Inspection on 02/10/07 for TNP House

This inspection was carried out on 2nd October 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

TNP House 09/09/08

TNP House 06/12/05

TNP House 04/07/05

TNP House 25/10/04

TNP House 24/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE TNP House 15 Comberford Road Tamworth Staffordshire B79 8PB Lead Inspector Sue Jordan Key Unannounced Inspection 2nd October 2007 10:00 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 TNP House DS0000005029.V352255.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. TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service TNP House Address 15 Comberford Road Tamworth Staffordshire B79 8PB 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) 01827 316177 01827 68857 TNP Homecare (UK) Limited Janine Owen Care Home 12 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (12), of places Physical disability over 65 years of age (7) TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th September 2006 Brief Description of the Service: TNP is a family run residential care home registered for 12 service users over the age of 65, 5 of whom may have dementia care needs and 7 may have physical disabilities. The Home is set in a large detached house with an extension at the rear. The property is located in a pleasant area of Tamworth and has a rear garden, which is presently being improved. There is adequate car parking space at the front of the Home. The Home has two lounges and a separate dining room, although some of the service users choose to eat and sit in their bedrooms. The Home provides accommodation in six single bedrooms and three shared bedrooms. Ensuite facilities are provided in five of the single rooms and in one of the shared rooms. There is a lift to the first floor. The home provides two assisted baths and has sufficient toilet facilities. The Home is owned and managed by Janine Owen who is supported by a team of twelve staff, many of whom have worked at the Home for a long time. The fees range from £377- £420 per week. The people using the service need to pay extra for chiropody, hairdressing, toiletries, alcohol, newspapers and luxury items such as sweets and chocolates. A small charge is made for transport costs and the hourly staff costs if they accompany a resident on visits, including hospital visits. The manager has been asked to be more specific about the transport charges and staff costs. TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a total of six hour and a half hours. This was a ‘key inspection’ and the core standards were assessed. The methodologies used were: A day of pre-inspection preparation, including scrutiny of the Commission for Social Care Inspection Annual Quality Assurance Assessment completed and returned by the manager, and of the eight questionnaires completed by staff and five completed by residents and/or their relatives. During the visit, a number of residents were chatted to and informal discussions were held with three of the staff on duty. Two residents, two visiting relatives and a District Nurse were also interviewed. Discussion and feedback was held with the manager The medication systems were examined and a tour of the environment undertaken. Three residents’ care records were checked and the recruitment records of three new staff member employed since the last inspection. Fire safety and some maintenance records were checked. A random inspection took place on 29/01/07 to check the progress made to meet requirements made at the last Key Inspection on 18/09/07. What the service does well: The manager does not admit anyone into the Home unless his or her needs have been assessed. In the case of Local Authority referrals people are assessed by social workers and copies received before agreeing admission. A member of the management team also undertakes an assessment of any potential resident. The residents and/or their families say that the manager gave them enough information about the Home to enable them to make an informed choice as to whether they wanted to live there. The residents have access to a range of medical professionals to maintain their health and wellbeing. TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 6 Families and visitors are made welcome and the Home is praised for having a flexible approach. All of the people involved in this inspection were positive about the manager and the staff and their caring attitudes to the residents. Many of the staff have worked at the Home for many years providing consistency. The residents surveyed and spoken to during this visit confirmed that they enjoyed the food. The atmosphere in the Home is relaxed and the residents say that they find the staff and manager approachable. There have been no complaints about the Home. What has improved since the last inspection? What they could do better: It is recommended that some information in the care plans be expanded, especially where there is an element of risk in order that the staff know exactly how to care for the people using the service safely. Recruitment procedures are poor and do not safe guard the people using the service. Staff must not start work until a Protection of Vulnerable Adults check is complete and the results received. The management must obtain all the required information about the prospective staff member. TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 7 Medication coming into the Home must be recorded to ensure an audit trail of drugs at all times. The manager needs to periodically assess the staffs continuing competency to administer medication. Staff do receive supervision, although this now needs to be formalised and evidenced. The manager should explore how the Quality Assurance system could be improved to involve the views of more people involved in the service, for example staff and professionals. The results of any surveys should be available to interested parties. The staff say that they receive adequate training although this is hard to confirm with the available records. The manager needs to evidence that staff have received mandatory training at the required frequencies. The manager and staff should continue to explore how they can offer more activities and stimulus to the people using the service, including those with dementia care needs. The infection control procedures in the Home should be improved to ensure that suitable arrangements are in place to prevent infection. A fire risk assessment must be completed and the evacuation plan must be finished to ensure that all staff know what to do in an emergency. Control of Substances Hazardous to Health products must be safely locked away. 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. TNP House DS0000005029.V352255.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 TNP House DS0000005029.V352255.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): 1, 2, 3, (6 is not applicable). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are assessed before they move into the home affording them confidence that the Home can meet their needs. The residents are given relevant information in a standard format. EVIDENCE: TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 10 Each person using the service is given an admissions pack, which contains the terms and conditions of the Home, complaints procedure, clients’ rights, inventory and key contract terms. It wasn’t clear from this inspection whether they are all given a copy of the Home’s Statement of Purpose and Service Users Guide, although the surveys received by the people using the service indicated that they had had enough information before moving into the Home. Comments from relatives included: “Whilst looking for a suitable home for my relative, I looked at 8-10 different homes. TNP House ticked all the boxes and I am very happy with the service my relative receives and she really loves it where she is”. The Service Users Guide was examined and the information about fees is out of date. There is no date on the Statement of Purpose and it is available in a standard format only. These documents should be kept under review and amended as required. Therefore it is recommended that they be dated as evidence of such. Four out of five people completing a survey said that they had received a contract. The manager was able to evidence that she receives a Local Authority contract for referrals from Social Services and that she produces a Home’s contract for people paying privately. Information is provided to prospective residents and/or their families about the fees and any extras they may have to pay for. It was noted that the residents are informed that they will be charged for the cost of transport and the staff hourly rates when they are accompanied out of TNP House, for example for hospital appointments. However, people also need to be informed what these charges are. In total three sets of residents records were checked during this inspection. All contained an assessment completed by the manager and care plans and assessments had been received from the Local Authority, if applicable. TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 11 TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is evidence in the Care Plan of health care treatment and intervention, and a record of general health care information. There are some gaps in information but staff are able to think in a person centred way and are able to give a verbal update. Health needs are monitored and appropriate action and intervention taken. Medication systems do not always follow good practice or safe practice guidelines and has needed action, the manager has made some improvements although minor enhancements are required. EVIDENCE: Three sets of care records were checked during this inspection. They contain TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 13 basic information as to how the residents’ needs are to be met and it was recommended that they be expanded to include the actual assistance required by staff. The care plans are being reviewed monthly. Risk assessments are now being undertaken and these include mobility, falls and nutrition. However it was noted that one resident had had 8 falls since moving into the Home in August 2007 and on checking the individual records there was no separate mobility assessment and information about mobility was brief. The manager was able to explain the support given to this resident and that this issue had been discussed at the six weekly review, but staff need more written information about the risks and how to avoid them. Five out of the five surveys completed by residents and/or their relatives state that the service users always get the care & support they need, including medical support. Comments included: “There is a mixed clientele in TNP House, but I think that the service is very high”. “My relative always looks well groomed and dressed and eats well”. A visiting district nurse praised the care provided at the Home and said that the staff monitor the health of the residents and take appropriate action, this was also confirmed in discussions with two visiting relatives. She also said that the staff follow any instructions given by the district nurses and respect the residents’ privacy. This was confirmed in observations of non-personal care tasks throughout this visit. Both relatives spoken to during this visit praised the staff and their care of the residents. Comments included: “They are absolutely brilliant, they treat the residents with respect and love”. “The staff are very ‘hands-on’ and they know everybody”. “I am always informed of any changes straight away”. “By being one of the smaller service providers I feel that it provides the service user with a friendly and homely environment and personal care”. The care records show examples of where the staff have sought medical help and intervention for the residents when they are ill. The residents have had support from community psychiatric nurses, general practitioners, chiropodists, dentists, district nurses and opticians. The residents are weighed regularly. TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 14 The medication systems in the Home were checked and although administration was not observed, the senior care worker explained the procedures used. The Home has secured the medication trolley to the wall, however as a result the staff are not able to take it with them when administering and are having to secondary dispense medication. This needs to be addressed. There were a few gaps in the medication administration records and although it was noted that these were mainly for painkillers, this also needs to be addressed. Staff administering medication have received training, but the manager needs to periodically check their on-going competency. It was suggested that this could be cross-referenced to the Home’s medication policy and used as a supervision session. Records are kept of any medication returned to the pharmacist, but not of the medication received into the Home. It was recommended that this be done on the actual medication administration records, as there is space for this information. This will ensure that there is always an audit trail of medication in the Home. The medication administration sheets now have more information about how medication is administered and ‘as directed’ instructions were not seen. At the time of this visit there were no controlled drugs in the Home, but the senior care worker said that the facilities are available if required. Some of the residents share a bedroom and the manager is able to demonstrate that this is based on choice. She has recently provided more permanent screening in two of the shared rooms to further respect the occupants’ privacy. It was noted that there is only one wash hand basin in the shared rooms and the manager should consider supplying each person with their own. TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home is flexible, welcomes visitors and provides a good healthy diet, however some people feel that there are not enough activities and stimulus for the residents, especially for those with more complex needs. EVIDENCE: There is a friendly, family style atmosphere in the Home and the staff were observed chatting and laughing with the residents as they go about their work. The staff and residents were asked in surveys whether the Home provided enough activities. Two out of five residents and/or relatives said that there are always activities that the service users can enjoy, one said usually and two sometimes. They did however make comments about the welcoming atmosphere, which included: “I take my relative out for day trips or family celebrations. She may have to have breakfast early or arrive back late in the evening. They are always very accommodating”. TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 16 “I can call in anytime of the day or phone to talk to my relative. They always make you welcome and never say that it isn’t convenient. I can stay 10 minutes or 3 hours, nothing is too much trouble”. The staff also referred to activities within their surveys and their comments included: “I think that TNP is a good, pleasant and friendly home for the residents to live in and welcomes friends and families, like they’re still at home”. “It could probably involve more days out as the residents seem to get bored and frustrated”. “The weather has not permitted outdoor activities”. “More activities are needed for the residents to do”. The cook explained that she usually spends at least two afternoons a week doing some activities with the residents and examples were floor games, large playing cards and bingo. The manager said that they have recently bought some new games and equipment. There is some doubt as to whether enough stimuli is provided for the people less able to participate and relatives’ comments included: “My relative is unable to take part but in her own way enjoys the atmosphere if there is something going on”. “Due to my relative’s condition it is difficult for her to take part”. The manager and staff need to further explore how they can provide more regular activities and stimulus for all of the residents. The Home has its own mini bus, but there have only been a few outings into the community. All five people completing the surveys said that they always enjoy the food. The cook explained that she and a colleague plan the meals between them to ensure that the meals are varied. All meals are homemade with a plentiful supply of fresh produce. The manager said that the environmental health officer had not made any requirements at his last visit. The training records seen evidenced that four staff have current food and hygiene certificates. In a home this size all staff will have some involvement in food preparation and need the appropriate training. The Home caters for people with diabetes and those who require a soft diet. People who require assistance are helped with respect and sensitivity. People are able to choose where they eat their meals, including their own rooms. The TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 17 staff are aware of the residents’ likes and dislikes and their preferred portion sizes. The routines in the Home are flexible and people can spend time alone or with other residents. One resident said that she can ‘do what she wants’. A relative said that her Mother can ‘still please herself’ and that the Home is very adaptable. TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents are enabled to express their concerns and feel safe. EVIDENCE: All of the five residents and/or relatives completing surveys said that they knew who to speak to if they were unhappy, four said that they knew how to make a complaint and one said that they did not. Comments included: “Only had one incident where I was concerned, but this was sorted straight away with discretion and professionalism”. This was confirmed during the inspection. Two residents were asked whether they knew how to complain and who to speak to and both confirmed that they did. However both wanted to stress that they had not had the need to make a complaint. The two relatives interviewed reiterated this. The Commission for Social Care Inspection has not received any complaints about the service and the manager confirmed that she also had not. TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 19 Eight staff completed surveys and all said that they knew what to do if a resident or relative had concerns about the service. The staff learn about adult abuse, how to recognise and respond to it when completing their National Vocational Qualifications. The manager said that the staff have also received ‘in-house’ training, although this was not seen within the training records. The two staff interviewed during this inspection confirmed that they understood the principals of adult protection. The Home has not had to make any referrals to the Safe Guarding Adults team. The Home’s recruitment procedures must be more thorough to fully safeguard the residents. TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally clean, tidy and warm and improvements are continually being carried out. The Home needs to continue addressing the Health and Safety requirements, including fire safety to ensure that the residents live in a safe environment. EVIDENCE: Work has been carried out to improve the environment and meet the requirements made at previous inspections: The carpets have been replaced in the lounge and dining room. The leaking roof has been repaired. Signs and symbols have been put onto doors to help people with dementia orientate themselves. TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 21 There are plans to fit a shower in the upstairs bathroom and fit bedroom doors with privacy locks, which comply with fire safety. The fire officer visited on 09/03/07 and left a number of requirements. These are gradually being addressed. A tour of the environment was taken during this inspection. Generally the Home is clean and comfortable and the manager was able to demonstrate that she has continuing plans to redecorate and refurbish the Home as required. More permanent screening has been placed in two of the shared bedrooms, although consideration should be given to providing a hand washbasin for each occupant. A new nurse call system is being fitted in some areas of the Home, although the manager said that she is gradually providing them, because of the cost. This needs to be done as soon as possible to maintain the safety of the residents and enable them to call for help when needed. The manager needs to check the infection control procedures in the Home. For example, in communal areas, liquid soap and paper towels should be available for hand washing and personal toiletries, flannels and towels should be kept in the residents’ own bedrooms. The manager has recently received training in this area, which she now needs to transfer to the Home’s procedures. All of the five residents and/or relatives completing a survey said that the Home is always fresh and clean. TNP House is a large detached property with an extension at the rear. There is a rear garden, which is presently being improved to provide an even patio and seating area. There is adequate car parking space at the front of the home. The home has two lounges, a separate dining room, six single and three shared bedrooms. En-suite facilities are provided in five of the single rooms and in one of the shared rooms. The home has a lift to the first floor. The home provides two assisted baths and has sufficient toilet facilities. TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staff team is responsive to the needs of the residents and there is a core of experienced, consistent and highly regarded employees. Staff recruitment must be improved to ensure that the residents are fully safeguarded. More evidence is needed that the staff receive the training required to support and protect the residents. EVIDENCE: Four out of the five residents and/or their relatives completing the surveys say that the staff are always available when needed, one says they usually are. The rotas indicate that there are two care staff on duty at all times, including through the night. A cook and domestic also work daily. These staff support a maximum of twelve residents. The self assessment document completed and returned to the Commission for Social Care Inspection by the manager prior to the inspection indicates that eight of the eleven care staff have National Vocational Qualification 2 or above. TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 23 Three members of staff were spoken to at length during this inspection and they were able to give details of numerous training courses attended, including manual handling, first aid, food and hygiene, adult protection, dementia, infection control and medication. Two of them had achieved National Vocational Qualification level 3. A staff survey contained the following comment: “Janine ensures all our training is up to date. She enrols us on courses for specific illnesses, e.g. dementia, pressure sores etc. This enables me to give better care to the residents”. The training records and certificates seen during this inspection did not provide evidence that the staff receive mandatory training at the required frequencies. The manager has thought about developing a matrix for monitoring and evidencing staff training and this is highly recommended. The residents and relatives speak highly of the staff working at TNP House, many of who have worked there for many years. Comments included: “The staff are smashing, couldn’t get a better place”. “The staff are wonderful, it doesn’t matter what you ask them for”. All five residents completing the surveys say that the staff always listen and act on what they say. Three staff have been employed since the last Key Inspection and their recruitment files were checked during this visit. All had completed an application form, although they had not completed a health declaration. The application form implied that employed staff would be asked to complete a health declaration, but they were not present in the files. Two references had been obtained for two members of staff, but there were none for the third. Proof of identity had not been obtained for one staff member. There was no evidence of Protection of Vulnerable Adults and Criminal Records Bureau checks for one member of staff and the checks had been completed some time after the other two started work in the Home. The manager must follow Protection of Vulnerable Adults, Criminal Records Bureau and Care Homes Regulations and legislation. Staff must not work in the Home until the results of a Protection of Vulnerable Adults check have been obtained. They can start work once this is obtained and whilst waiting for the results of the Criminal Records Bureau disclosure. The present recruitment TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 24 procedures do not indicate that prospective staff are thoroughly vetted and therefore do not fully safe guard the residents. The staff speak positively about their work at TNP House and comments included: “I enjoy working here, the staff are friendly and the residents well cared for”. TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect. This needs to be supported by better written evidence and recording. The Home needs to continue the work to meet Health and Safety requirements, including fire safety. EVIDENCE: The manager, Janine Owen, has the Registered Managers Award and National Vocational Qualification 4. She is considered to be very approachable by the staff and the residents and their families. TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 26 A staff member commented: “Janine is approachable when you have concerns either about work or a resident”. The manager has a basic Quality Assurance system in place. She works with the staff, residents and relatives to ensure that all are happy with the service and addresses any concerns they may have. Questionnaires were sent to the residents and/or their relatives in February 2007, although the results were not evaluated or available to interested parties. It was suggested that she also send surveys to staff and external people involved in the Home. The manager holds limited amounts of residents’ monies and in most cases she invoices relatives for any costs incurred. Discussions with the staff, manager and reading of staff surveys indicate that although the manager is very approachable there are no formalised supervision systems in place. Two staff said, within the completed surveys that they need more 1:1’s. The staff should attend a mixture of individual and team meetings. Since the last inspection an electrical installation check has been completed as required. The fire officer visited TNP House in April 2007 and made a number of requirements. The manager is gradually working through them. Those areas still to be fully completed include a fire risk assessment and evacuation plan. A carpenter has made sure that all fire doors fit properly although the Home still needs to find a suitable locking system for the front door. The airing cupboard is to be removed from the upstairs bathroom and a shower installed. The senior care worker has been trained as a Fire Marshall and is looking to access external fire training for staff. The fire records indicate that the fire safety systems are checked regularly and there are regular fire drills. Control of Substances Hazardous to Health items need to be locked away and personal toiletries should be kept in personal bedrooms. The manager has been asked to examine the Home’s infection control procedures and to evidence that the staff are completing mandatory Health and Safety training at the required frequencies. Reports of accidents should be stored individually to comply with Data Protection. TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X 2 X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 2 2 TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 6 (a) Requirement The Statement of Purpose and Service Users Guide must be kept up to date to ensure that the people using the service have access to current information about the Home The information in the care plans should be expanded upon to ensure that needs are fully identified, particularly complex needs, which pose a risk to the people using the service. This will ensure that all staff have the information needed to assist the people using the service and keep them safe. Medication should be administered straight from the prescriber’s receptacle to ensure that the people using the service get the correct medication. (see recommendation no 4) The medication coming into the Home should be clearly recorded to ensure that there is an audit trail. The manager and staff should continue to explore how they can offer more activities and DS0000005029.V352255.R01.S.doc Timescale for action 01/12/07 2. OP7 15 13 (4) © 01/12/07 3. OP9 13(2) 01/11/07 4. OP9 13 (2) 01/11/07 5. OP12 16(2)(m) &(n) 01/12/07 TNP House Version 5.2 Page 29 6. OP22 16 © 12 (1) (a) (b) 13 (3) 7. OP26 8. OP29 19 Schedule 2 9. OP31 21 A 10. 11. OP36 OP38 18 (2) 23(4)(c) (iii) 12. OP38 23(4)(a) stimulus to the people using the service, including those with dementia care needs. The nurse call system must be available in all bedrooms to ensure the safety of the people using the service. The infection control procedures in the Home should be improved to ensure that suitable arrangements are in place to prevent infection. The manager must make sure that the required checks are made on prospective staff members before they are employed and obtain all of the elements listed in Schedule 2 of The Care Homes Regulations 2001. The Registered Person shall produce an improvement plan setting out the methods by which, and the timetable to which, the registered person intends to improve the recruitment procedures and provide evidence that that the results of a Protection of Vulnerable Adults check has been obtained and a Criminal Records Bureau applied for or received. The manager must evidence that staff are being appropriately supervised. To complete the evacuation plan to ensure that all residents are included, including their specific needs and provide enough detail for safe evacuation in the event of an emergency. To ensure that a fire assessment is completed. Previous timescale 29/03/07 01/12/07 01/12/07 01/11/07 05/11/07 01/12/07 01/12/07 01/12/07 TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 30 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 OP1 Good Practice Recommendations It is recommended that more specific detail be included in the information about fees and costs to the people using the service to demonstrate openness and transparency. In this case this pertains to possible transport and staff costs for residents attending appointments. The manager should date the Statement of Purpose and Service Users Guide upon review as evidence of such. The care plan information should be expanded to make sure that the staff know the assistance required to meet the needs of the people using the service. The staff should be able to take the medication trolley to the people using the service to avoid secondary dispensing and ensure that they administer the correct medication. The manager should consider carrying out six monthly competency checks to ensure that the staff continue to administer medication correctly, follow the home’s procedures and meet legislative requirements. The manager should provide in-house training regarding the safe guarding of adults to supplement National Vocational Qualifications and ensure that all staff have the knowledge needed to recognise and respond to adult abuse. The manager should consider providing two wash hand basins in the shared rooms to promote the privacy of the people using the service. Evidence must be available that the staff receive mandatory training at the required frequencies. The manager should explore how the Quality Assurance system could be improved to involve the views of more people involved in the service, for example staff and professionals. The results of any surveys should be available to interested parties. Accident reports should be filed individually to comply with the Data Protection Act 1998 and maintain the confidentiality of the people using the service. Control of Substances Hazardous to Health products should be securely locked away and the manager should DS0000005029.V352255.R01.S.doc Version 5.2 Page 31 2 3 4 5 OP1 OP7 OP9 OP9 6 OP18 7 8 9 OP19 OP30 OP33 10 11 OP37 OP38 TNP House provide a lockable cupboard to fully safe guard the people using the service and comply with the Control of Substances Hazardous to Health Regulations 1988. TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Birmingham Local Office Commission for Social Care Inspection 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI TNP House DS0000005029.V352255.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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