Inspection on 06/06/07 for The Manor House

This inspection was carried out on 6th June 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

The Manor House 07/10/09

The Manor House 25/02/09

The Manor House 30/11/08

The Manor House 20/10/08

The Manor House 15/05/08

The Manor House 11/12/07

The Manor House 28/12/06

The Manor House 15/08/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Uphill Court 62 Uphill Road South Weston Super Mare North Somerset BS23 4TA Lead Inspector Patricia Hellier Unannounced Inspection 6th June 2007 14:00 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 Uphill Court DS0000067101.V337085.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. Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Uphill Court Address 62 Uphill Road South Weston Super Mare North Somerset BS23 4TA 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) 0208 5606691 01934 628386 uphillcourt@tiscali.co.uk Shreyas S.A.I.N. Ltd Mrs Jana Harris Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Manager must be a RN on parts 1 or 12 of the NMC register. Staffing notice dated 26 May 1999 applies. May accommodate up to 25 persons aged 65 years and over. That the manager achieves the Registered Manager’s Award within one year of registration. 28th December 2006 Date of last inspection Brief Description of the Service: Uphill Court is a listed building that has been converted to a registered care home with nursing. It provides accommodation for up to 25 older people with nursing needs. Accommodation is provided over two floors with a passenger lift giving easy access to one of the upper floors. The other upper floor is accessed by a stair lift. There are nineteen single rooms, and three that may be shared. Seven of these have en-suite facilities and all have a call bell system. Communal space is provided in a lounge in the main building and conservatory /dining room attached to the lounge. This looks out onto an enclosed garden. Provision is made within the home for some activities and outings, which also enable close links with the local community to be maintained. All local facilities are within easy walking distance but some are closed in winter. Information about the home is available through a brochure that incorporates key information from the Statement of Purpose and Service User Guide. CSCI reports are displayed in the entrance to the home and available for all to read. The fess range from £480 - £630 per week with additional charges being made for hairdressing, chiropody, newspapers, escorts, toiletries and some transport. This information was provided in June 2007. Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place over two days with the manager present for parts of the inspection. Before the inspection the information about the home was received from a review of the last inspection report; review of file information in the office; review of the AQAA from the home, and all correspondence and regulatory activity since the last inspection. The accumulated evidence for this report comes from the above and also fieldwork that included the following: discussions with 9 residents, 6 relatives and 6 staff, observation of practices, tour of the premises, review of documents relating to care, recruitment and health and safety; review of policies; inspection of medication records and storage. Of the 9 resident surveys sent none were returned. Residents interviewed during the inspection felt the staff were ‘kind and caring’. Of the 9 relatives surveys sent 3 were returned. All felt they are welcomed and most of the staff are kind and caring. Ongoing concerns regarding food, shortage of staff and activities were raised. All relatives spoken with during the inspection felt welcomed at the home and that they were consulted regarding their relatives care and needs. All knew how to make a complaint and felt that it would be listened to although not always resolved. Comments included “the staff are very friendly and welcoming”, “the staff’s kindness and care help my relative to settle in”. Relatives felt there are ongoing issues regarding the food at the home and the shortage of staff and activities. All residents and staff spoken with told the inspector that the home was nice and the staff very kind. Comments received were “it is very homely, the girls are very kind”; “my care needs are well met”. What the service does well: Residents live in a comfortable, and homely environment. It is decorated and furnished to an adequate standard and there are many homely touches. The staff ensure the well-being and comfort of the residents’ and treat them with great respect and kindness. For example 9 residents spoken with said, “the staff are kind and caring.” Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 6 Residents feel that if they had something to complain about they would speak to a member of staff. Three residents said ‘the home is good and the staff good ’. What has improved since the last inspection? What they could do better: The Statement of Purpose does not clearly reflect the current registration and situation of the home. It requires updating to ensure prospective residents and their relatives have accurate information on which to make an informed choice. Contracts and Terms and Conditions of occupancy documents do not clearly state the room to be occupied or by whom the fees are to be paid and if the amount stated includes the Registered Nursing Care Contribution or not. The home should provide a clearly documented breakdown of fees showing how the free nursing care contribution fits into the charges. Care plans are not a working tool and do not always contain clear and current information regarding residents’ needs. Care plans should be reviewed to enable them to become a working document to inform person centred care. Medicines are not well managed. The home needs to review its practices to ensure that an audit trail is possible for all medicines entering and leaving the home for the protection of residents. Residents are provided with very limited activities. The home should review the activities provided and implement a plan of these based on residents’ wishes to meet their social needs. The food at the home is not sufficient for some residents and does not always provide a well balanced diet. Food stocks and menus should be reviewed along with mealtimes to ensure residents receive sufficient food at intervals through the day, and ensuring a balanced diet. While staff are aware of what constitutes abuse they are not aware of the policy of reporting and managing such situations should they occur. When using beds rails and recliner chairs consent from the residents or a best interest group, should be obtained to ensure they are safeguarded from potentially abusive practices. Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 7 The outside environment is poor and the interior although homely is in need of maintenance and refurbishment. The provider must produce a planned programme of redecoration and refurbishment, so that residents, relatives and staff have knowledge of, and are involved in, the improvements. Recruitment practices do not ensure that all the necessary checks, to safeguard residents, are completed prior to a member of staff commencing work in the home. Robust recruitment practice must be put in place for the safety of residents. Staffing levels are not always sufficient to meet residents’ needs adequately. Staffing levels must be reviewed to ensure adequate staff to meet residents’ needs. Regular maintenance and Health and Safety checks are not currently being done. The provider should ensure that these checks and actions are undertaken to provide a safe environment for residents. 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. Uphill Court DS0000067101.V337085.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 Uphill Court DS0000067101.V337085.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 1,2,3,4,5 The Brochure and Service User Guide is comprehensive and provides prospective residents with information to make an informed choice. The home’s assessment process is thorough to ensure that it is able to meet residents’ needs. Prospective residents and relatives are encouraged to visit the home to assess suitability. EVIDENCE: The Statement of Purpose is informative but needs reviewing, as some information it contains is out of date. This document is not displayed in the home for residents or relatives to access, however the brochure of the home is available in the hallway and includes the aims and objectives of the home. The most recent inspection report is also available. Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 10 Copies of Contracts and Terms and Conditions documents were inspected for three residents. These did not contain the room to be occupied. Fees are mentioned in these documents but the breakdown of fees charged, outlining the contributions and by whom, to make up the weekly chargeable amount, are not clearly stated. This is required as outlined in the recent ‘Fair Price for Care’ report. The individual care files inspected for three residents indicated that a preadmission assessment had been undertaken which ensured that the home was able to meet identified needs in two cases. In one file, the assessment was undertaken after admission to the home. One recently admitted resident when spoken to said ‘I am well looked after; they know what I need, and if they don’t I tell them”. Care practices observed showed that staff were aware of the residents needs as stated in their assessments. Prospective residents are invited to visit the home prior to moving in. Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 7,8,9,10 Care plans do not always contain current information to enable staff to meet residents’ health and social care needs. Personal and environmental risks are not always well managed. The system in place for the management of medicines does not provide all the safeguards necessary for the protection of residents. Kind and caring staff treat residents with respect and dignity EVIDENCE: Individual records are kept for each of the residents, and are person centred including a social history. Of the three records inspected, two did not reflect the current state of the resident’s needs and carers were not following the plan. In discussion with staff it was clear that they do not see the care plans as working documents to enable them to provide good person centred care. Care routines are conveyed by word of mouth. Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 12 One of the care plans showed appropriate and satisfactory involvement of specialist Health Care Professionals. Other aspects of the plan clearly reflected good practice as to how to meet the resident’s identified needs. None of the care plans stated dietary needs, or preferences and choices. One of the care plans did not include clear guidelines and actions to meet a specific health care need. Care plans should contain clear guidance for staff as to how needs are to be met and any parameters within which to work. All care plans had risk assessments for Manual Handling, Nutrition and where appropriate pressure sore management. Risk assessments had been completed with the identified risk and it’s rating of probability, but there were no actions stated as to how the risks are to be minimised to protect the resident. Residents being cared for in bed were comfortable and looked clean, tidy and well cared for. The manager informed the inspector that the home does not have any residents with a pressure sore. Clear evidence of pressure relief equipment and good management was seen. None of the care plans showed resident or relative involvement. This practice needs to be implemented. Residents spoken with said, “the home is nice and the staff are good although not enough of them”. Three residents said, “the staff are kind and caring in the main. You occasionally get a rough one”. Another resident, and a relative, spoke of the “language difficulty sometimes with staff from overseas”. All staff have a caring approach and provide care as they see fit for the individual residents. The outcome for the residents, as evidenced from their comments during the inspection, is positive in this aspect. Comments received were, “I am happy and contented living here”; “the staff are kind and caring in the main”. Evidence was seen of regular visits by the chiropodist and optician and residents being taken to other appointments as needed. Residents’ comments supported this. Care practices observed showed caring interactions and good communication skills from staff. The home has an Equality and Diversity policy that recognises the cultural and social needs and differences that are present in society. This policy was seen being implemented in the care provision to residents. The home uses the Monitored Dose System of medication. The teatime medication routine observed was safe and complied with the guidance. Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 13 Regular audits of Medication Administration Record charts are not undertaken and it is not possible to clearly trace all medication received, administered and disposed of, in the home. Stocks held of some medications were excessive and not being well managed. These practices potentially put residents at risk, as the necessary safeguards are not in place. No homely remedies were seen on the Medication Administration Record Sheets or in the drug book entries sampled. The policy for Homely Remedies clearly states the medication that can be given and for a limited time. The Homely Remedies policy is clear but not agreed with the local GPs. Medication requiring refrigeration was not properly stored and fridge temperatures recently had been above the recommended level, potentially altering the potency and suitability of the medications for administration. Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 12,13,14,15 Social activities are limited but routines are flexible. Local links are maintained through visits from organisations within the town and personal visitors Friendly staff always welcomes relatives and visitors Quality of meals varies enormously and menus are repetitive. EVIDENCE: Many residents commented on the atmosphere of the home. One person described it as nicely informal, and residents’ felt that their visitors are also helped to feel relaxed and at home. When asked about activities and their daily routine two residents said, “we just sit here and talk or sleep all day”. Another resident told the inspector “there is nothing to do. We make our own entertainment”; and another said, “I would like to go outside more”. As mentioned in the previous section care records do not always show personal preferences and routines recorded. During the inspection a number of residents were seen just sitting in the lounge. No activities were observed being offered to residents on either of the afternoons of the inspection, and staff did not seem able to sit and talk with them. Resident’s social and recreational needs are not being met. Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 15 Several visitors were seen coming and going during the inspection. Relatives spoken with said they could come any time and felt “their relatives were well looked after by friendly staff”. Two relatives spoken with raised concerns regarding the lack of activities and lack of stimulation for their relative. The quality and presentation of the meals remains variable with residents and relatives unhappy about the amount of food and menu variety. Two residents and three relatives spoke of residents being hungry at times. Staff verified that the last meal is given at 5.30pm. They also told the inspector that residents may have a jam sandwich later if requested. One resident told the inspector that she did not know this. The kitchen was inspected and looked clean and tidy. Cupboards in the kitchen appeared to contain adequate supplies, and fresh fruit and vegetables were seen. During teatime residents were observed enjoying their meal of soup, sandwiches and cake. The kitchen staff spoken with had completed their food handling training. Two relatives said they felt the food had begun to improve again in the last two months. Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 16,18 Residents are confident that they are listened to and their requests acted upon. Residents are potentially at risk from staff who are not fully aware of the North Somerset “No Secrets” policy and the use of equipment that can potentially restrain them against their will. EVIDENCE: The home has a comprehensive complaints procedure and all residents receive a copy on admission. Residents spoken with were aware of the procedure for making a complaint, and felt they would be able to tell staff or the owners if they had a complaint. The home has had 3 complaints since the last inspection and all were resolved to the satisfaction of the complainant. There has been one allegation of abusive behaviour from a member of staff to a resident, which is currently being investigated. Bed rails and recliner chairs were observed in use for residents, however consent for the use of these had not been obtained from the resident or from a best interest group, in the care files inspected. This is required to protect residents from potentially abusive practices. Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 17 The home has a copy of the North Somerset ‘No Secrets’ guide for responding to allegations of abuse. In the handling of the recent allegation it was demonstrated that the management are not familiar with the policy and thus it was not followed. Four staff when interviewed had knowledge of what abuse is but were not fully conversant with how incidents of abuse should be handled. The staff were aware of the Whistle Blowing policy for the safeguarding of residents. Four residents said, “the staff look after me well”. Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 19,20,21,22,23,24,25,26 Residents are provided with homely and comfortable surroundings. Outdoor space is attractive but not accessible for residents to enjoy. The home has suitable equipment to maximise resident independence. Robust infection control practices are not always followed which potentially places residents at risk from cross infection. EVIDENCE: The building is old and has lacked investment and therefore the improvements made so far have not significantly impacted on the environment. The property is not well maintained,and many maintenance tasks are outstanding. A plan for maintenance and refurbishment of the home was developed following the last inspection but this has not yet been implemented. The living accommodation décor is looking tired but homely. Residents’ rooms are personalised and comfortable. Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 19 On a tour of the premises the inspectors noted that bath water temperatures are kept well below the suggest temperature of 43°C. Hot water outlets in some areas of the home were hot, and did not feel to be within the recommended 43°C guidelines. Furniture in rooms in the old part of the building were observed not fixed to the walls and posing a potential hazard for residents and staff. It is recommended that all furniture that is unstable be securely fixed to the wall. The outside of the home remains inaccessible to residents. One side of the home was seen to have a lot of old fixtures, fittings and furniture ready for disposal for the tip. It is near to the fire exit and blocks the use of this exit with a wheelchair as well as resting against the care home wall causing a fire risk. In another area a load of disused wood was piled up against the conservatory and also a fire risk. The home has grab rails situated at relevant points and a shaft lift that is easily used to assist resident mobility and aid independence within the home. A hoist is provided to assist with moving and handling of residents also a Stand Aid. One relative when speaking to the inspector was concerned about the bruising on their relative’s legs from having to be hoisted, but said, “I suppose it’s inevitable”. Staff were observed using the hoist during the inspection in the recommended manner, with no injury to residents. Staff showed the inspector slings to be used with the hoist that are too small for the residents using them. Staff also spoke of the slow response to maintenance requests for equipment leaving them vulnerable or without equipment. The home was clean and free from offensive odours throughout. The laundry facilities were well organised. Staff interviewed demonstrated good understanding of Infection Control procedures and practices and the use of personal protective equipment (PPE). While PPE is provided and used, robust infection control practices are not followed. Dirty commode pots were seen in the sluice area and the clinical waste bin was overflowing with clinical waste bags propped against the walls and windows of the care home, posing a potential risk of spreading infection. An Immediate requirement was issued to make the external environment of the home safe. Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 27,28,29,30 The home’s staffing levels are not always sufficient to manage the care needs of residents. The procedures for the recruitment of staff are poor and do not provide the necessary safeguards to protect residents. Staff have received the necessary training to ensure they are competent to do their job. EVIDENCE: The staffing rota for the week was available in the office. Staffing levels are not always adequate to meet residents’ needs in a timely and unhurried manner. The team of ancillary staff supporting them has vacancies. The managers duties are not recorded on the rota, thus it is not possible to verify all staff on duty in the home at a specified time. It is recommended that the manager’s duty times be recorded. Both staff, residents and relatives spoken with felt that there is not always sufficient staff to meet residents needs. At night there are two waking staff. The manager should keep the staffing levels under review against the changing needs of the residents. The home has a Key Worker system in place for all residents. Staff approached residents with directness, openness and consideration. Each of the resident’s with whom the inspector spoke said, “how nice the staff are”. Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 21 Staff interviewed said, “they liked their job and felt that the home provided good care, but the building and environment need improving”. These concerns were support by relative and residents comments. Recruitment practices for the new staff employed are poor. Two personnel files for recently employed staff were inspected. Neither of the files contained PoVA first checks or Criminal Record Bureau checks prior to their commencement of employment at the home potentially putting residents at risk. There was no recorded evidence of qualifications, or interview records and exploration of gaps in employment. An Immediate Requirement was issued. One relatively new member of staff told the inspector that she had received an induction, which covered Fire and Health and Safety issues. The home has their own induction programme that adequately covers the required areas. However it is recommended that staff undertake the Common Induction Standards programme to ensure they have the skills and knowledge to meet residents’ needs. A training programme is displayed in the home and training is offered monthly on a variety of topics. The manager said that it had got behind recently due to lack of staff and therefore time. Staff interviewed verified that training had been planned but cancelled due to staffing issues. Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 31,32,33,34,35,36,38 The home has sound policies and procedures, which the manager effectively reviews in line with current good practice guidance. The manager provides leadership and guidance to staff in the provision of care. The underpinning management structures of the home are lacking in some areas to ensure the safety of the home. Residents’ views are sought and acted on, but a formalised system is not in place. The management of resident’s monies are handled safely by the home. Health and safety issues are not regularly monitored in the home and a safe environment not always maintained. Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager is well qualified and has a number of years experience in this area. The manager gives clear leadership, guidance and direction to staff. Residents feel she is approachable, available and seeks to ensure all their needs are met. Residents’, staff and relatives are aware that financial support from the provider would assist the manager to provide a better service. The registered provider is not actively involved in the management of the home, but supports any actions the manager takes. The home carries out a quality assurance procedure, forwarding questionnaires to residents and relatives. Until recently relatives meetings were held regularly to encourage involvement in the running of the home. These have now stopped due to lack of interest and attendance. The manager now seeks to speak with relatives and residents individually, or as need arises. The quality assurance report does not show what the organisation intends to do when comments are made by residents. Some residents had stated activities were poor but there was no written indication to say how the organisation was going to improve activities, or consult with the residents about the activities they wanted. During the course of the inspection the home had 19 residents, a level of 75 occupancy. In discussion with the manager it seems that the home is in need of financial expenditure in a number of ways to improve the service. The provider has been asked to submit to the Commission documentation regarding the financial viability of the home. Policies and practice guidance are provided in the home. They are dated and signed for accountability purposes, and have recently been updated to ensure they reflect the current good practice guidelines. Residents’ pocket monies held by the home were inspected and found to be accurate and to have clear records. All entries are supported by two signatures for any transactions made for the safeguarding of all concerned. Supervision of staff is sporadic and poorly documented. While staff feel supported by the manager they told the inspector that supervision does not take place. Supervision of staff is required to ensure that staff have the skills and knowledge to meet the resident in a competent and safe manner and in accordance with the aims and objectives of the home. Supervision records need to show that supervision is provided at least six times a year and includes discussion regarding care practices and training needs. Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 24 All the documentation for health and safety checks and service records were available and but they were not all up to date. Firefighting equipment was regularly serviced as was indicated in the service record until March of this year when the maintenance man left. They have not been done since, and there was no record of visual checks being carried out by senior staff in between the service dates. A majority of bedroom doors did not shut properly. These are fire doors and it is essential for the safety of residents in the event of fire that these doors create a secure seal against smoke. Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 1 2 3 2 3 3 3 2 STAFFING Standard No Score 27 2 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 1 3 1 2 1 Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 14.2 Requirement The registered nurses must ensure that they document fully any change in health care needs of the residents, and if necessary, produce a plan of care to meet the presenting need. Previous timescale of 28/012/06 not met The registered person must review the system for the receipt, storage, administration and disposal of medicines to ensure that an audit trail of all medicines entering and leaving the home can be made. The registered person to provide a programme of activities to meet the social and psychological needs of residents. The registered person to review the menus and mealtimes to ensure residents receive enough food at well spaced intervals. To ensure that a balanced and nutritious diet is provided. DS0000067101.V337085.R01.S.doc Timescale for action 30/06/07 2 OP9 13.2 30/06/07 3 OP12 16.2 (m) 15/07/07 4 OP15 16.2 (i) 30/06/07 Uphill Court Version 5.2 Page 27 5 OP18 13.6 The registered person must ensure that all staff have a clear understanding of the abuse policy and how to raise a concern and the process of reporting and dealing with it. The registered person must ensure that all refuse is cleared from the outside of the building, and make arrangements to prevent the overflowing of the clinical waste bin. An Immediate Requirement was issued. The registered person to provide a programme of maintenance and renewal of the fabric of the building, and implement it. Previous timescale of 16/04/07 not met The registered person shall ensure that external grounds that are suitable for, and safe for use by, residents is provided and appropriately maintained. Previous timescale of 16/04/07 not met All required information and checks must be undertaken prior to a person commencing employment at the home. An Immediate requirement was issued The registered provider to submit to the Commission information and documents showing the financial position of the care home The registered person must ensure that persons working in the home are appropriately supervised. DS0000067101.V337085.R01.S.doc 31/07/07 6 OP19 23.2 (o) 18/06/07 7 OP19 23(2)(b) 30/06/07 8 OP20 23(2)(0) 31/07/07 9 OP29 19.1 Schedule 2 30/06/07 10 OP34 25.2 30/06/07 11 OP36 18.2 31/08/07 Uphill Court Version 5.2 Page 28 12 OP38 23.4 (c) (i) The registered person must ensure that all fire doors close fully to provide the necessary safeguards for residents. . 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP1 OP2 Good Practice Recommendations The Statement of Purpose to be revised to clearly reflect the current categories of resident catered for in the home Contracts of residency need to clearly state the fees to be paid, showing a breakdown of what is to be paid to make up the weekly rate and by whom. Contract and terms and conditions documents must show the room to be occupied. Care plans to be reviewed and practice changed to ensure they become a working document inform person centred care. The provision of suitable and sufficient equipment in the home to met the needs of residents at all times. To ensure that all infection control practices and policy are followed for the protection of residents. To keep the staffing levels under review to ensure sufficient numbers to meet residents needs. To continue to implement a formal quality assurance system to ensure reviewing and improving the care of the home take place regularly for the benefit of residents. To ensure that all significant events that affect residents, or have the potential to are report to the commission without delay. 3 4 5 6 7 OP7 OP22 OP26 OP27 OP33 8 OP37 Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Bristol North Local Office 300 Aztec West Almondsbury South Glos BS32 4RG 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 Uphill Court DS0000067101.V337085.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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