Inspection on 06/07/05 for Tithe Farm Nursing Home

This inspection was carried out on 6th July 2005.

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

Tithe Farm Nursing Home 01/12/06

Tithe Farm Nursing Home 06/06/06

Tithe Farm Nursing Home 07/02/06

Tithe Farm Nursing Home 03/02/05

Tithe Farm Nursing Home 31/08/04

Tithe Farm Nursing Home 16/03/04

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Tithe Farm Rest Home Park Road Stoke Poges Bucks SL2 4PJ Lead Inspector Gill Gentles Nicky Cahill Announced 22 June/6 July 2005 09:30 a.m. nd th 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 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. Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 Page 3 SERVICE INFORMATION Name of service Tithe Farm Rest Home Address Park Road, Stoke Poges, Bucks, SL2 4PJ. Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01753 643106 01753 642141 saraogi@btconnect.com Pressbeau Ltd Mrs Pushpalata Saraogi, Dr Krishna Kumar Saraogi Care Home 35 Category(ies) of Dementia (6), Old age, not falling within any registration, with number other category (35) of places Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 03 February 2005 Brief Description of the Service: Tithe farm is a home for older people with Nursing needs. The home is owned by Pressbeau Ltd who have a number of homes across the south of the country. Tithe farm is situated in large grounds next to the golf course in Stoke Poges. Access to the home is via a long drive leading up to the front of the home into a small car parking area. Pressbeau Limited also have their main offices in the grounds, close to the main house. There appeared to be an infrequent bus service to the vicinity of the home. Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days, of which only one day was planned. During the visit on June 22nd 05 it was noted that there were some major issues relating to the recruitment practices in the home, which resulted in an enforcement notice being issued. The outcome was that there were a number of staff in the home without Criminal Record Checks and POVA first clearances, which meant that the manager needed to amend the rota to ensure that the service users were safe from potential harm. Due to the enormous task of covering the rota and assessing all the recruitment files it was decided to defer the inspection till the 6th July 05, leaving the manager ample space and time to solve her dilemma. The second day took place as planned with Marlene Lewis the Matron/Deputy Manager, as the manager was on annual leave. The matron was very capable and had a clear understanding of the Commission and the role of the inspectors visiting the home. Throughout the visit, records were viewed, service users, relatives and staff were spoken to and a tour of the building took place. What the service does well: Provide sufficient, adequate and appropriate information for prospective service users. Provide specialist equipment, in particular in relation to preventing pressure sores. Respect privacy and dignity of Service Users. Ensure all service users are offered, and receive a varied and appealing meal. Have a clear and concise complaints procedure. Maintain a safe, comfortable, homely environment. The home is financially viable for the forthcoming years. Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Care plans, ensuring social and emotional needs are incorporated as well as health. Increase nurses on the shift during the day hours. Improve and maintain a robust recruitment practice. Record health appointments, such as opticians, dentist etc. Ensure staff are trained in the Protection of Vulnerable Adults, all mandatory courses, and NVQ’s. Ensure service users are consulted and involved in the quality assurance audits. Ensure all service users personal information is safely secured in compliance with the data protection act 1998. Forward copies to the Commission of Regulation 37 and Regulation 26 reports. Produce generic risk assessments, for Service Users, Staff and Visitors to the home. Please contact the provider for advice of actions taken in response to this Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 2 3 There is sufficient information relating to the home, to ensure that prospective Service Users are able to make an informed choice about where they live. A comprehensive pre-admission assessment is utilised to ensure that the home can meet individual Service Users needs. Contracts, signed and dated are in place, ensuring Service Users and their representatives understand the terms and conditions of living in the home. EVIDENCE: The manager and Deputy recently reviewed and produced a comprehensive Statement of Purpose and Service Users guide with copies now being held by the commission. The manager is reminded that she must date the documents and review them annually. Both documents comply with Standard One and Schedule 1 of the National Minimum Standards and Care Home Regulations Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 Page 10 2001. The manager is advised to include a more detailed account of the nursing and care staff’s qualifications. It was noted, that all new service users have received either a Care Service Order from social services or a contract from the home for private Service Users. It was noted that the home has a pre-admission assessment in place, which is utilised when assessing all prospective service users. A number of preadmission assessments were viewed during the course of the inspection and one out of the four seen was found to contain limited information pertinent to that Service User. The assessment was not dated when carried out. The home has an adequate pre-admission assessment form,which when completed in detail, proves to be an essential tool for ensuring all service user needs are identified and transferred to their care plans appropriately. The home also has a nursing admission record in situ, those viewed were found to be appropriately detailed. Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 8 9 Care plans were found to be limited in information and medically biased. Therefore, Service Users personal and social needs were not being met. Healthcare records were limited to those relating to Service Users seeing a General Practitioner, therefore there was no evidence to meeting other healthcare needs. The home has improved, and now maintains good practice for the receipt, recording, storage, handling, administration and disposal of medicines, which ensures that Service Users are safeguarded from harm. EVIDENCE: A number of care plans were seen during the course of the inspection it was noted that all care plans were heavily medically biased, with little or no written information regarding service users, social and emotional needs. One care plan perused clearly identified 10 needs, which included mobility, continence, constipation, pressure areas and mental cognition. Information relating to Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 Page 12 mobility was clearly written and reviewed in June and July with new comments added. One care plan was found to have a very descriptive profile of a service user. However, the information was found at the back of the care plan and written by the previous home. A number of records were found to be missing or not recorded. These included seeing specialists such as opticians and dentist. There was little or no mention of how to meet individual social needs, no signature of service users to evidence involvement in planning their care, and no current risk assessments available. Discussion took place with the matron of the home regarding the content of the current care plans. It was clear that the matron understood the need to develop the care plans further by incorporating all the needs of individuals and not just the nursing requirements. This was also fed back to the owners during the feedback meeting at the end of the day two. It was noted that the home has made some improvement in relation to the care plans since the previous unannounced inspection. One care plan, seen exhibited shocking photographs of pressure sores, these had not developed in the home but in hospital. The home had ensured that all appropriate equipment was in place, and that advice had been sought from the tissue viability nurse, who visited the home between the two inspection days, giving the nurses advice, support and direction. The home uses the waterlow scoring, to ascertain the risk factor of each individual service user and issues the appropriate apparatus to prevent pressure sores. Nutritional screening is undertaken prior to admission, and periodically following admission. All service users are registered with a GP in the local area, one GP visits the home regularly at least once a week. It was difficult to ascertain how often service users accessed the dentist, chiropody, opticians and hearing tests, as there was nothing recorded in the care plans. The home has a clinical room designated to the storage of all medication, which is kept locked at all times. Entrance to this room is accessed, using a key code and number. There is a medication trolley locked and chained to the wall, along with a number of wall cupboards, which are also locked. The home has an adequate and appropriate policy and procedure for the safe handling, administration and disposal of medicines. The nurses are responsible for administering all medication to service users. Records are maintained on all medication that is received into the home and administered to service Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 Page 13 users. The home also follows a clear procedure for the disposal of medication and records this appropriately. There is also a clear procedure for “managing a drug error”, which was last updated in December 03. The manager needs to include within this procedure that drug errors are notifiable to the Commission for Social Care Inspection under Regulation 37. Medication Administration Records (M. A, R) were found to be appropriately completed. No errors were observed. The home maintains controlled drugs cupboard and records were inspected and found to correspond to the amount of medication held in the home. GP consent for homely remedies was found to be in place in individual care plan, along with GP notes. It was noted, however, that there were a number of homely remedies in the cabinets not labelled appropriately. It appeared the Service Users, privacy and dignity were respected most of the time. Personal care, nursing care, bathing, washing and toileting were carried out in private. However, during the course of the inspection, a Parkinson nurse came to see a service user and her husband. They were treated with respect, and people were polite to them, however it was not suggested that an area be used which offered them greater privacy. Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 Greater emphasis has been placed on making daily living and activities flexible and varied to reflect individual service users needs. Existing relationships are encouraged and supported with family and friends, and facilities are being explored in the local community, which will enable Service Users to maintain contacts, meet people and experience new activities. Service Users receive a varied, wholesome and nutritious diet, ensuring that individual tastes and needs are catered for. EVIDENCE: During this inspection, it was noted that greater emphasis had been placed on making daily living and activities flexible and varied to suit a service users preferences. There was a programme of events displayed in the main reception of the home for the months of June and July clearly identifying gentle exercise with the carers, board games, a hand massage, old time music, indoor skittles, reminiscence with carers, walk in the garden, quizzes, arts and crafts and “activities with Fiona” who visits the home twice a week. Fiona works at Wexham Park hospital and has been working with service users, one-to-one to get to know individuals and to find out what their needs are in relation to interests, hobbies and activities. Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 Page 15 The deputy manager/matron recently arranged for Bell ringers from her village church to visit the home to entertain service users, which was warmly received. The deputy manager, informed the inspectors that she is exploring facilities within the local community of Stoke Poges, Farnham Royal, Farnham, and Farnham Common. The plan is to try and encourage service users to visit these villages and take part in activities that may be occurring. The downside to this at the time of the inspection was that the home does not have its own transport, alternatives are being sought. The chef in the home stated that he is given appropriate information relating to service users, in particular their likes and dislikes regarding food. Alternative meals are available, and choices given to service user if they do not like the main meal available. Service users are encouraged to eat their meals in the dining room; however, service users are welcome to eat in their rooms, if they wish. During the twoday inspection service users were observed as being served their meals in their bedrooms. The home also caters for partners that visit during mealtimes. The home has set mealtimes. However, these are approximate, as, as it depends on individual needs. The home tries to meet religious and spiritual needs by arranging for the local clergymen to visit as and when required. The visitors book identified that the Reverend from St Giles Church visited in February. It was nice to observe, during the course of the inspection a large number of visitors in the home. This is a major improvement on previous inspections. Visitors spoken with confirmed that they were welcomed into the home by all the staff and encouraged to join in with whatever was occurring in the home, such as activities, meals etc. The deputy manager confirmed that the home had an open house policy for visiting, as long as the staff were made aware of who was due to visit they would be welcomed at any time within that 24-hour period. Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 There is clear and concise complaints procedure accessible to all service users and families, which ensures that Service Users complaints are taken seriously and concerns listened to. There is a policy in place in relation to the protection of vulnerable adults; very few staff have received training in this area, potentially putting Service Users at risk from abuse. EVIDENCE: The home has a clear and concise complaints policy and procedure. Information about how to make a complaint, who to make a complaint to, and the response times from the home is available in the Service User’s guide. The complaints file in the home identified that no complaint had been received since the previous inspection. No complaints had been received by the Commission for Social Care inspection directly relating to the home. The home has a policy in place in relation to the Protection of Vulnerable Adults. It was apparent that although there is policy in place, staff have not received any training. An immediate requirement was issued to ensure that all staff receive training in the Protection of Vulnerable Adults in line with Buckinghamshire’s interagency policy and procedure. A tight timeframe was issued as this was a repeat requirement. Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25, 26. The location and layout of the home is suitable for its stated purpose. There are safe and comfortable indoor and outdoor communal facilities. Specialist equipment is installed in all communal areas and bedrooms, there is adequate heating and lighting and appropriate fixtures and furnishings, which ensures that Service Users live in a comfortable and well maintained, homely environment. EVIDENCE: Tithe farm is located on the outskirts of Stoke Poges next to the golf course. The home is situated in large and well maintained grounds. There is a long drive leading up to the main house and parking area. Within the grounds, there is a separate, smaller building, which is utilised as the companys head office. The home is a listed building, with many of its original features maintained. There is a program of routine maintenance and decoration in place, the Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 Page 18 manager and the owners confirmed that a new kitchen would be installed within six to eight weeks of the inspection. Records indicate that the building complies with the requirements of the local fire service and the environmental health departments. The home offers two lounges and a dining room, four bathrooms or shower rooms, seven toilets, 23 single bedrooms, six double bedrooms and six bedrooms with en-suite. There are no rooms identified as visitor’s rooms, however, when the dining room is empty, it can be used for privacy, or service users can take visitors to their bedrooms. Lighting in all communal rooms is domestic in character and positioned appropriately. Gas central heating is installed, and all radiators are covered to protect Service Users from harm. Toilet and bathing facilities all appeared to meet the needs of service users. There are two sluice rooms available, one on each floor. The home provides grab rails and other aids in all rooms that are accessible by Service Users to aid mobility. All Service Users have had call systems installed in their bedrooms. The home provides accommodation for each Service User, which meets the minimum space requirements for pre-existing care homes. Where rooms are shared, privacy curtains are fitted. The home provides accommodation to each service user, which is furnished and equipped to ensure comfort and privacy, by ensuring that there is a bed, bed linen, curtains, a mirror, adequate lighting, seating, space for hanging clothes, a bedside table and wash hand basin. All rooms have appropriate floor covering. The premises were found to be clean and free from offensive odours in most areas of the home. However, slight odours were detected in a couple of bedrooms. Laundry facilities are sited across the courtyard from the main house and soiled linen does not get carried through areas where food is stored or prepared. The laundry was purpose-built in what used to be the old garage, prior to the home becoming a nursing home. The home now employs a person to work in the laundry, whereas previously care staff had been carrying out a dual role. Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30, There are insufficient nurses, on each shift, to ensure that Service Users medical needs are being met as and when required. There is a poor record of NVQ qualification training, which may mean that Service Users are not in safe hands. There were poor and inadequate recruitment practices in place, which meant that the home was placing Service Users at risk from abuse. Improvements have been made in relation to staff receiving mandatory training, shortfalls were still identified, which questioned whether Service Users are being looked after by competent staff. EVIDENCE: During the inspection, it became evident that there were not enough qualified staff on duty. The rota showed that one nurse is rostered on to care for 29 Service User’s nursing needs. It was discussed with the deputy and the owners that there was a need to increase the nursing staff on the morning and evening shifts from one to two, this is a requirement. The rota indicated that there were ample care staff to meet service users needs. The home employs one nurse and two carers to cover the night time duties. The home does not employ anybody under the age of 18 years old, and each person left in charge of the home is over 21 years old. Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 Page 20 At previous inspections, it was felt that the home did not have enough domestic staff to maintain a high standard of cleanliness in the home, when areas were found to be thick with dust. It was noted during this inspection that the home appeared cleaner then at previous inspections leading to believe that the home now employees sufficient numbers of domestic staff. The home appears to have a poor record of NVQ Training, having only two members of staff NVQ qualified and the manager is reminded that they must achieve a 50 of the care staff having reached NVQ level 2 by the end of 2005. As previously stated, the first day of inspection resulted in an enforcement notice being issued to the home in relation to poor and inadequate recruitment practices. Criminal Record Bureau and POVA First checks had not been carried out on four overseas employees. Since the previous inspections, there have been some major improvements noted in the training of staff. However, there are still a number of shortfalls. An immediate requirement was issued on the second day of the inspection, reminding the deputy and manager that all staff must be trained in the mandatory areas such as Fire Safety, First Aid, Infection Control, Basic Food Hygiene and Manual Handling. The training file confirmed that Staff had been receiving some training in the ease identified areas. However, most were in-house training, and not by external trainers. Certificates were issued to each member of staff confirming their attendance. A reminder was given to the matron that some of the training needs to be carried out by external trainers and refreshed annually or three yearly. Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, 36, 37, 38 Improvements have been made in ensuring that the home has a manager in situ. However, she has not been registered with the Commission. Quality assurance audits are being carried out quarterly, however, it was not clear as to whether service users were being directly asked their views, which would ensure that the home is run in their best interests. The manager and matron have recently implemented formal one-to-one supervision on a regular basis for all staff, therefore, Service Users will benefit from receiving care from confident, supported staff. Records stored in the home were found to be accessible to all visitors, potentially putting service users at risk by affording access to personal data. There are major shortfalls in relation to the Health, Safety and Welfare of Service Users, Staff and visitors in the home, potentially putting service users at risk from harm, with unsafe working practices being carried out. Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 Page 22 EVIDENCE: The manager in charge at Tithe Farm has been in post since November 04. During this time it has not been possible to register Alexandra Radford with the Commission for Social Care Inspection. The main reason for Alexandra not being registered is due to the delay in the Commission receiving the manager’s application. This is now being processed. The home had records of a quality assurance audit having being carried out. This was dated August 04. It was unclear who received a quality assurance questionnaire, and when. The organisation is reminded that feedback should be actively sought from Service Users, friends, family and any other stakeholders in the community such as doctors. The commission for social care inspection has not been receiving reports in relation to monthly unannounced, Regulation 26 visits to the home. This is the second inspection at which the owners have been reminded to produce these documents; further failure to comply may result in the commission seeking legal advice and considering enforcement. Upon request, the owners produced financial statements for Pressbeau Limited year end June at 2004, which incorporates Tithe Farm. Copies are held with CSCI. Insurance certificates were displayed in the home and are valid until March, 2006. The manager and the matron of the home have recently improved supervision arrangements for all employees. It was noted that all staff are beginning to receive formal one-to-one supervision, records were seen confirming this. Annual appraisals take place, covering topics such as, communication skills, caring skills general abilities, reliability, general knowledge of health and safety etc management skills, strengths and weaknesses. Records required by regulation the protection of service users are maintained within the home. Service Users are able to access these records as and when required. It was observed that these records are stored in the staff office or the managers office and throughout the two days of inspection, these rooms were not locked. Visitors entering the home could gain access to documents such as care plans. All documentation must be stored in accordance with the Data Protection Act 1998. As previously stated in standard 30, there are a number of shortfalls in the mandatory training area, which means that the Health and Safety of the Service Users could be compromised. The manager ensures that there is safe storage of hazardous substances in place. Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 Page 23 Regular servicing of boilers and central heating systems, electrical systems and electrical equipment are carried out annually. Water chlorination tests are carried out annually to eliminate the risk of Legionella. Thermostatic valves are fitted to all hot water outlets and first-floor windows are installed with window restrictors to ensure the Safety of Service Users. Checks in relation to the fire detection are carried out adequately and recorded appropriately. Hoists and the stair lift are serviced twice yearly and certificates were seen. Accident and incident records identified a number recorded some with injuries such as a bang to the head and bruising around the eye, the home needs to carry out an audit to analyse how often individual service users have an accident receiving injury. Regulation 37 reports are only being received by the Commission in relation to death. The manager is reminded to inform the Commission of any incident that affects the well-being or safety of any Service User. The home has outdated generic risk assessments, which were dated the 27th of November 2002. The home’s health and safety policy was dated 2003, these will need reviewing and amending in the light of the home changing from a care home to a nursing home. Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x 2 3 x 3 2 2 Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 Page 25 YES Are there any outstanding requirements from the last inspection? 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 7 Regulation 15 Requirement To ensure that all care plans are written with the service user or a representative and encompassess their whole life not just medical To increase the numbers of nursing staff from one per day time shift to two excluding the manager. Instigate a thorough robust recruitment procedure,complying with all Regulations. Ensure ALL staff receive training in Adult Abuse Awareness, Fire Safety, First Aid, Manual Handling, Infection Control and Food Hygiene and commence NVQ training. To carry out Service User led Quality Audits and involving other stakeholders such as GP etc. Ensure that all Service Users data is stored in compliance with the Data Protection act 1998 Regualtion 26 reports must be forwarded to the CSCI area office monthly. Failure to comply could result in an enforement notice being issued. To Ensure Regulation 37 reports Timescale for action 30.11.05 2. 27 18(1)(a) 15.9.05 3. 4. 29 30 19(1)(a) schedules 2 and 4 18(1)(c) 24.6.05 1.12.05 5. 33 24 31.12.05 6. 7. 37 33 17(1)(b) 26(3)(5) (a) 15.9.05 30.9.05 8. 38 37 30.9.05 Page 26 Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 9. 38 are sent to the CSCI office for all welfare issues not just death. 13(4)(a-c) Produce generic risk asessments for the internal and external areas of the building for all service users, staff and visitors. 15.11.05 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 1 Good Practice Recommendations It is recommended that the manager incorporate a more detailed account of staff qualifications and experiences within the Statement of Purpose. Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 Page 27 Commission for Social Care Inspection Cambridge House, 8 Bell Business Park, Smeaton Close, Aylesbury, Bucks, HP19 8JR National Enquiry Line: 0845 015 0120 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 Tithe Farm Rest Home 220605_Tithe Farm_AI_Stage 4_S23030_V226502_H53_GG-PS_ces.DOC Version 1.30 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!