time of the visit to the home this indicated that there is an open culture where residents are confident in expressing their views and concerns to staff, with the expectation that any issues will be resolved to their satisfaction. Residents and others involved with the service say that they are generally happy with the service provision, feel safe and well supported by a management and staff team that has their protection and safety as a priority. The service has a complaints procedure that is clearly written and easy to understand and is freely available within the home. It is available in large print in the foyer of the home, summarised within the service users guide and within contracts given to residents or their representatives. Whilst not all residents when asked were aware of the homes complaints procedure they all stated that they knew who to raise issues with and expressed confidence in the fact that they would be listened to, and issues sorted out to the best of the homes ability. All the relatives responding to the CSCI questionnaire stated that the The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 16 home would always (80 ) or usually (20 ) respond appropriately if concerns were raised. Comments included the following: “The care home makes me feel my mother is safe and I do not have to worry about her wellbeing like I would if she was at home on her own”. “In the short time my mother has been in the shrubbery I have found they have responded quickly regarding any slight problems or concerns I’ve had” The home keeps a full record of complaints and this includes details of the investigation and any actions taken. Unless there are exceptional circumstances the service always responds within the agreed timescale. The policies and procedures for Safeguarding Adults have been reviewed since the lat inspection and are available giving clear, specific guidance to those using them. Staff working at the service when questioned were aware of the need to observe for indicators that may suggest a resident is unhappy or being abused (giving clear examples of these) knowing when incidents need external input and who to refer the incident to, whether in house or externally. The management understands the procedures for Safeguarding Adults and have demonstrated since the last inspection that they will provide information to external agencies as needed. There have been some issues that have arisen earlier this year that the home has now addressed. Based on discussion with the Responsible Individual the homes awareness of how to approach such issues has improved due to practical experience of involvement in such. Training of staff in the area of protection is regularly arranged by the Home. Other training around dealing with physical and verbal aggression is also made available to staff as needed. Whilst the home’s ethos is to protect resident’s rights there is a need to fully consider the impact of the mental capacity act in respect of involvement of residents in formal choices. In many instances relatives have signed to indicate agreement with such as contracts, assessments, care plans and disclaimers. There needs to be clear indication through risk assessment that the resident is unable to make these decisions themselves, this in accordance with guidance available from the Department of Health. The home also needs to ensure that any disclaimers signed are fully completed prior to signing so there is no doubt as to exactly what limitations are placed on residents, with clear reasoning as to why in care plans or risk assessments. The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24 & 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in an overall safe, generally well-maintained and comfortable environment, which encourages independence, although there are instances where minor works that potentially compromise this are not quickly remedied. EVIDENCE: The home provides a physical environment that meets the specific needs of the people who live there. The home is comfortable, and has a programme to improve the decoration, fixtures and fittings, this evident from the redecoration that has taken place since the last inspection with areas appearing far cleaner and lighter than previously. This has been assisted with improvement of the lighting in some communal areas. Discussion with a resident who had a visual impairment indicated that they felt the home was The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 18 sufficiently light to allow them to move around safely. There has been slippage in terms of addressing an issue in terms of fire safety that has resulted in an enforcement notice been issued by the fire service, this related to a fire door not fully closing into its rebate. The Responsible Individual was fully aware of this issue and stated that this was to be addressed. All other fire precautions at the time of the last visit by the fire service inspection were found to be satisfactory. It was positive that the homes layout since the last inspection has been reorganised based on the wishes of the resident group with the home now having two lounge areas and a dining room as opposed to three lounge/dining areas. The Responsible Individual also stated that there were benefits in that residents were encouraged to be mobile in moving from one area to another. Whilst all bedrooms are fitted with locks there was a resident spoken to whom whilst not key holding, expressed a wish to have a key so that she was able to lock her door. Whilst there was documentation in her case file in respect of non key holding the decision in respect of this needs to be revisited as the reasons for non key holding, based on documentation, were judged to be insufficient for non provision of this facility. Residents in general did however state that they were happy with their bedrooms and the furniture contained within them. Residents are able to bring personal possessions into the home within space and safety constraints. Residents confirmed that the home was warm and there was sufficient hot water available when needed. There was found to be an excessively hot tap in the staff toilet, this a potential issue as it was at the time of the inspection accessible to residents. This was seen to have been identified within the homes legionella risk assessment and the Responsible Individual stated that a mixer valve was to be fitted in the near future. The home was found to be generally clean and tidy, with no odours detected at any time during the visits to the home. The home was seen to have appropriate procedures in place in terms of infection control. A number of staff have received training and in discussion were well aware of the basic steps needed to ensure there was good practice carried out in respect of ensuring their were no outbreaks (i.e. washing hands properly, single use of gloves, wearing appropriate protective coveralls etc). Observation of staff practices confirmed that their knowledge was carried over to practices in the home. The use of appropriate red bags for potential infected laundry would however be advisable (these not currently available at the home). The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff in the home are mostly well trained, skilled and in sufficient numbers to support the people who use the service, in line with their needs and preferences. Recruitment practice is robust and protects residents. EVIDENCE: People who use services have confidence in the staff that care for them. Rotas that were in accord with the staff on duty at the time of the visits show that there was sufficient staff on duty to meet the dependency levels of the residents accommodated at the time. Discussion with the Responsible Individual indicated that he was at the time of the inspection reviewing staffing levels in line with resident’s dependencies and was considering ways in which to potentially reduce staffing costs without impact on the homes ability to meets the resident’s needs. One method suggested was the use of dedicated staff at specific times of day employed to carry out ancillary tasks (such as preparing tea) that would release care staff from what was not a direct care task. The Responsible Individual was however reminded that it is the responsibility of the service to ensure that staffing levels are sufficient to meet the residents needs at all times of day and night. Resident’s comments indicated that at the time of the inspection they felt that staff were usually available at the times they were needed. The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 20 The service has a commitment to training this reflected in the fact that the majority of staff are now qualified to a minimum of NVQ 2 level 2 in direct care, and dementia training (this including some of the ancillary staff). There was however noted to be some shortfalls in the training of staff in some mandatory areas, although there was some evidence that the home was putting forward staff for this training. Whilst the home was seen to have a training plan the Responsible Individual was advised that documentation of provisional training dates on this would assist in evidencing the steps the home was taking to address shortfalls. Residents spoken to took the view that staff were good at their jobs with comments such as the following evidencing this: “Staff treat me well, think they do their job well enough” “Staff are great – anything wants they will get within reason” Relative’s comments via questionnaire also indicated that 60 thought staff had always have the right skills and experience to look after people properly, with 40 stating this was usually the case. The service has a good recruitment procedure; this revised earlier this year and clearly defining the process to be followed. This procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. There were some concerns as to the robustness of the homes induction procedure, as there was a lack of documented evidence to show staff were continually assessed and supported throughout their probation/induction period. Discussion with staff who had recently commenced employment at the home did indicate that they felt well supported however with good teamwork and mentoring from other staff. It was confirmed that this was on a more informal basis though. The Shrubbery DS0000004831.V340740.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37 & 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The administration of the home has suffered due to the current management of the home been overstretched, this impacting on effective recording keeping, which includes care planning. This has not impacted on the resident’s view of the home as been generally well managed and shortcomings have been recognised by the provider. Some of the shortcomings identified do indicate that the homes quality monitoring is not as effective as it could be. EVIDENCE: The Registered Manager is currently on extended leave and as a result the Responsible Individual is currently managing the home until her return. The Responsible Individual does however have full knowledge of the organisation’s The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 22 strategic and financial planning systems and the operation for the home links into these. Supported by these systems the Responsible Individual is competent in delivering effective financial planning and budgetary control. The Responsible Individual stated that he uses dedicated professionals to assist with the financial management of the home (i.e. chartered accountants), advice from the same used to assist in provision of a value for money service. The Responsible Individual has a clear understanding of the key principles and focus of the service, based on organisational values and priorities set with the provider, although the period of time spent running the home was said to have given him a valuable insight into day to day management issues that has assisted him to have a more measured view of service provision. He spoke of working to improve the service and provide an increased quality of life for residents with a strong focus on equality and diversity issues. The Responsible Individual in discussion was aware of current developments both nationally and by CSCI and tries to plan the service accordingly. Discussion in respect of recruitment indicated a wish to promote equal opportunities so as to ensure the home maintained a diverse staff group. The service generally has sound policies and procedures, which were seen to have been effectively reviewed, in line with current thinking and practice. There were issues in respect of the home following its own procedures and good practice in terms of record keeping in a number of instances however (see earlier comments) and the Responsible Individual recognised that there was an issue with time, with tasks such as updating care plan formats initiated yet not completed leaving some individuals case files incomplete. The Responsible Individual did state that he was employing a deputy to take on the day to day running of the home under his direct supervision so freeing time for him to complete the tasks he had precipitated with the aim of improving the homes administration. Based on the outcomes of this inspection it was indicative that the provider has responded to numerous concerns raised by the local authorities commissioning officer. The home was seen to have a quality assurance system in place with use of stakeholder’s questionnaires (including residents and relatives), residents meetings (although none of these have been held since April 2007) and regular staff meetings. Comments within the stakeholder questionnaires were positive about the service citing such as the service providing very good care and friendly staff although indicating there was a need for more outside activities. The service does need to develop an annual development/business plan based on the findings of the homes quality system. The effectiveness of the audits on the homes administration also needs to be improved. The home was seen to have satisfactory policies in place in respect of the protection of resident’s monies and valuables and inventories of their property were seen to be updated on a regular basis. A spot check on resident’s monies in safekeeping showed that there was an error on one residents account as the The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 23 money in safekeeping was over what the records stated he should have, this despite no errors found on records. Another concern was that the resident’s comforts fund records did not tally with the documented total, this by a significant amount. The Responsible Individual stated that money had been taken to purchase a karaoke machine for the residents use, although when requested there was no receipt available to evidence this. This evidence is yet to be forwarded to the CSCI and the Responsible Individual was told that monies should not be removed unless the record shows exactly why it is withdrawn and there is evidence to ratify any expenditure. The home works to a clear health and safety policy, all staff are fully aware of the policy and based on comments in discussion with them are trained to put theory into practice. Regular random checks take place to ensure they are working to it. The homes risk assessments in respect of general health and safety and safe working practices when sampled were found to be acceptable, and there are robust audit systems in place with records in this area generally to a good standard and routinely completed. Observation of staff practices during the course of the inspection raised no concerns in respect of these. It should be noted that there was an issue in respect of fire safety as previously mentioned within this report. The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 2 18 3 2 3 X X 3 2 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X 2 2 The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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(1) Requirement The registered provider must ensure that there are complete and accurate care plans in place for every individual that uses the service. Care plans must also reflect the information in the most recent assessments unless there is change in which case this must be reflected through clear documentation in reviews. Timescale for action 30/10/07 2. OP7 15(1) & (2) 3. OP9 13(2) 4. OP9 13(2) This is necessary to ensure that the care provided to residents is clear and understood by all involved. Where a resident is diabetic 30/09/07 there must be a robust detail as to how there dietetic needs will be met in full within the individual’s care plan, this detailing all implications this may have for their health care. The registered provider must 30/09/07 ensure that all areas that present significant risks to residents are fully assessed, this to include such as selfadministration of medication. The registered provider must 30/09/07 DS0000004831.V340740.R01.S.doc Version 5.2 Page 26 The Shrubbery ensure that all medication including prescribed creams must be signed out at the point of administration, and creams are in locked storage when not in use. This necessary to reduce potential risks to residents. The registered provider must ensure that any controlled drugs held by the home are stored and administered in accordance with pharmaceutical requirements. 5. OP9 13(2) 30/09/07 6. OP17 12(2)&(3) This necessary to reduce potential risks to residents. The registered provider needs to 30/10/07 ensure that any disclaimers signed are fully completed prior to signing so there is no doubt as to exactly what limitations are placed on residents, with clear reasoning as to why in care plans or risk assessments. This is necessary to ensure that any limitations are appropriate, measured, fair and agreed with residents. The registered provider must ensure that monies are not removed from any safekeeping account that belongs to residents, either individually or collectively, without the record showing exactly why it is withdrawn, with evidence to ratify any expenditure. This is necessary to protect resident’s interests. 7. OP35 17(2) sch 4(9) 30/09/07 The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 27 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 OP3 Good Practice Recommendations The registered provider should obtain copies of the social workers assessment of prospective resident’s in addition to the care plans where residents are funded through care management arrangements. The registered provider should ensure that resident’s weights are taken or weight loss/gain monitored on a regular basis. The registered provider should ensure that documentation in respect of residents bathing is accurate. The registered provider should ensure all eye drops are stored at the correct temperature (if necessary in an appropriate fridge). The registered provider should ensure that all medication no longer in use is returned to a pharmacist for disposal. The registered provider should ensure that where an assessment identifies resident’s choices these are followed in practice (for example nights checks are carried out in accordance with residents choice unless there is to great a risk). The registered provider should ensure that residents meetings continue on a regular basis. The registered provider should progress the development of activities that are specific to dementia care. The registered provider should ensure that residents are allowed to hold keys to their bedrooms unless there are valid risks that are fully explored through risk assessments. The registered provider should ensure support offered to staff during induction is formalised in the form of regular formal supervision. The registered provider should ensure that planned training is clearly evidenced on the homes training plan The registered provider should produce an annual development plan based on the findings of stakeholder comments. 2. 3. 4. 5. 6. OP8 OP8 OP9 OP9 OP10 7. 8. 9. OP12 OP12 OP24 10. 11. 12. OP30 OP30 OP33 The Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Shrubbery DS0000004831.V340740.R01.S.doc Version 5.2 Page 29 - 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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