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Inspection on 16/11/07 for Thurnscoe Hall Nursing Home

Also see our care home review for Thurnscoe Hall Nursing Home for more information

This inspection was carried out on 16th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

There had been some developments to include in the plan of care how the social care needs of people could be met. How staff spoke with people to meet their needs showed respect and dignity for them. Systems had improved to enable staff to be available to help people leave the dining table and go to the toilet when they wanted/needed to. We saw the menu for the day displayed. We also saw people being able to make choices about what they ate, which supported the person`s health and wellbeing. In the AQAA the manager described how the complaints procedure had been developed to improve the recording of complaints that are made. There had been some refurbishments and redecoration since the last site visit, which had improved the living environment for people. The recruitment policy had been followed to demonstrate a thorough recruitment process was now in place that safeguarded people. Staff were seen putting the training they had received into practice, which safeguarded people. Servicing and maintenance of the electrical fixed wiring had been carried out. This identified to the provider the work that was needed to make sure people were safe. A gate had been placed at the top of two steps that lead to a cupboard where cleaning materials are kept and the laundry. This kept the area safe for people. A report had been completed and placed in the entrance, of the outcome of the home`s quality audit. This meant people and their representatives were aware of what this was.Fire exits were clear, which meant there was an adequate means of escape if there was a fire. The area outside the conservatory had been cleaned which had removed the moss, which made it slippy. This should make it safer for people to use. The gate outside that lead to some steep steps had been repaired. This meant it could be closed, which improved the safety of the area for people. There were adequate gloves and aprons provided for staff so their health and safety was maintained.

What the care home could do better:

Although the admission process was well managed, the admission assessment could contain more detail. Make sure that all the action that staff need to take to meet peoples` needs is documented in the plan of care, for example, pressure area care. This should ensure they receive the care they need and demonstrate that their care needs are being monitored. Ensure toilet and bathroom doors close easily so that the lock on the door can be used, so that peoples` privacy and dignity is not compromised. When medication is received to check the records against the actual medication to make sure they are the same. Where there are discrepancies for this to be checked so that people received the correct dosage of medication. Also, where the details of medication are handwritten on to the record, for this to be verified by another member of staff and for them to sign the record to confirm this. Although there had been some refurbishment and redecoration there were still areas that needed improvements to provide a well-maintained living environment for people. The manager said some of these were planned. For the owner and manager to take a more proactive approach with quality assurance systems to ensure the service meets its responsibilities, for example, implementing relative meetings.

CARE HOMES FOR OLDER PEOPLE Thurnscoe Hall Nursing Home High Street Thurnscoe Rotherham South Yorkshire S63 0ST Lead Inspector Mrs Jayne White Key Unannounced Inspection 16th November 2007 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000006492.V349706.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. DS0000006492.V349706.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thurnscoe Hall Nursing Home Address High Street Thurnscoe Rotherham South Yorkshire S63 0ST 01709 890086 01709 894363 none www.thurnscoehall.co.uk Mr Rajendra Prasad 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) Vacant Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places DS0000006492.V349706.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered person may provide the following category of service only: Care home with nursing - Code N, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 24 3rd April 2007 2. Date of last inspection Brief Description of the Service: Thurnscoe Hall is a 17th Century stone built Grade 2 listed building with a purpose built extension and conservatory. The home is registered to provide nursing, personal care and accommodation to 24 older people. The home stands in its own extensive gardens with mature trees and shrubs and has a sitting area for people and their families. Accommodation is on three floors, served by a passenger lift. The bedrooms are for single use. There is a car park to the side of the building. The home is situated in Thurnscoe village ten miles from Barnsley town centre, close to the A635 Barnsley to Doncaster Road, with easy access by bus or train. The home is within walking distance of all local amenities, including, supermarkets, chemist, optician, post office, hairdressers, community centre, bowling green, pubs, clubs, the village church and health centre. Information about the home, including the service user guide is available in the entrance hall. This includes the most current Commission for Social Care Inspection (CSCI) report about the service. The manager said the fees ranged from £335.00 to £368.00. If nursing care is required this contribution is free of charge to people. Additional charges are made for hairdressing, private chiropody, individual toiletries, papers and magazines and spending money on day trips. DS0000006492.V349706.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. I visited the home with Amanda Lindley, my manager without giving them any notice between 8:30 and 15:15. Before the visit I took into consideration other information I had received. This included an Annual Quality Assurance Assessment (AQAA). An AQAA is a document completed by providers. It gives them the opportunity to tell the CSCI how well they think they are meeting the needs of people using their service. Surveys were also sent to a range of people, asking them about the home. Six came back from people that lived there and two from health and social care professionals. During the visit we spoke with people that lived there and their relatives, friends and advocates. We also spoke with staff, the manager, looked round parts of the building and read some records. We would like to thank the people and their representatives, staff and manager for their time and co-operation throughout the inspection process. CSCI have reviewed their guidance on requirements, therefore, some requirements have been removed if they would have no direct affect on the outcome of the service provided for people. What the service does well: The manager had a good knowledge of the needs of people and was committed to providing a good quality service. When we spoke with people they spoke highly of the staff team saying, “all the staff are good – you couldn’t pick out ‘the best’”, “excellent staff”, “staff good” and “staff are good and helpful”. The admission process was well managed and people said they received enough information about the home. People praised the service stating they always or usually received the care and medical support they needed. Their comments included, “we’re well looked after, particularly when you’re ill” and “if anything they wash clothes more than they need to”. During the visit we saw people following their preferred routine. Mealtimes were a relaxed and leisurely time for people. DS0000006492.V349706.R01.S.doc Version 5.2 Page 6 People said their representatives could visit “at anytime”. Relatives confirmed this and the fact that they were always offered a drink, made to feel welcome and kept up to date about the care their relative was receiving. There was a complaints procedure that people had access to. People were protected from abuse and had their rights protected. When we spoke to people they said they had no complaints or grumbles. What has improved since the last inspection? There had been some developments to include in the plan of care how the social care needs of people could be met. How staff spoke with people to meet their needs showed respect and dignity for them. Systems had improved to enable staff to be available to help people leave the dining table and go to the toilet when they wanted/needed to. We saw the menu for the day displayed. We also saw people being able to make choices about what they ate, which supported the person’s health and wellbeing. In the AQAA the manager described how the complaints procedure had been developed to improve the recording of complaints that are made. There had been some refurbishments and redecoration since the last site visit, which had improved the living environment for people. The recruitment policy had been followed to demonstrate a thorough recruitment process was now in place that safeguarded people. Staff were seen putting the training they had received into practice, which safeguarded people. Servicing and maintenance of the electrical fixed wiring had been carried out. This identified to the provider the work that was needed to make sure people were safe. A gate had been placed at the top of two steps that lead to a cupboard where cleaning materials are kept and the laundry. This kept the area safe for people. A report had been completed and placed in the entrance, of the outcome of the home’s quality audit. This meant people and their representatives were aware of what this was. DS0000006492.V349706.R01.S.doc Version 5.2 Page 7 Fire exits were clear, which meant there was an adequate means of escape if there was a fire. The area outside the conservatory had been cleaned which had removed the moss, which made it slippy. This should make it safer for people to use. The gate outside that lead to some steep steps had been repaired. This meant it could be closed, which improved the safety of the area for people. There were adequate gloves and aprons provided for staff so their health and safety was maintained. 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. DS0000006492.V349706.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000006492.V349706.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for 1 and 3 were inspected. The home did not provide an intermediate care service. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People had information available to assist them in choosing a home. People had their needs assessed before they moved in, but these could contain more detail. EVIDENCE: We saw the service user guide displayed in the entrance to the home as was the latest CSCI inspection report. All people, via the survey said that they had received enough information about the home before making a decision to move there. DS0000006492.V349706.R01.S.doc Version 5.2 Page 10 They commented, “I went in as an emergency. Not happy about going into a home at first. Had to stay for 2½ months but they were very kind to me”. When we spoke to people they all said family had chosen the home. They commented, ‘they had chosen well’. The manager said prospective people were visited so they could carry out their own assessment before the person moved in. This enabled them to confirm the service was appropriate to meet the person’s individual needs. We looked at two peoples’ files for the assessment that was undertaken. These did contain an assessment, but could contain more detail. One contained an assessment undertaken by other professionals. DS0000006492.V349706.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for 7, 8, 9 & 10 were inspected. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The plan of care did not always document and therefore confirm the health care that people received was sufficient to meet their needs. People were treated with respect and dignity. EVIDENCE: People, via the survey said that they always or usually received the care and medical support that they needed. When we spoke to people they said that they were well cared for. Their comments included, “we’re well looked after, particularly when you’re ill” and “if anything they wash clothes more than they need to”. DS0000006492.V349706.R01.S.doc Version 5.2 Page 12 The AQAA stated: • • • The service had an excellent record of only two pressure sores in seven years. General care was of a high standard. Staff are very aware of residents’ needs and quickly note any changes in conditions. We looked at two care plans. In both plans there were areas where there was no information to identify what staff needed to do to meet the needs for the person. These areas included pressure area care, assistance with dressing and mobility. The entries for each shift, on the whole contained good detail, including information about pressure areas, which had not been identified in the plan of care. Where information about pressure areas had been documented, the following entry did not refer to it. This did not confirm there had been monitoring of the pressure area. When we spoke to staff they were aware of the pressure area and acknowledged the poor recording. They described how they were working through all care plans to make sure all peoples’ needs were recorded to improve this. The district nurse had not been notified of the pressure area. Risk assessments for nutrition, falls and moving and handling were in place. Consent forms were being used for equipment that was being used as a restraint, for example, bed rails. We discussed with the manager that the appropriate documentation would be to risk assess the application of the restraint being used. This would demonstrate the restraint was appropriate to the risk identified and other aspects of safety had been assessed, for example, the type of mattress being used. When we spoke to people they said that staff treated them with respect and they were able to spend time in their room if they wished. We saw staff approaching people in a respectful manner and respecting individual preferences. They explained what it was they would be doing for them, but there did not seem to be other conversation between them. We discussed with the manager that staff chatting to people whilst undertaking tasks for them may enhance the ambience of the surroundings. We saw how staff respected the privacy and dignity of people, for example, knocking on peoples’ doors before entering. People were immaculately dressed, their hair and nails were clean and no one had food spillage on their clothes. DS0000006492.V349706.R01.S.doc Version 5.2 Page 13 When we looked round the building all toilet and bathroom areas did not have a working lock because the doors did not close easily to allow the lock to be used. This may compromise the privacy and dignity of people. Qualified nursing staff administered medication and medication, including controlled drugs, was stored appropriately and securely. This maintained the heath, safety and welfare of people. Amanda looked at the recording, administration and storage of medication on a sample basis. Records were kept of medication being received. Amanda saw that hand written entries had been made on the medication administration record that did not have two signatures. The member of staff was advised to get another signature for these entries, as verification the information is correct. This should reduce the risk of any errors to administering that medication. There was also an error with the medication of one person where the medication administration record did not correspond with the information on the actual bottle. The nurse on shift clarified what the correct dosage should be on the visit and ordered further medication. When we spoke with the manager she confirmed appropriate arrangements were in place for the disposal of medication and explained the procedure for disposing of controlled drugs. We saw that when people were given their medication it was done in a respectful and dignified way. A drink was available to assist people take their medication. People were prompted and encouraged to take their medication where this was necessary. When people did not think they should be taking the medication this was explained to them. DS0000006492.V349706.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 12, 13, 14 & 15 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were assisted to make choices, decisions about their daily life and social activities. EVIDENCE: The AQAA stated: • The service encouraged family activities and involvement • The service provided entertainment • Residents’ birthdays and other special occasions are celebrated • Residents are involved in the summer and Christmas fayre • It said they could improve activities and crafts available for residents • The service are planning a memorial garden which people and their families are involved When we spoke to the manager she also said she had received the first stage of a government grant, which was to used to improve the lives of people. She had used this grant to purchase: DS0000006492.V349706.R01.S.doc Version 5.2 Page 15 • • • • • • • • • • • ‘Memory’ pillows for each person A hostess trolley A digibox An electric standaid Rotating floor discs to transfer people A transferring disc for use with transport New dining tables New ‘ski’ chairs for the dining room New cutlery, mats and centre pieces for the dining tables Lamps for peoples’ bedrooms Bath spa Of the six surveys returned, two said the home usually arranged activities they could take part in, four said sometimes. When we spoke to people they described how they chose how to spend their day. They said they could choose what time to get up and go to bed within reason, accepting the constraints as part of group living. They said they spent time talking with other people in the lounges, reading, doing crosswords and word searches and knitting. Some people said they liked listening to music, others watching DVDs and others “just watching what was happening”. One person said, “what I like is you can please yourself what you want to do – it’s like home from home”. In contrast another person said, “the worst thing is the long days when you’ve nothing to do”. When they were asked what they would like to do they didn’t know. People said there hadn’t been a summer fayre this year. When we walked round the home we saw a clothes party and Christmas party were advertised for people. People said their family and friends could visit “at any time”. We saw a number of visitors. When we spoke to them they said they could visit at any time and that they were made to feel welcome by being offered a drink and staff being friendly. The six surveys returned by people stated they always or usually liked the meals. A menu written on a board in the dining room gave the menus for the day. At breakfast time there were cereals and toast. A hot option was available if people requested this and the cook said this would be prepared at the time. The lunchtime menu was fish, chips and mushy peas. The alternative was scampi. The pudding was ice cream. Teatime was beans on toast or a selection of sandwiches. When we spoke to people they said they enjoyed their meals and had enough to eat. They said their individual preferences were catered for and explained that staff came round after breakfast so they could choose what they wanted for dinner. DS0000006492.V349706.R01.S.doc Version 5.2 Page 16 We saw the breakfast and lunchtime meals being served. The dining room was welcoming, being bright and clean. There was no rush to the mealtime and people were given sufficient time to eat. People were seen eating different meals. We saw people being offered drinks and one person said, “I know it’s important to have drinks”. DS0000006492.V349706.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 16 & 18 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There was a complaints procedure that people had access to. People were protected from abuse and had their rights protected. EVIDENCE: All surveys returned confirmed people knew how to complain and people always or usually knew who to speak to if they weren’t happy. One commented, “this would be matron”. When we spoke to people they said they had no concerns or grumbles. We saw the complaints procedure displayed in the entrance hall. This demonstrated people had access to information about how to make a complaint and who would deal with it. Since the last inspection, no complaints have been to the CSCI or the home. There was a record of complaints maintained in a loose leafed file. DS0000006492.V349706.R01.S.doc Version 5.2 Page 18 The AQAA stated policies/procedures/codes of practice were in place to protect people from abuse. It also stated all staff had attended an adult protection course. We discussed with the manager about the amalgamation of South Yorkshires adult safeguarding procedures. She had arranged to attend an information day about the new procedures. When Amanda spoke with staff they said they were aware of the procedures and would use them should an allegation of abuse be made. DS0000006492.V349706.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 19 & 26 were inspected. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The living environment was clean but improvements were still required to make it a well maintained home for people to live. EVIDENCE: All people that we spoke to said that they were happy with their living environment, their bedrooms were comfortable and that they had everything they needed. For some people, however, the conservatory where they sat needed repairs. They said there were areas where it leaked at times. Towels were placed on the windowsill to soak up the water. They also said it was draughty where the DS0000006492.V349706.R01.S.doc Version 5.2 Page 20 windows didn’t fit well. I felt the heating was not sufficient to warm the room to compensate for the draughts. However, some of the people that sat there enjoyed the bright feel to the room, the fact that it was cooler than the other sitting areas and didn’t want to sit elsewhere. They suggested that blinds at the windows might reduce the draught in the winter and heat in the summer. All of the six surveys returned by people said the home was always fresh and clean. There had been some refurbishments and redecoration since the last site visit, which had improved the living environment for people. The manager said further refurbishments were planned including, the retiling of the bathroom floor where it was cracked, uneven and loose. Until this is completed this still has the potential to cause injury to people should they go to the bathroom without footwear or if they had a fall in the room. She also said decorators were due to redecorate the upstairs corridor areas and stair wells where water had leaked through. When we looked round the building it was clean and did not have any offensive smells. There were a number of lounges and a large dining room, which gave people sufficient space. The gardens were generally tidy with mature trees and shrubs. This would improve if all areas were tidy by removing old wheelchairs. DS0000006492.V349706.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): The outcomes for standards 27, 28, 29 & 30 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There was an experienced, trained and stable staff team that were in sufficient numbers to meet the needs of people living there. EVIDENCE: Six people, via the survey, said that there was always or usually staff available when they needed them. They also said staff listened and acted on what they said. When we spoke with people they spoke highly of the staff team saying, “all the staff are good – you couldn’t pick out ‘the best’”, “excellent staff”, “staff good” and “staff are good and helpful”. The manager said a nurse was on duty on each shift to assist with the nursing needs of people. In addition to this there were two care assistants on the morning and afternoon shift and one on the night shift. We saw staff provide assistance for people when they needed this without having to wait an unreasonable amount of time. DS0000006492.V349706.R01.S.doc Version 5.2 Page 22 The employment of a member of staff for specific kitchen duties at teatime has ensured that sufficient care staff were available to meet peoples’ needs at this time. The AQAA stated: • • • All staff have NVQ Level 2 and 50 have Level 3 All staff have first aid training, health and safety, hygiene, nutrition and food handling 43 have infection control training When Amanda spoke with staff they confirmed they had received moving and handling training, food hygiene and fire. Some of these needed updating and the staff were advised of this. They said training was planned for end of life care and tissue viability. This was recorded in their personal training record and certificates to demonstrate qualifications and training of staff were also in place. They said they received support and guidance appropriate to what they needed. The AQAA stated there was a recruitment policy in place. Amanda looked at four staff files on a sample basis to confirm this was followed. A thorough recruitment procedure was demonstrated including criminal record bureau disclosures, written references and satisfactory written explanation of gaps in employment. This confirmed thorough recruitment practices were in place, which was sufficient to safeguard people. DS0000006492.V349706.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 31, 33, 35 & 38 were inspected. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management and administration of the home was based on openness and respect. A more proactive approach with quality assurance systems would ensure the service meets its responsibilities without relying on external systems. EVIDENCE: Information we knew about the manager was that she had many years experience within the caring profession. She had a good knowledge of the needs of people and was committed to providing a good quality service. Her DS0000006492.V349706.R01.S.doc Version 5.2 Page 24 direction and leadership promoted a relaxed and friendly atmosphere. However, she has been in post a number of years and is not registered with the CSCI. The manager states the owner is aware of this. People and their advocates expressed satisfaction with the service. The manager had implemented a quality audit, with the results displayed in the entrance hall. The audit report identified there were no serious problems, with good outcomes being the refurbishment and social functions. One improvement identified the possibility of relative meetings. When I spoke with the manager she had not implemented these because no-one had attended in the past. I explained another opportunity ought to be given it was an improvement that had been identified on the current quality audit. I also suggested she took the lead in arranging them as opposed to stating on the report for people to let her know if they want one. This would show people and their relatives their ideas were listened to and acted on. The manager said the owner visits the home frequently but does not complete reports of his visits. This does not provide CSCI with any information of their opinion of the quality of the service and action they are taking to improve any areas. A valid insurance certificate was in place. People were encouraged to maintain control over their own finances unless they did not want to or lacked capacity. When we spoke to people they said ‘the home looked after their monies, but they could get it at any time’. When we looked round the building fire exits had been kept clear, which should make it easy for people and staff to leave the building should there be a fire. A window in a bathroom on the top floor, that was low to the ground and a good size could be opened wide because the window restrictors were broken. This presented a safety risk to people and staff. On the whole, we saw people being moved safely, but care must be taken that brakes are applied when transferring people from/into wheelchairs. When we spoke to staff they said there were adequate gloves and aprons available to control the spread of infection. The AQAA stated servicing and maintenance was in place for electrical circuits, portable electrical appliances, the lift, hoists, fire detection and fire fighting equipment, emergency call equipment, the heating and gas. I looked at some of these for verification. The status of the fixed electrical inspection report identified it was unsatisfactory. A number of the emergency lighting had failed the test. When I spoke to the manager she said a quote had been obtained and the work was due to be carried out next week. DS0000006492.V349706.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 DS0000006492.V349706.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 OP8 Regulation 17 (1) (a) Requirement The plan of care must include a record of the incidence of pressure sores, that the district nurse has been contacted and of the treatment to be provided for the person. This will demonstrate people are receiving the health care they need. When medication is received the medication administration record must be checked against the actual medication. This ensures people receive the dosage of the medication they have been prescribed. The floor in the bathroom with the assisted hoist must be replaced so that it is a pleasant area for people to take a bath and their safety is not compromised. Previous timescale of 31/10/07 not met The window restrictors in the bathroom on the top floor must be repaired. This will keep areas DS0000006492.V349706.R01.S.doc Timescale for action 16/11/07 2. OP9 13 (2) 16/11/07 2. OP19 23 (2) (b) 31/01/08 3. OP38 13 (4) (a) 17/11/07 Version 5.2 Page 27 of the home which people have access to, safe. 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 admission assessment should cover in detail all the assessment information identified in 3.3 of the National Minimum Standards. This would demonstrate the service had obtained enough information to formulate the plan of care. Where a restraint is being used, for example, bed rails, the plan should demonstrate this has been done as part of a risk assessment. This would demonstrate the restraint is appropriate to the risk identified and other aspects of safety have been assessed, for example, the type of mattress used. That the plan of care is regularly reviewed to ensure the plan is accurate and up to date and being followed. This will mean staff have accurate information of the care required by people. When entries for medication are hand written on to the medication administration record they should be signed by another person. This is for verification that the entry is correct and therefore reducing the risk of errors. All toilet and bathroom doors should close easily so that the locks work. This is so that the privacy and dignity of people is not compromised. The ceiling on the second floor should be redecorated. This would provide a well-maintained living environment for people. Old wheelchairs should be removed from the outside area so that is a pleasant area for people to enjoy. DS0000006492.V349706.R01.S.doc Version 5.2 Page 28 2. OP7 OP8 3. OP7 4. OP9 5. OP10 6. OP19 7. OP19 8. OP19 The conservatory should be maintained in a good state of repair so people can sit in comfort in the environment they choose. Consider placing blinds in the conservatory to compensate for draughts in the winter and heat in the summer. The manager should be registered with the CSCI. This is so that the CSCI can make a formal decision that the person has the qualifications, skills and experience necessary for managing a care home and is physically and mentally fit to do so. A written report of the owner’s monthly visit should be completed and forwarded to the CSCI. This provides CSCI with information of their opinion on the quality of care the service provides. For the manager to take the lead and implement relative meetings. This would show people their comments and ideas of how the service could improve had been listened to. 9. 10. OP19 OP31 11. OP33 12. OP33 DS0000006492.V349706.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 DS0000006492.V349706.R01.S.doc Version 5.2 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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