Inspection on 14/08/06 for Valley Court

This inspection was carried out on 14th August 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

Valley Court 08/08/08

Valley Court 09/08/07

Valley Court 15/03/06

Valley Court 07/09/05

Valley Court 07/03/05

Valley Court 26/08/04

Valley Court 19/03/04

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 Valley Court Valley Road Cradley Heath West Midlands B64 7LT Lead Inspector Key Unannounced Inspection 14th August 2006 09:15 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 Valley Court DS0000004829.V306855.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. Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Valley Court Address Valley Road Cradley Heath West Midlands B64 7LT 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) 01384 411 477 Pepperhall Limited Joan Green Care Home 69 Category(ies) of Old age, not falling within any other category registration, with number (69) of places Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th March 2006 Brief Description of the Service: Valley Court is a purpose built Care Home, opened in 1998, which provides 69 beds for frail older people, 39 who require residential care and 30 who require nursing care. It is independently owned. The Home is located within easy reach of main routes between Halesowen, Cradley Heath, Dudley, etc., with public transport and local amenities easily accessible. It is situated next to a primary school, with a shared driveway. There is ample car parking to the front of the Home and gardens and patio areas to the rear. The Home is separated into two units, one dedicated to Residential Care, the other to Nursing Care. Shared facilities include the kitchen and laundry. Service Users accommodation is provided on two floors, all bedrooms are single, and 64 out of 69 have en-suite facilities. There are lounges and dining rooms on both units. The home currently has a range of bathing facilities, nurse call system, passenger lifts and some disabled facilities. The Home has separate staff teams; with the Registered Manager who is a first level nurse, undertaking responsibility for the Residential beds and the Nursing beds. Fees vary between £335 and £439 and are dependant on the needs of the service user and the type of room that will be occupied. The following are not included in the fee: non NHS Chiropody (£10), hairdressing (£4.50),toiletries, telephone calls and activities such as bingo (20p a book). Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by one inspector. The inspection was carried out between 09.15.30 and 15.30 on the 14 August and 13.15 to 19.15 on the 15 August 2006.The inspection included a tour of the building, talking to service users and staff and a review of records. Fifteen service users completed questionnaires that asked their views on the home identifying life at the home. A review of information supplied by the Manager (pre inspection questionnaire) was also undertaken and expanded upon during the visit. Care records were reviewed as part of the “case tracking” of six service users. The registered manager is Joan Green. The home is privately owned by Pepperhall Limited. Twenty-eight of the previous fifty-three requirements from the previous inspection have been met. Seven new requirements were made as a result of this inspection. What the service does well: Staff are caring, committed and flexible. Comments from residents and relatives about the staff are generally positive with relief that more permanent staff have recently been employed. Members of staff are committed to the development of the home and have been positively involved in the inspection process and have answered questions in an open and honest manner. The multidisciplinary team and CSCI have commended the manager and deputy manager for their actions to instigate multi-agency procedures for the protection of vulnerable adults and ensure that this process continued despite the length of time that the was required by other agencies to complete this investigation. This inspection was conducted with full co-operation of the Registered Manager, staff and residents. The atmosphere through out the inspection was relaxed and friendly. The Inspectors would like to thank staff, and residents for their hospitality during this inspection visit. Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 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 Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 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): 1,2,3,5 The overall outcome for this group of standards is judged to be good. Service users can be assured that they have the required information in order to make a choice about living at Valley Court. Service users have an assessment of their needs giving assurance that the home will be able to meet their needs. EVIDENCE: The Statement of Purpose and service users guide are reviewed and kept updated providing current and prospective service users with a good source of information about the suitability of the home and the services they offer. A copy of the most recent inspection report is also available in the reception area of the home. Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 9 The home has introduced new contracts of residency as required at the previous inspection. All service users responding to the survey undertaken by the Commission for Social Care Inspection confirmed that they had a contract of residency and files of service users seen also all contained completed contracts. The Manager was advised to review the part of the contract that specifies that residents belongings left at the home were liable to a storage fee. The Manager agreed that as service users had never been charged for belongings that were not promptly collected and she would be happy to amend the contract of residency. Service users are admitted following an assessment of their needs undertaken by either the Manager or a senior member of staff. Service users are whenever possible involved in their assessment of needs and this is usually recorded. A letter is given to the service user or their representatives prior to admission confirming that assessed needs can be met by the home. Services and their families are also encouraged to visit the home before making the decision to come and stay. The home does not accommodate service users requiring intermediate care and does not intend to do so. Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 10 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): 7,8,9,10 The overall outcome for this group of standards is judged to be adequate. The home generally meets service users healthcare and personal care needs and respects their privacy and dignity, Medicines are not stored safely and which may result in their lack of effectiveness. EVIDENCE: Service users have a plan of care that generally identifies all their needs. Care plans are developed and regularly reviewed. Care plans do not always include new needs and did not always reflect changes in the residents care. One resident was observed to be lifted by staff yet her care plan identified that she required hoisting with two carers, staff said this was because her ability to stand fluctuates and on occasions she can weight bear and does not need a hoist but this information had not been recorded in her plan of care. Staff need to ensure that residents always have a care plan for the use of as required medication, which identifies the reasons it should be given and evaluating the effect of the medicine. There is not evidence that care plans are reviewed with the resident or their representative and this should be recorded. Care plans are standard and are photocopied as required, further development in care planning must ensure that the care plan is person centred. Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 11 Service users generally have all required risk assessments for the risk of pressure sores, moving and handling, nutrition, bedrails and falls but some service users did not have a risk assessment for falls, although they had previously been identified at risk of falling. One nutritional risk assessment was not accurate and did not reflect the service users recent weight loss. Files seen showed that risk assessments are not reviewed at least monthly as required with some risk assessments not updated since February 2006. Service users are usually weighed shortly after their admission and then at least monthly. Weight records were inconsistently recorded and one residents care files seen had not been weighed between the 1/5/06 and the 4/8/06. One comment from a service user was: “ The girls are very good and help me because they know my legs are not very good.” One comment received prior to the visit identified that some residents are left sitting in chairs and wheelchairs for long periods of time. The Inspector supported this, finding that not all residents were taken to the table for their meals and were observed to be left to sit in the same position all day. The lack of movement and lack of pressure relief increases resident’s risk of developing pressure sores. Care records and service users identified that they are appropriately referred to and have visits from Health Professionals such as GPs, specialist nurses, dentists, opticians and chiropodists. The administration, safe- keeping and storage of medicines is undertaken by a nursing staff on the nursing unit and by senior care staff who have had additional medicine training on the residential unit. There is a record of all medicines service users have received. Staff record the temperature of the treatment room and the drug fridge temperature. Both treatment rooms and the drugs fridge temperature (Residential unit) was considerably warmer than the required maximum temperature and outside the safe temperature for the storage of medicines and which may affect the effectiveness of medicines stored. Staff also need to ensure that the drugs fridge is regularly defrosted and that this is recorded. The home has made good progress in meeting requirements made at the previous inspection although two staff on the nursing unit do not check and sign confirmation of the accuracy of hand written treatment sheets. All arrangements for controlled drugs were found to be satisfactory. Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 12 Over the period of the inspection staff were observed to interact with residents with respect and sensitively particularly on the residential to protect service users dignity. There was friendly banter between staff and residents. Care staff on the residential unit tried to encourage on lady to cover her legs but she informed them: “ I like to show my legs!” Service users spoken to said that the staff were very good, kind and treated them with respect although one comment received said: “Some members of staff do not protect residents dignity especially when they are being hoisted”. Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The overall outcome for this group of standards is judged to be poor. The daily life and social activities of the home does not consistently meet service users needs, capabilities and preferences. EVIDENCE: There is little evidence that residents leisure and social interests are explored and identified. When interests are identified they need to be incorporated into their social plan of care. The home does have an activity plan but residents spoken to said that this is rarely followed. Activities are mainly bingo, other residents read, watch the television and listen to music. Staff did play a Tom Jones tape although the central television was also left on giving a confusion of sound. The television was left on throughout the day even when the children’s programmes came on, although residents were not asked whether they would like another channel on or another tape (as the Tom Jones tape had finished by this time. On the morning of the second day of the visit a movement to music session had been arranged. A visit to Walsall illuminations was also being planned during the visit. Residents spoken to during the inspection said that: “Activities- they are very rare”. Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 14 A visitor said: “ Sometimes they play bingo, my relative is on the nursing side, they think they don’t need any stimulation but they do, but they don’t get it I’m afraid”. Visitors are welcome at any time and all met said that they always felt welcome at the home. Care plans identify residents individual food likes and dislikes and choices about their individual routines such as getting up and going to bed. The home has a four-week menu providing a balanced and nutritious food with a choice of meal always provided. Special diets such as pureed, soft and diabetic diets are catered for. Service users spoken to said that they enjoy their meals served and that there is always a suitable choice available: “my relative eats all their meals but they are very repetitive and sometimes it nice to have a change”. There is a need to review the menu, particularly as it was not being followed during the inspection. Dining tables were appropriately laid although disappointing not all residents are given the choice to come to the table. Staff said this was because: “ they can mess with other peoples dinners, or that they made a mess”- given previous concerns about residents being left in their chairs all day this needs to be reconsidered with additional dining tables available. Staff give residents discreet assistance to feed themselves whenever it is required. Residents do not have a hot drink with their dinner but squash is freely available. Two residents were heard to ask for a cup of tea during the afternoon but care staff told them that they would make one at 3pm- although it was ten to three when the second residents asked! Residents must be able to have a choice of hot drink when they want it and ways that this can be met must be explored ensuring a stop to institutional practice. Requirements made during the previous inspection, relating to the replacement of kitchen equipment and cleanliness of the kitchen store room have been addressed. Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The overall outcome for this group of standards is judged to be good. The home has appropriate policies and procedures to highlight concerns and complaints protecting its residents. EVIDENCE: The complaints procedure is on display on the notice board and is in the terms and conditions of residency. Discussions with residents and comment cards received before the inspection said if they had any concerns they would either speak to the Manager or a member of staff. The home has received one complaint. Records seen identified that it had been appropriately and timely investigated. The home has appropriate policies for staff to highlight concerns whilst feeling safe to do so. There is a programme of training in adult protection procedures. Recent investigation into adult protection concerns were appropriately and effectively managed by the home. All agencies involved have commended the home for their actions and ongoing cooperation in and following multi-agency procedures. Requirements made at the previous inspection to update adult protection policies have been met. Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 16 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): 19,26 The overall outcome for this group of standards is judged to be poor. Residents live in an environment that is generally clean and homely but would be considerably improved by refurbishment EVIDENCE: Valley Court is a purpose-built property, currently providing accommodation for up to for 69 older people requiring residential or nursing care. The property stands in its own grounds, with car parking at the front, with accessible gardens to the sides and rear. The garden needs to be developed to provide a pleasant place for residents to sit in during the summer months and give residents something to attractive to look at rather than the wire fencing. The Home has communal bathing / showering facilities located on the ground and first floors in addition to the en suite facilities in bedrooms. There are assisted baths suitable to meet the current needs of the residents, however to bathrooms identified a previous visits to be in need of adaptation have yet to be completed. Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 17 Residents’ bedrooms are furnished appropriately according to the needs of each person. The bedrooms are pleasantly decorated and it is evident that people are encouraged to personalise their rooms with their own possessions, pictures, mementos and furniture. The majority of bedrooms were redecorated last year but some bedroom walls have been marked since. Bedroom carpets are generally shabby, marked with an unpleasant odour in three bedrooms. There has been limited redecoration since the last inspection, but six new arm chairs have been purchased and damaged carpet joints have been repaired. The home currently has a handy man employed for two and sometimes three days each week, which is insufficient for a home of this size. There is currently no documented audit and programme of maintenance, repair, replacement and redecoration available- this is an outstanding requirement. See the requirements section of this report that highlights improvements required in relation to the environment of the home. The home is generally clean although the marked and shabby carpets do detract from this and make the home appear dirty. Comments received were: “The home needs to be kept a lot cleaner than it is, the windows never get cleaned and the dining tables are not always clean.” and “I think they need more cleaners because the residents have to live in a low standard home regarding cleanliness.” The home’s infection control practices are generally satisfactory. The laundry has appropriate policies and procedures for the management of dirty laundry. The requirement made at the previous inspection that liquid soap is available in all communal toilets and bathrooms has been met. Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 18 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): 27,28,29,30 The overall outcome for this group of standards is judged to be poor. The number and continuity of staff has improved although staffing levels are not always adequate. Recruitment and selection procedures although generally satisfactory may not always safeguard the service users. Training opportunities are available but new staff must have required training. EVIDENCE: Staffing levels have been more stable recently with the appointment of several new members of staff. The home is also now using minimal agency staff which is improving the continuity of staff for residents. A review of staffing levels has been undertaken since the previous inspection and staffing levels on some shifts increased, although there remains a concern about the sufficiency of one trained nurse and two care staff on the nursing unit on night duty. Additional kitchen, laundry and domestic staff are also available seven days a week. The home also has an Activity Organiser. The home currently has 18 of its 47 care staff (38 ) with a minimum of National Vocational level 2 qualification (NVQ) or equivalent. The home is working toward the requirement that they have at least 50 of care staff with NVQ 2. Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 19 Recruitment and selection procedures at Valley Court do meet the requirements of the regulations. Some care staff had convictions included in their Criminal Records check, although they had not disclosed these convictions in their application form. The homes recruitment policy identifies that staff who fail to disclose convictions employment will be terminated, although this has not be undertaken. New staff do receive induction training, although required records were not available for all staff. The current induction programme does not meet National Training Organisation standards. Recent training has included fire safety, moving and handling, health and safety, supervisory management, naso gastric tube feeding, infection control and palliative care. Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 20 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): 31,33,35,36,38 The overall outcome for this group of standards is judged to be adequate. Managerial arrangements need to be further developed to ensure that the home is run in the best interests and the protection of the service users. EVIDENCE: The manager is qualified nurse and has been Home Manager for almost two years. The manager trains and develops staff who are competent to care for older people. Staff and service users all stated that she is approachable. Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 21 The home does not have a quality assurance programme. The Home Manager did undertake a service user survey twelve months ago. A further survey should now be undertaken to solicit more recent views and ensure that the home is service users focused as some observations made during the visit suggest that this is not always so. The manager has started to audit some areas of the homes practice but further systems to monitor practice need to be developed to ensure compliance with the homes plans, policies and procedures. Staff supervision has commenced but is not always undertaken as frequently as required with insufficient records seen during the visit. Secure facilities are available for the safe keeping of service users personal money and valuables. The management of service users money is undertaken separately for each unit. It was identified as a concern that the keys to the safe are held by a number of staff and that the contents of the safe are not checked each time the keys are handed over. Written records are available for all transactions which detail the reason for the withdrawal and two signatures, receipts are available as proof of purchases. Money that was randomly checked in the safe was found to be correct and equal the balance identified. Regular external audits of service users personal money is undertaken. The majority of services users have their finances managed by their families or by the Court of Protection. It was pleasing to hear that a number of service users manage their own money. Procedures to protect service users include regular checks on the fire alarm, emergency lighting, fire extinguishers, nurse call points and hot water. Records identify that staff regularly attend mandatory training in fire safety, moving and handling, food hygiene, health and safety and resident welfare. Maintenance records and contracts were up to date. With regular checks undertaken on the fire alarm system and emergency lighting system. Hot water checks have not been undertaken as frequently as recommended for the nursing unit. Mandatory staff training is undertaken by the majority of staff. Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 22 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 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 2 1 X 2 Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 17(2) sch 3 Requirement To continue the process of obtaining documentation for service user case records as identified in Regulation 17(1)(2) Schedules 3 (previous timescale of 31/10/04 and 31/10/05, 01/05/06 not fully met) - Next of kin home address was not always available and photographs were not available for all service users. To ensure that all plans are signed by service users/and/or their representatives and reviewed monthly (nursing) (previous timescale of 31/10/04, 31/10/05 and 01/05/06 not fully met) To provide additional detail in service user plans relating to : - Oral care - Diabetic care - Agreed limitations on choice, freedom or decision making (previous timescale of 31/10/04, 31/10/05 and 01/05/06 not fully met) Need to include actions to be taken in the event of a high blood sugar. DS0000004829.V306855.R01.S.doc Timescale for action 01/09/06 2 OP7 15(1) 01/10/06 3 OP7 15(1) 01/10/06 Valley Court Version 5.2 Page 24 4 OP7 15(1) 5 OP7 15(1) To ensure that service user care plans are updated to identify any changes in need (previous timescale of 31/03/05 and 31/10/05 not met) Timescale of 01/05/06 not fully met. To devise and implement the following wherever needed: - short-term care plans for use of antibiotics - care plan for the management of pain relief -Guidance for PRN medication, example Promazine, Temazepam Timescale of the 01/05/06 not fully met. No care plan was available for a service user prescribed prn (as required) diazepam. Another service user did not have a revision to their care plan following the commencement of antibiotics. Service users must have all required risk assessments that are reviewed at least monthly or as clinically indicated. Service users must be moved and lifted safely which also includes the regular relief of pressure. Service users must be weighed at least monthly or as clinically indicated. 1) To ensure that there are two signatures to witness hand written MAR sheets (Previous timescale of 31/10/05 and 01/05/06 not met (nursing unit) 3) To keep the room temperature in the treatment room on the nursing unit under review to maintain the temperature below 25oC. 01/10/06 01/10/06 6 OP8 15,13(6) 31/08/06 7 OP8 13(5) 22/08/06 8 9 OP8 OP9 15 13(2) 22/08/06 22/08/06 Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 25 10 OP9 11 OP12 (Previous timescale of 31/10/05 and 01/05/06 not met)- an immediate was issued. 13(2) To ensure that medication is stored safely within required temperatures: Drug fridge temperature to be maintained between 2 and 8oC Treatment rooms to be maintained below 25 oC. 16(2)m)n) 1) To encourage service user led activities, which may occur spontaneously for staff to follow and participate (Previous timescale of 31/10/04, 31/10/05 and 01/05/06 not met) 2) To devise and implement weekly activity planners for each person to include structured and spontaneous activities at weekends / holiday times and introduce a documented evaluation process for all activities taking not of refusals (previous timescale of 31/04/04, 31/10/05 and 01/05/06 not fully met) 22/08/06 01/10/06 12 OP12 16(2)17(2 ) 1) To complete details of hobbies 01/10/06 / interests and an activities audit for each person which is them kept under review, particularly for less able people (Previous timescale of 31/10/05 and 01/05/06 not fully met) 2) To ensure the activities log is completed for each person (previous timescale of 31/10/05 and 01/05/06 not fully met) 13 OP13 13(4) To ensure that ALL visitors to the 01/09/06 Home are requested to identify themselves, enter their details in the visitors’ book and are appropriately escorted, as necessary. DS0000004829.V306855.R01.S.doc Version 5.2 Page 26 Valley Court 14 OP15 16(2)(i) Timescale of the 01/04/06 not met. The home must ensure that residents have drinks of their choice when they wish. 1) To review and expand the restraint policy / procedure including references to staff training in physical intervention and appropriate documentation of any incidents (previous timescale of 31/10/04, 31/10/05 and 01/05/06 not fully met) 2) To obtain staff training relating to the protection of vulnerable adults, dealing with challenging behaviour, use of physical intervention (previous timescale of 31/10/04, 31/10/05 and 01/05/06 not fully met) 18/10/06 15 OP18 13(6) 01/10/06 16 OP19 23(2) 1) To produce a documented 01/10/06 programme of (planned) routine maintenance and renewal of the fabric and decoration of the premises (previous timescale of 31/10/04, 31/10/05 and 01/05/06 not met) 2) To submit a copy of the planned programme to the CSCI office, Halesowen by 01 May 2006 – timescale not met. 17 OP19 23(2) To conduct a documented review of the storage space (especially on the nursing unit) and identify appropriate storage for the large numbers of wheelchairs, walking frames, hoists and screens (previous timescale of 31/10/05 and 01/05/06 not met) 01/10/06 Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 27 18 OP19 23(2) 1) To progress the repair/replacement of carpets in communal areas which are heavily stained or have worn joints (timescale of 31/05/05, 30/11/05 and 01/06/06 not fully met) 2) To progress the renovation/redecoration of corridors and consider the provision of some means of protection against ongoing damage to the walls from trolleys and wheelchairs (timescale of 31/05/05, 30/10/05 and 01/06/06 not fully met) 01/12/06 19 OP22 23(2) To seek an assessment/advice from an appropriately qualified occupational therapist or other appropriate professional regarding access to bathroom / toilet facilities, which are currently not been used (stated to be because of lack of accessibility for service users) (previous timescale of 31/05/05, 30/11/05 and 01/06/06 not met) To investigate and resolve the poor water pressure in bedroom 29 (previous timescale of 31/10/05 not fully met) 01/10/06 20 OP25 23(2) 01/10/06 21 OP26 13(4) 22 OP27 13(4) To continue to improve levels of 01/09/06 cleanliness throughout the home in response to comments from some resident and relatives (previous timescale of 31/10/05 and 01/05/06 not fully met) 1) To ensure that yellow clinical 01/09/06 waste bags are disposed of in a secure container in a secure area Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 28 2) To ensure that there are sufficient collections of clinical waste to avoid overflowing containers Timescale of the 01/05/06 not met clinical waste bins were unlocked and were seen to be overflowing. 1) To review staffing levels throughout the home, in conjunction with an assessment of residents dependency and occupancy levels particularly on the nursing unit 2) To undertake a documented audit of the clinical nursing needs / nursing hours provided 3) To ensure that there are adequate numbers of all designations of staff on duty to meet residents needs and avoid residents having to wait for lengthy periods for attention (previous timescale of 31/10/05 and 01/05/06 not fully met) 24 OP29 17(1)19(1 ) To continue with the process of 01/09/06 obtaining all information required for staff files to meet the documentation identified in Regulation 17(1) Schedule 2 and 4 (Previous timescale of 30/11/04 and 01/05/06 not fully met) All staff did not have a photograph To obtain information for agency 01/09/06 staff working at the home relating to: - personal information - POVA/CRB clearance - training undertaken (previous timescale of 31/10/05 and 01/05/06 not fully met) 23 OP27 18(1)(a) 01/09/06 25 OP29 17(1)19(1 ) Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 29 26 OP29 17(1)19(1 To provide documentary evidence that all new staff have been registered to undertake Skills for Care accredited induction within six weeks and foundation training within six months (previous timescale of 30/11/05 and 01/05/06 not met) Breaches in the home policy on criminal records must be explored and appropriate actions undertaken. To produce an annual development plan for the home with continuous self monitoring, preferably using an accredited quality assurance system and evidencing the involvement of service users, representatives and other community stakeholders, to be forwarded to the CSCI satellite office Halesowen (previous timescale of 31/10/04, 30/11/05 and 01/06/06 not fully met) Care staff receive at least 6 supervision sessions annually with a record made of the supervision. 1) To ensure that all areas of risk associated with individual service users are clearly documented, such as moving and handling, challenging behaviours, falls, personal safety within the Home’s environment and on any activities where the Home has a duty of care (timescale of 31/10/04, 30/11/05 and 01/06/06 not fully met) 01/10/06 27 OP29 19 01/09/06 28 OP33 24 01/10/06 29 OP36 18 01/10/06 30 OP38 13(4) 01/09/06 Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 30 31 OP38 13(4)23(4 1) To ensure that new members of staff receive the following mandatory training as a priority: - fire training / drill - moving and handling - using of hoists - food hygiene - infection control New members of staff must not undertake duties until appropriate training has been undertaken (previous timescale of 31/10/05 and 01/05/06 not met) 2) To provide Dementia training ( previous timescale of 01/05/06 not met.) To provide a bedrail risk assessment / evidence of regular checks for all rooms where they are in use (previous timescale of 01/05/06 not fully met.) A monthly check of the flow and return hot water temperature must be undertaken at least monthly. 01/10/06 32 OP38 13(4) 01/09/06 33 OP38 16 01/09/06 Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 31 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 OP3 Good Practice Recommendations The element of the terms and conditions of residency that specifies that belongings left at the home were liable to a storage fee is reviewed. Care planning is “person centred”. Where residents have their meals is reviewed. The provision of hot drinks is reviewed with consideration given to ways that drinks can be more freely availablesuch as “press” bottom hot water flasks. The menu is reviewed. The garden is made attractive for residents to enjoy. That the rarely used bathroom on the residential unit should be changed into a walk in shower facility to give service users a choice of showering or bathing That the number of maintenance and gardening hours provided is increased to maintain satisfactory standards at the home The number of staff that hold and have access to the safe keys is reduced. 2. 3 4 OP7 OP15 OP15 5 6 7. OP15 OP19 OP22 8 OP27 9 OP35 Valley Court DS0000004829.V306855.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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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