Inspection on 03/04/07 for Thurnscoe Hall Nursing Home

This inspection was carried out on 3rd April 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.

Other inspections for this house

Thurnscoe Hall Nursing Home 16/11/07

Thurnscoe Hall Nursing Home 25/04/06

Thurnscoe Hall Nursing Home 09/11/05

Thurnscoe Hall Nursing Home 03/05/05

Thurnscoe Hall Nursing Home 12/10/04

Thurnscoe Hall Nursing Home 04/06/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

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 3rd April 2007 08:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000006492.V331559.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.V331559.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 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places DS0000006492.V331559.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons accommodated shall be aged 55 years and above Of the 26 beds, 12 are nursing care (N) and 14 are personal care (PC) Date of last inspection 25th April 2006 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 for 26 residents aged 55 years and above. Twelve of the registered places can be used for residents requiring nursing care. The home stands in its own extensive gardens with mature trees and shrubs and has a sitting area for residents and their families. Accommodation is on three floors, served by a passenger lift. There are 22 single rooms and two double rooms. 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. The fees for the home ranged from £327.50 to £358.00. The National Health Service nursing care contribution is in addition to these fees and ranges from £65.00 to £133.00 dependant on the level of National Health Service assessed need. Additional charges were made for hairdressing, private chiropody, individual toiletries, papers and magazines and spending money on day trips. This fee applied at the time of inspection and people may wish to obtain more up to date information from the care home. The home had a service user guide that provided some information about their service for current and prospective residents. A CSCI report about the service was also available to current and prospective residents in the entrance of the home. DS0000006492.V331559.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced site visit carried out between the hours of 8:00 am and 5:00 pm. The home had provided some information to assist with the site visit. As part of the inspection process, 5 surveys were sent to residents to obtain their opinions on aspects of living at the home. All surveys were returned, four completed on behalf of residents by staff who worked at the home. Five questionnaires were sent to staff to obtain their opinions of the home, three were returned. Five questionnaires were sent to health and social care professionals, none were returned. In comments received about the draft report from the manager, she states four professional questionnaires were completed on site at Thurnscoe Hall and returned in one envelope prior to inspection. At CSCI there is only one record of a professional questionnaire being received. This was on 02 April 2007. The inspection took place 03 April 2007 and the inspector had not been in the office since 28 March 2007. As a consequence the questionnaire was not included in the inspection process. The inspection process included a partial inspection of the premises, inspection of a sample of records, observation of care practices and speaking with residents, their relatives/advocates and staff. The inspector spoke in detail to four of the staff on duty about aspects of their knowledge, skills and experiences of working at the home, seven residents about their opinions on aspects of living at the home and one relative of their opinion of the home. Also taken into account was other information about the service since the last inspection. In addition the CSCI have reviewed their guidance on requirements, therefore, some requirements have been removed if they had no direct evidence of service user outcome, or reworded. The inspector wishes to thank the residents, staff and owners for their time and co-operation throughout the inspection process. What the service does well: Residents moving into the home had, had their needs assessed, which enabled an individual plan of care for residents to be formulated. On the whole residents were protected by the home’s policy and procedures for dealing with medication. DS0000006492.V331559.R01.S.doc Version 5.2 Page 6 Residents confirmed that they maintained links with their family and friends and that they could visit “at anytime”. Relatives confirmed this and the fact they were always offered a drink, made to feel welcome and kept up to date about the care their relative was receiving/needed. People who used the service were protected from abuse. The living environment was clean. What has improved since the last inspection? What they could do better: The service user guide would benefit from more detailed information so that prospective people to use the service and their representatives had more information they needed to choose a home, which would meet their needs, including the contract/terms and conditions and the fees to be charged. Identify individual’s social, cultural and recreational activities in individual plans of care would demonstrate individual’s expectations and social care needs are being met, particularly where individuals may lack capacity. Complete monthly reviews of care plans to ensure the plan of care is accurate so that actions to be taken to meet residents health needs are followed in accordance with the plan, for example, monitoring blood glucose levels. The plans also needed more detail of the action to be taken to meet resident’s care needs as it was noted resident’s being offered drinks with sugar and they didn’t take sugar and positioning drinks where residents did not have the skills to reach the drinks. DS0000006492.V331559.R01.S.doc Version 5.2 Page 7 Ensure all toilet and bathroom areas have a working lock, so that the privacy and dignity of residents is not compromised. Provide a telephone for use specifically by residents so that respect for privacy of the resident’s own action is maintained. Remove continence protectors from chairs in the lounge, as this practice does not promote the dignity of those residents. Respond more swiftly to residents’ requests for the toilet so that their dignity is maintained and they do not become distressed. Offering a choice at the main meal would provide an alternative to residents, enhancing their lifestyle, rather than giving a choice when they dislike the meal. Respond swiftly to people who make complaints so that complainants can be confident their complaints will be listened to, acted upon and the outcome relayed to them. Improvements were still required with the environment to ensure it was well maintained and safe for residents. Improve recruitment practices to ensure as far as possible that residents are protected from risk of harm. For the manager to develop her competence in regard to knowledge of the regulations and standards and implement effective quality assurance and supervision systems to ensure these are met, for example, when staff undertake training they put this in practice so that residents are not placed at risk of harm, for example, moving and handling residents in an unsafe way and ensuring fire exits are not blocked. 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.V331559.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.V331559.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 standards 1 and 3 were inspected. The home does not provide an intermediate care service (standard 6). Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective people who may use the service and their representatives had some information they needed to choose a home, which would meet their needs, but the service user guide needed to contain more information. They had, had their needs assessed and had a contract, which confirmed the service they would receive, but the contract needed more information in regard to the fees charged for the service. DS0000006492.V331559.R01.S.doc Version 5.2 Page 10 EVIDENCE: The service user guide was displayed in the entrance to the home. The guide did not include the latest CSCI inspection report, although it was on display elsewhere in the entrance hall. The service user guide would benefit from more detailed information in regard to the description of the accommodation and services provided, including individual and communal accommodation, relevant qualifications and experience of the provider and the number of places provided. The guide did not include a standard contract including the service and facilities to be provided, fees to be charged and the arrangements for paying that fee, what’s included in the fee, how items not included in the fee are to be paid for and a statement of whether any of the charges would be different if paid for by someone other than the resident. Neither did it include where a local authority has made the arrangements, a copy of the agreement between the provider and the local authority. The assessment of need for a resident who had been admitted to the home was inspected. A detailed assessment was in place both from the hospital and the home, which enabled an individual plan of care to be formulated. A contract/terms and conditions with sufficient information was not in place. All resident surveys confirmed they had a contract and had received sufficient information about the home prior to admission. DS0000006492.V331559.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 and 10 were inspected. 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 received was based on their individual needs, however, this could not be demonstrated for social care needs as these were not identified in the plan of care. The principles of respect, dignity and privacy were known by staff, but there were some areas where practice could be improved. EVIDENCE: Residents spoken with spoke positively about their personal care needs being met. The five surveys returned identified residents always received the care and medical support they required. One resident commented “they were very kind when my husband died in home last year”. DS0000006492.V331559.R01.S.doc Version 5.2 Page 12 Two individual care plans were inspected on a sample basis. The plan contained relevant information on the care required to meet the resident’s health and personal care needs but lacked detail of how social care needs were to be met. Risk assessments for nutrition, falls and moving and handling were in place. There were no residents with pressure sores and discussions with staff identified they were proud of their interventions to improve the continence needs of residents. The inspector would suggest that at least monthly reviews of care plans are needed to ensure the plan of care is accurate and that actions to be taken to meet residents health needs were followed in accordance with the plan, for example, monitoring blood glucose levels. The plans also needed more detail of the action to be taken to meet resident’s care needs as it was noted resident’s being offered drinks with sugar and they didn’t take sugar and positioning drinks where residents have the skills to reach the drinks. The recording, administration and storage of medication were inspected on a sample basis. On the whole records were kept of medication being received into the home and the manager confirmed appropriate arrangements were in place for the return of medicines to the pharmacy. Generally medication administration records were fully completed. Qualified nursing staff administered medication and medication, including controlled drugs, were stored appropriately and securely, maintaining the heath safety and welfare of residents. Residents spoken with said that they were well cared for, staff treated them with respect and they were able to spend time in their room if they wished. Staff were observed approaching residents in a respectful manner and respecting individual preferences. Good relationships between staff and residents were evident. There were areas where the privacy and dignity of residents was respected, for example, knocking on residents’ doors before entering, but all toilet and bathroom areas inspected did not have a working lock, which may compromise the privacy and dignity of the residents. To use the telephone the resident’s had to use the office telephone, as one was not available for use specifically by residents. This meant staff were aware when residents chose to make telephone calls, which did not respect their privacy for their own actions. Continence protectors were placed on some chairs in the lounge and hoist slings were also left in place beneath residents who had moving and handling needs. These practices do not promote the dignity of those residents and leaving the hoist sling beneath residents can be a health and safety risk. There was an occasion where a staff member confronted a resident about the choice they made about their drink by saying “well I’ve never given you a drink without sugar – I’ll get you another if you want?” Had the resident not been assertive in their answer, the response by staff does not support the philosophy of resident’s choice and rights. Also, there were two occasions when residents were kept waiting for the toilet and they became distressed. Residents also said when they wanted assistance they had to shout because a call alarm system was not available. DS0000006492.V331559.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): The outcomes for standards 12, 13, 14 and 15 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who used the service were able to make some choices about their life style. Offering a choice at the main meal would provide an alternative to residents, enhancing their lifestyle, rather than giving a choice when they dislike the meal. Identifying individual’s social, cultural and recreational activities in individual plans of care would demonstrate individual’s expectations/needs are being met, particularly where individuals may lack capacity. EVIDENCE: All five surveys returned said the home usually arranged activities they could take part in. One comment from these however said “but personally I like to entertain myself”. DS0000006492.V331559.R01.S.doc Version 5.2 Page 14 Individual care plans did not identify residents’ social care needs so clarity of what these might be could not be determined, other than residents saying they would like to go to church/chapel. As information of their religious activities was not in the plan of care, how these were going to be met in discussion with them could not be demonstrated although one resident did say the vicar had visited. They also said they would like to go to church, but had not been. Residents’ spoken with described how they could choose to spend their day and confirmed that they could choose what time to get up and go to bed within reason, accepting the constraints as part of group living. The majority of residents were observed to spend time in the lounges with interaction between themselves and/or the staff and in the morning a staff member was observed involving three residents in a trivia quiz. The residents were pleased with a recent clothes party the home had arranged and an event was planned for Easter. Personal items and furniture were brought into the home by residents to personalise their rooms. Residents confirmed that they maintained links with their family and friends and that they could visit “at anytime”. Relatives confirmed this and the fact they were always offered a drink, made to feel welcome and kept up to date about the care their relative was receiving/needed. The dining room was welcoming, being bright and clean. The ambience of the meals was spoiled by an inappropriate choice of radio station that continued to play all day. Although there were some residents that initially said they enjoyed it, later in the day they said “the music was driving them mad”. Of the five surveys returned residents identified the meals were always or usually good. Discussions with residents and relatives were in the main positive about the food; residents said they could have a cooked breakfast if they wished although on the visit only cereal and toast was observed to be offered. Residents spoken with said that they had enjoyed their breakfast and lunch and had, had enough to eat. When the meals were served they were unhurried and residents’ were given sufficient time to eat, however, some residents were asked to wait to leave the table until other residents had, had their breakfast, which for some of the residents was one and a half hours. The pre inspection questionnaire said breakfast was served between 8:00 – 10:00, lunch 12:00 12:30, tea 17:00 – 17:30 and supper 20:00. Menus were not displayed and residents did not know what the meal was. Although the menu was varied it did not provide a choice. A choice was offered if the cook/staff were aware of anything the resident disliked. The manager stated that the catering team had been awarded a silver award for catering. Staff files identified there were staff who had undertaken relevant training in food hygiene, food preparation and health and safety and held NVQs in Hospitality and Tourism. DS0000006492.V331559.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): The outcomes for standards 16 and 18 were inspected. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who used the service were able to express their concerns and had access to a complaints procedure, however, this was not robustly implemented in practice and therefore complainants cannot be confident their complaints were listened to, acted upon and the outcome relayed to them. People who used the service were protected from abuse. EVIDENCE: All surveys returned confirmed residents knew how to complain and four of the five surveys said they always knew who to speak to if they weren’t happy, one usually. There was a record of complaints maintained in a loose leafed file. The record did not include how the complaint would be investigated, the outcome of the complaint and action taken as a result of the complainant to reduce the likelihood of the same complaint again. A previous complaint made to the CSCI, that had been unresolved in regard to residents receiving timely assistance when requested and not left in rooms unassisted for any length of time was not in the record, neither was a complaint made to CSCI on 11th October 2006, although correspondence was in the file in regard to this complaint. The complainant was unhappy with the response and a copy of the response was sent to CSCI. The response had not responded fully to all aspects of the complaint, namely the brochure resembling five star DS0000006492.V331559.R01.S.doc Version 5.2 Page 16 accommodation and whether or not the guttering was broken with water gushing out. The manager/provider was required to respond directly to the complainant. The manager stated she felt unable to deal with these aspects of the complaint and said the complaint was now with the provider, Dr Prasad. He had not responded to the complainant as far as the manager was aware. A copy of the Barnsley and Rotherham multi agency adult protection policies and procedures were available to staff. A resident funded by another local authority was living at the home; the adult protection policy and procedure for this local authority had not been obtained, but the manager was aware she needed to obtain this. Some staff had received adult protection training. Where training had not yet been facilitated staff could describe the action to be taken should an allegation of abuse be made. DS0000006492.V331559.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): The outcomes for standards 19 and 26 were inspected. Quality in this outcome area is adequate. 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 ensure it was well maintained and safe for residents. EVIDENCE: All residents spoken with said that they were happy, their bedrooms were comfortable and that they had everything they needed. All of the five resident surveys returned said the home was always fresh and clean. One resident commented “I love my room and the gardens”. DS0000006492.V331559.R01.S.doc Version 5.2 Page 18 Staff surveys returned felt the cleanliness of the building was fine, but the maintenance of the building could be improved. Their comments included “cleanliness is fine. Some parts of the building need maintaining but the building is old and will need a lot of maintaining”, “the cleanliness of the building is good but the maintenance of the building could be better – better maintenance would improve the home” and “fairly good and there is continuous maintenance going on”. There has been some refurbishments and redecoration since the last site visit, including repairing the plastic covering on the handrail on the stairs, a bedroom ceiling where it had sustained some damage from a leaking pipe and the kitchen area, improving the living environment and comfort of residents. There was a bathroom area where the tiling on the floor had not been maintained as it was now cracked, uneven and with loose grout from between the tiles on the tiles. This could cause injury to residents should they go to the bathroom without footwear or if they had a fall in the room. To the outside area there was dirty patio furniture, old lounge chairs and wheelchairs. This detracted from the otherwise tidy gardens with mature trees and shrubs. Laundry facilities were sited on the lower ground floor/cellar away from food preparation and storage areas. Hand washing facilities were provided. DS0000006492.V331559.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): The outcomes for standards 27, 28, 29 and 30 were inspected. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff were trained, but didn’t always put that training into practice so that residents were not placed at risk of harm. Staff were in sufficient numbers to support the people who use the service and to support the smooth running of the service, but as with staff training staff recruitment was insufficient to protect residents from risk of harm. EVIDENCE: Residents stated that they were satisfied with the level of care they received and that staff knew how to care for them. Good relationships between staff and residents were evident. The manager said a nurse was on duty on each shift to assist with the nursing needs of the eleven residents requiring nursing care. In addition to this there were two care assistants on the morning and afternoon shift and one on the night shift. The staff rota confirmed this and was in line with the staffing notice agreed by the home in November 2000. Observation of staffing on the afternoon identified assistance for and supervision of residents may be of concern at that time due to the needs of residents, the layout of the building, DS0000006492.V331559.R01.S.doc Version 5.2 Page 20 with a number of residents in their own rooms and staff also carrying out kitchen duties. The pre inspection questionnaire identified ninety nine per cent of care staff held NVQ level 2 in Care and ten staff held a current first aid certificate. Staff stated they had opportunity for training and this had included infection control, health and safety, moving and handling, first aid, food hygiene, fire and health care. This was recorded in their personal training record and certificates to demonstrate qualifications and training of staff were also in place. The pre inspection questionnaire identified in the past twelve months training had included fire and evacuation, moving and handling, nutrition, health and exercise, blind association, catheter care, control of substances hazardous to health, NVQ, management modules, dementia and optical assessments. The pre inspection questionnaire identified future training as dementia counselling and equality and diversity. Staff were positive about the advantages of receiving training and their comments included “I have achieved my NVQ 2 and waiting to start level 3. I have also done food hygiene, moving and handling, incontinence and all other courses containing information that would help me in my job”, “various training courses completed. The matron of the home makes sure the staff are kept up to date with training – health and nutrition, loss and grief, health for life, exercise” and “my training is ongoing and I am willing to continue any training that helps my role as an RGN”. Although staff had received training moving and handling practices were poor, fire exits were blocked and systems to control the spread of infection could be improved – see management and administration. Two staff files were inspected on a sample basis. A thorough recruitment procedure could not be demonstrated as the documentation for criminal record disclosures was insufficient and documentation indicated criminal record bureau checks were being transferred from previous employment. Written references had not always been obtained, although records indicated verbal references had been sought. Although there was documentation a verbal reference had been undertaken, it did not record any information only the date it was undertaken. Satisfactory written explanation of gaps in employment were not documented. As a result of the inspection of recruitment practices at the home, the manager was required not to commence the member of staff, due to commence work at the home that night and to obtain current criminal record bureau checks for all staff that had commenced employment without them. Until POVA first checks could be obtained the manager was informed of the requirements in regard to supervision of those staff. DS0000006492.V331559.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): The outcomes for 31, 33 and 38 were inspected. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management and administration of the home was on the whole based on openness and respect, but needs to adopt a more proactive approach in dealing with complaints so that complainants feel that they are listened to. The manager was qualified, but needs to develop her competence in regard to knowledge of the regulations and standards and implement effective quality assurance and supervision systems to ensure these are met. DS0000006492.V331559.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager is a nurse with management experience, however she is not currently registered with the Commission for Social Care Inspection. The owner is aware of this and the manager states she has completed an application but this has not been submitted. Residents’ and their advocates on the whole expressed satisfaction with the service. The manager had implemented questionnaires for staff and residents in regard to the service provided. Although the manager had initialled the questionnaires to confirm she had sent them a report on the outcome of the questionnaires and any action to be taken had not been formulated. Although the owner visits the home frequently reports of his visits as required by the regulations were not sent to the manager or the CSCI. This does not demonstrate a proactive involvement to improve the quality of the service provided by the owner. A valid insurance certificate was in place. Residents were encouraged to maintain control over their own finances unless they did not want to or lacked capacity. One resident was aware the provider dealt with their finances. The manager said personal allowances were paid weekly into the bank account of residents where the provider was responsible for dealing with their finances. Although there was a record of finances that could be inspected, this was insufficient to make a judgement of whether finances were safeguarded as access to actual monies, receipts and bank books could not be achieved as the person that dealt with this was not on duty, even though the manager was. The manager said she checked this information weekly, but to safeguard the monies one member of staff maintained responsibility for dealing with the monies. Residents could however access their monies as the person in charge had access to a float (resident fund) where monies had been raised. When the building was inspected three fire exits were blocked routinely during the day, which would compromise the safety of residents and staff should there be a fire. Fire training and drills were inspected for two members of staff; one had received training and drills, the other hadn’t. Information provided to the CSCI identified servicing of the gas installations, central heating system, fire equipment, portable electrical appliances, hoists and call systems together with confirmation that appropriate repairs/replacements had been completed where necessary. There continued to be no confirmation that the fixed wiring was satisfactory. The manager said the owner dealt with that. There were appropriate measures in place to ensure the security of the premises and prevent intruders. Notifiable incidents were being reported to the CSCI. The water temperature record identified water temperatures were checked on a sample weekly basis. The laundry is located on the lower ground floor down a set of steps. The door was not locked and did not have a notice warning of DS0000006492.V331559.R01.S.doc Version 5.2 Page 23 steps immediately inside the door. This was highlighted as a risk to residents and/or staff at the last inspection, but no action had been identified and/or a risk assessment been put in place. The cleaning cupboard also located on the lower ground floor down a set of stairs was again unlocked on this visit giving access to hazardous substances, which could place residents at risk of harm. Inappropriate moving and handling techniques were observed including residents being moved without footplates, despite in one instance it being documented in the plan of care that footplates were to be used, not applying brakes to wheelchairs when transferring and moving residents using an underarm manoeuvre. This compromises residents being moved in a safe way. Staff had received moving and handling training and were aware inappropriate moves were being carried out, but said “this is what happens here and I don’t know where the moving and handling belts have gone”. The manager said there was moving and handling belts. It was observed and staff confirmed, plastic gloves were used for carrying out personal care tasks unless specific infection control measures for a particular resident was in place, when a more substantial type was provided. Discussions with staff identified they felt this compromised their health and safety as they split when being used and consequently compromised the protection of residents by using inadequate infection control measures. Ants were noted to be crawling in a chair, over a resident and table in the conservatory. At that time it was observed action had been taken by the home. This was discussed with the manager and she was told if they hadn’t gone in three days, professional assistance must be sought. Subsequent to the inspection, the manager confirmed there were now no ants. Outside the premise, the area outside the conservatory was very slippery, which could place residents and staff at risk of falling. Likewise a gate leading to some steep steps was loose and from its hinges, again placing residents at risk of falling should they access the area. DS0000006492.V331559.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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 1 DS0000006492.V331559.R01.S.doc Version 5.2 Page 25 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 OP1 OP16 Regulation 5 Requirement Timescale for action 31/05/07 2. OP7 OP12 15 & 17 3. OP7 12 & 15 4. OP10 12 The service user guide must contain all the details required by the regulation so that prospective people to use the service and their representatives had more information they needed to choose a home, which would meet their needs, including the contract/terms and conditions and the fees to be charged. The care plan must detail how 31/05/07 the social care needs of residents are to be met so that the activities and stimulation provided is what each resident would like to do. Previous timescale of 30.06.06 not met. Include sufficient detail in the 30/06/07 plan of care to ensure staff take appropriate action when providing drinks for residents so that their rights and choices are not compromised. Ensure a more swift response for 31/05/07 residents needing the toilet so their dignity is maintained and they do not become distressed. DS0000006492.V331559.R01.S.doc Version 5.2 Page 26 5. OP10 12 & 23 6. 7. OP15 OP14 OP16 12 22 (3) 22 (8) 8. OP16 17 (2) 9. OP19 23 10. OP19 23 (2) (b) 11. 12. OP19 OP19 23 (2) (d) 23 (2) (o) 13. OP29 OP31 19 All toilet and bathroom areas must have locks that work, so that the privacy of residents is not compromised. Previous timescale of 30/06/06 not met. Implement systems/recruit staff to enable residents to leave the table as they wish. The provider must ensure complaints are fully investigated, including the identified complaint so that complainants can be assured their complaints are listened to, investigated and informed of the action to be taken where necessary. A record of all complaints made by residents, representatives, relatives or staff about the operation of the care home and the action taken as a result of the complaint must be made so that the provider an demonstrate complaints are listened to, investigated and action is taken where necessary. The ceiling on the second floor must be redecorated. Previous timescale of 09/01/06 and 31/08/06 not met. The floor in the bathroom with the assisted hoist must be replaced so that it is a pleasant area for residents to take a bath and the safety of residents is not compromised. Patio furniture must be cleaned so that is suitable for residents to use. Old lounge chairs and wheelchairs must be removed from the outside area so that is a pleasant area for residents to enjoy. The recruitment process must demonstrate a full employment DS0000006492.V331559.R01.S.doc 31/05/07 31/05/07 31/05/07 31/05/07 31/05/07 31/10/07 31/05/07 31/05/07 31/05/07 Page 27 Version 5.2 14. OP29 OP31 19 Schedule 2 19 Schedule 2 19 (11) 15. OP29 OP31 16. OP29 OP31 17. OP29 OP31 19 18. OP29 OP31 19 19. OP31 9 history, together with written explanation of any gaps in employment. Previous timescale of 30/06/06 not met. Two written references must be obtained or a documented reason why these have not been obtained so that suitability for employment can be assessed. A new worker must not commence employment unless a CRB has been applied for and a satisfactory POVA first check obtained. Where a POVA first check is in place and a full CRB check has not been received the worker may commence employment if a member of staff who is appropriately qualified and experienced (“the staff member”) is appointed to supervise the new worker pending receipt of the outstanding CRB. So far as is possible the identified “staff member” must be on duty at the same time as the new worker. Where staff members have been appointed with CRBs from previous employment, current CRBs must be applied for, so that appropriate recruitment checks are obtained in order that so far as is possible residents are protected from risk of harm. Where agency staff are used, documentation must be obtained that verifies the agency has appropriate recruitment checks in place for that member of staff so that so far as is possible residents are protected from risk of harm. The manager of the home must be registered. DS0000006492.V331559.R01.S.doc 31/05/07 03/04/07 03/04/07 06/04/07 03/04/07 31/05/07 Page 28 Version 5.2 20. OP33 26 21. OP33 24 (4) 22. OP35 17 23. OP38 13 (4) 24. OP38 13 (4) 25. OP38 OP28 23 (4) (b) 26. OP38 OP28 OP30 23 (4)(c) Previous timescale of 04/01/05, 09/03/06 and 30/06/06 not met. A written report of the owner’s monthly visit must be completed and forwarded to the Commission for Social Care Inspection (CSCI). Previous timescale of 09/12/05 and 30/06/06 not met. A report must be completed of the outcome of stakeholder involvement in the quality assurance survey so that stakeholders know what measures the provider is taking to improve the quality and delivery of the services in the care home. The financial record must include an audit trail of the payment of personal allowances. Not able to be inspected on this site visit. The home must demonstrate servicing of electrical fixed wiring, so that residents can be assured their safety is not place at risk. Previous timescale of 30/06/06 not met. The cleaning cupboard must be locked when a member of staff is not in the vicinity, so that residents are not placed at risk of harm. Previous timescale of 30/06/06 not met. Fire exits must remain free from obstruction, so that there is an adequate means of escape should there be a fire. Staff must use safe moving and handling techniques when providing care to residents so that their health and safety is not compromised. DS0000006492.V331559.R01.S.doc 31/05/07 31/07/07 30/06/07 31/05/07 31/05/07 03/04/07 31/05/07 Version 5.2 Page 29 27. OP38 13(4) (a) 28. OP38 13 (4) (a) Clean the area outside the 31/05/07 conservatory so that staff and residents are not placed at risk of slipping and injuring themselves. Repair the gate leading down the 31/05/07 set of steps outside so that residents are not at risk of falling should they access the area. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. Refer to Standard OP1 OP16 OP7 OP10 OP10 OP15 OP15 OP15 OP14 OP16 Good Practice Recommendations That the subjective description of the home as ‘five star accommodation’ is removed from the brochure as people have different perceptions of what this might be. That the plan of care is reviewed monthly to ensure the plan is accurate, up to date and being followed. A telephone specifically for the use of residents should be provided, so that respect for privacy for their own actions is maintained. Continence protectors should not be placed on residents’ chairs in order to maintain the dignity of residents. The meal on offer should provide an alternative for residents so that have a choice of what they would like to eat. The menu for the day should be displayed so that residents know what this is. To ask residents whether they would like to listen to music at meal times and what this might be. That each loose leafed complaint sheet in the complaints record is numbered to guard against misrepresentation of complaints. Provide adequate gloves for the provision of personal care so that staffs’ health and safety is not compromised. OP38 DS0000006492.V331559.R01.S.doc Version 5.2 Page 30 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.V331559.R01.S.doc Version 5.2 Page 31 - 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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