Inspection on 03/03/06 for Todwick Care Home

This inspection was carried out on 3rd March 2006.

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

Todwick Care Home 11/09/09

Todwick Care Home 08/05/08

Todwick Care Home 11/08/05

Todwick Care Home 09/11/04

Todwick Care Home 26/05/04

Todwick Care Home 02/12/02

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

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 Todwick Care Home 160 Kiveton Lane Todwick Sheffield South Yorkshire S26 1DL Lead Inspector Unannounced Inspection 09:50 3 . March 2006 rd 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 Todwick Nursing Home DS0000003091.V273310.R02.S.doc Version 5.1 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. Todwick Nursing Home DS0000003091.V273310.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Todwick Care Home Address 160 Kiveton Lane Todwick Sheffield South Yorkshire S26 1DL 01909 770248 01909 774956 info@todwick.com 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) Multi Counties Rest Homes Limited Mrs Susan Harrington Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Todwick Nursing Home DS0000003091.V273310.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th August 2005 Brief Description of the Service: Todwick Care Home is registered to provide care for up to 25 people in the category of older adults. It is owned by Mr & Mrs Marshall and managed by Mrs. Susan Harrington. The home is situated in the village of Todwick, close to bus routes and the local railway station. It is a two- storey building, which provides accommodation on both floors. There is a passenger lift to facilitate access between the floors. There are three lounges, one of which is on the first floor. The dining area, the kitchen and two lounges are located on the ground floor. One of the lounges is used by residents who smoke. There is a garden area, which can be accessed either through the front or side of the building. There is a car parking facility at the front of the building. Todwick Nursing Home DS0000003091.V273310.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 3 March 2006, starting at 09.50 hours and finished at 14.00 hours. It comprised of a tour of the premises, conversations with five residents and two relatives and four members of staff. Care documentation and other records were checked. The inspector was also able to observe some aspects of care practice by staff at the Home. The registered manager was not on duty at the time of this inspection. A senior carer was in charge of the home at the time of this inspection. What the service does well: What has improved since the last inspection? The registered manager and her care staff have started work on care documentation. Assessment of needs of residents on their admission to the Home is improving. Progress is also being made with care planning and the recording of care given to residents. This helps to monitor whether care needs of residents are being well met. Todwick Nursing Home DS0000003091.V273310.R02.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Todwick Nursing Home DS0000003091.V273310.R02.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Todwick Nursing Home DS0000003091.V273310.R02.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The Home provides some information about its services to potential clients, to enable them to choose where to live. However, improvement is needed to its statement of purpose and service user guide. EVIDENCE: Residents, who spoke to the inspector, felt that their relatives and themselves had enough information to help them make a choice of care home. The Home has produced its statement of purpose and service user guide, but they still need to include all the relevant information in order to comply with the regulations. This was a requirement from the previous inspection and must now be addressed. Todwick Nursing Home DS0000003091.V273310.R02.S.doc Version 5.1 Page 9 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 the following standard(s): 7, 9 Residents are provided with appropriate plans of care, which help care staff in meeting the individual care needs of residents. The handling and administration of medicines was not satisfactorily carried out and shortfalls identified require remedial action. EVIDENCE: A sample of care plans was checked. Care plans included action to be taken to address identified risks. Regular reviews were undertaken and recorded. Daily entries appeared relevant to the actions stated in care plans and this helped with care evaluation and review. Residents spoken to, confirmed that they were ‘very satisfied’ with the care they received from care staff. They described care staff as ‘ hard working and very caring’. One resident said ‘ The staff here, will do their very best to make sure you are as comfortable as possible’. The senior care staff, in charge of the home during the morning of the inspection was observed administering medicines to residents. She explained Todwick Nursing Home DS0000003091.V273310.R02.S.doc Version 5.1 Page 10 that she had started the ‘medicines round’ at 08:00 hours. The inspector noted that she finished that task by 11.30 hours. This is in line with the flexible meal arrangements within the home. However, two residents who have their medicines (diuretics) both in the morning and at midday were noted to have been administered the two doses within approximately a two hours interval. This should be checked with the GP and pharmacy to ensure that this is appropriate to their health needs. A sample of the medicines administration records (MAR) was checked. Prescribed medicines were not administered as required. An audit of an item of medicine, for one resident, showed that the amount of that medicine left to be administered was less than it should be. There was no explanation for this imbalance. In another instance, the time for the administration of a medicine, for a resident, had been changed without explanation or acknowledgement of the authority to do so. There was no evidence that a system of internal audit of medicines was in place. Todwick Nursing Home DS0000003091.V273310.R02.S.doc Version 5.1 Page 11 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 the following standard(s): 13, 14 Care staff are proactive in making sure that residents are able to keep in touch with their relatives and friends. This allows for residents to feel included in community life and valued. Residents are encouraged to express their preferences in various activities of daily living and their choices are respected and met. EVIDENCE: Residents, who spoke to the inspector, said that staff always asked about their preferences on matters like, time to get up and retire to bed, food menus, ways in which care is provided to them individually and activities that are organised. On the morning of the inspection, the inspector noted that residents were partaking breakfast at times to suit them. Residents commented that they were offered ‘personalised care and attention’ most of the time. One resident stated that she has her meals in her own room, as she likes to stay in most of the time. She was satisfied that she was receiving prompt attention and that all her care needs were seen to, in the way she prefers. Todwick Nursing Home DS0000003091.V273310.R02.S.doc Version 5.1 Page 12 Staff commented that relatives could visit at all reasonable times. In conversation, residents confirmed that their relatives were always welcomed at the Home. They could also keep in touch with relatives by telephone. Residents also felt that they were in touch with the local community through activities that are held at the Home. For example, the local church undertakes a regular communion service and members of the clergy, which relatives and friends attend. Todwick Nursing Home DS0000003091.V273310.R02.S.doc Version 5.1 Page 13 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 the following standard(s): The key standards were checked at the previous inspection. EVIDENCE: Todwick Nursing Home DS0000003091.V273310.R02.S.doc Version 5.1 Page 14 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 the following standard(s): 19 Although the Home continues to offer a well-maintained environment for the resident group, there is a need to improve on a few health and safety measures. EVIDENCE: A tour of the premises was undertaken. It showed that the building appeared adequately maintained. Repairs and decoration are carried out as and when necessary. The Home appeared clean and tidy. However, there were a few radiators in residents’ private accommodation, which did not have low temperature surfaces and did not have protective guards. A few doors continue to be left wedged open. Staff explained that they thought the Fire services had given the Home permission to use door wedges in cases that they had risk assessed. Such permission from the fire services, in writing, was not evidenced at this inspection. One of the bathrooms was out of use. Staff explained that it was being refurbished. It was stated that new bathing equipment had been ordered. Todwick Nursing Home DS0000003091.V273310.R02.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The key standards were checked at the previous inspection. EVIDENCE: Todwick Nursing Home DS0000003091.V273310.R02.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35, 38. Both staff and management at the Home are committed to providing a good service to their resident group. However, the maintenance and access to records relating to residents’ personal allowances and health and safety issues must be improved. EVIDENCE: Staff spoken to, expressed positive comments about the registered manager and her attitude and approach to care provision at the Home. They had confidence in her ability and were happy to be working under her leadership and guidance. However, at this inspection, it was not possible for the inspector to have access to various documents relating to residents’ welfare at the Home. This was caused by the absence of the manager on the day of this inspection. Todwick Nursing Home DS0000003091.V273310.R02.S.doc Version 5.1 Page 17 Whilst staff explained that they would be able to cater for a resident who wish to have access to some cash, in cases where the Home was managing the personal allowances of residents, they had no access to residents’ money and to any accounts. There were similar difficulties to access records relating to health and safety, for example, the certificate for the passenger lift and the Home’s overall risk assessment. It is advisable that senior staff who are given charge of the service, be given access to relevant records and to residents’ money, in appropriate ways, to ensure the welfare of clients in their care. Todwick Nursing Home DS0000003091.V273310.R02.S.doc Version 5.1 Page 18 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X 2 X X 2 Todwick Nursing Home DS0000003091.V273310.R02.S.doc Version 5.1 Page 19 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 4, 5 Regulation Requirement The Homes statement of purpose and service user guide must be improved to meet the Regulation. (Previous timescale of 19/12/05 not met.) The management of medicines must be reviewed and improved with regards to their receipt, recording, handling and administration. Timescale for action 09/06/06 2 OP9 12,13 09/06/06 3 4 OP9 OP19 12,13 An internal system of audit of medicines must be developed and implemented. 12, 13, 23 All radiators must be of low temperature surface ones or be fitted with appropriate safety guards. 12, 16, 17 Residents must have access to their personal allowances as and when they may need to. 12,16, 17 Information regarding residents’ accounts and other records must be made accessible to staff in charge of the service, or arrangements be made for appropriate access to the same. DS0000003091.V273310.R02.S.doc 09/06/06 01/09/06 5 6 OP35 OP35 09/06/06 09/06/06 Todwick Nursing Home Version 5.1 Page 20 7 OP38 12, 13, 17 A current ‘Loller’ certificate for the passenger lift, and the overall revised risk assessment for the Home, must be evidenced. 09/06/06 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 OP38 Good Practice Recommendations Senior staff who are given charge of the service should be given appropriate access to relevant records to ensure the continued health, safety and well being of the resident group. The refurbishment work in the bathroom identified, must be completed and the bathing facility be made available to residents. 2. OP19 Todwick Nursing Home DS0000003091.V273310.R02.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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. 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