Inspection on 15/03/06 for Valley Court

This inspection was carried out on 15th 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

Valley Court 08/08/08

Valley Court 09/08/07

Valley Court 14/08/06

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 Mrs Jean Edwards Unannounced Inspection 1st March 2006 07:15 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.V284651.R01.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. Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 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.V284651.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 7th September 2005 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 care 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 user’s 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 and the nursing beds. Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit has been undertaken by two inspectors from the Commission for Social Care Inspection (CSCI) using the following information : the action plan submitted by the home to the inspection in September 2005, reports of recent events and incidents from the home and records held at the home. The visit commenced at 07:15 and lasted until 17:30. During the inspection the inspectors spoke to the majority of the 63 residents who are currently living at the home. A tour of the building has taken place, looking in particular at the kitchen, treatment rooms, and communal areas of the home and a sample of residents’ bedrooms, with their permission. What the service does well: The majority of staff encourage the residents to treat Valley Court as their own home and to be as independent as their potential allows. Residents can generally make their own choices and can take an active part in meetings and surveys if they wish. Comments from visitors and some residents on the residential unit are, this is a very good home and I have recommended it to my neighbour, everyone is friendly, they are very good - all staff are friendly and helpful. The staff group, which has again experienced some upheaval, has a number of people who have worked at the home for some time and know the residents well. They continue to show that they are caring, committed and flexible, often willing to work extra shifts. Comments from residents and relatives about the staff are generally positive, though there are repeated comments about lack of available time chatting and helping residents and the heavily reliance on agency staff. Members of staff have been positively involved in the inspection process and have answered questions in an open and honest manner. District nurses visiting the residential unit have given positive comments, stating the staff are knowledgeable and helpful and respectful to residents. Members of staff at the home make contact with district nurses in an appropriate and timely way to make sure that residents health care needs are met. The multidisciplinary team and CSCI have been commended the deputy manager and registered manager for their prompt actions to instigate the Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 6 multi-agency procedures for the protection of vulnerable adults when recent incidents came to light. There has been a high level of co-operation from the home to ensure that all residents in the home are properly safeguarded. 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. What has improved since the last inspection? What they could do better: The organisation, has responded to the previous inspection report with a comprehensive action plan, giving dates for the required improvements to be put into place. However a number of improvements required at the last inspection visit are still to be put in place. The homes action plan with dates for improvements must be completed within those timescales. Although the home has previously improved security and generally all visitors are requested to identify themselves, enter their details in the visitors book, this has not been the experience of the Inspectors at this visit. Security relating to visitors must be maintained at all times and they must be requested to identify themselves and be appropriately escorted around the premises. There is an outstanding requirement for the Organisation needs to review the contract / terms and conditions using the publication from the Office of Fair Trading: Guidance on Unfair Terms in Contracts in Care Homes. All residents need to be issued with an updated contact / terms and conditions. Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 7 Although the home employs activities coordinator for four days each week, this person is often used to cover care shifts. As identified at the previous inspection in September 2005 a number of residents and relatives are dissatisfied with the lack of activities. A resident who has been at the home for two years states, I loved it here but its not so good now, there are not many activities even if we ask for them, the staff are wonderful but they do not have enough time. The registered person must provide the CSCI office Halesowen with a copy of an up-to-date programme of redecoration, maintenance and repair, expanded to include all areas, facilities and equipment and with timescales for work to be completed. Although there have been some improvements to the cleanliness of the home, there are still areas, which look grubby and have excessive dust and grime. A regime must be implemented to make sure that all areas of the home are cleaned to a satisfactory standard of cleanliness and infection control throughout the home at all times. In addition some armchairs, cantilever tables and inappropriate feeding cups must be replaced as a priority. Although the staffing levels appear generally adequate there continue to be comments from residents and relatives, which indicate that there are not sufficient numbers of staff to provide timely care, stimulation or outings. Currently the home is heavily dependent on agency staff and though there may be sufficient numbers of staff, this may not provide continuity of good quality care to safely meet the residents needs. The deputy care manager responsible for the residential unit, and two trained nurses have left the homes employ since the last inspection. Additionally a senior nurse has moved from the nursing unit to take charge of the residential unit, leaving only five trained nurses to cover all shifts on the nursing unit. As identified at the inspection in September 2005 the registered manager must review the numbers of staff on shift, including the numbers of nurses to provide clinical nursing care; this exercise must now be undertaken as a priority. Consideration must be given to residents needs and wishes and appropriate numbers of competent, permanent staff must be available at all times. The positive work of the majority of staff can only be continued and developed with sufficient numbers of permanent staff. The staff records must be more detailed, for example there must be a recent photograph on each persons file. The Organisation must take account of revised guidance from the Department of Health relating to the protection of vulnerable adults and Criminal Records Bureau clearances. In addition the Organisation must review and update its staff procedures in view of the introduction of the protection of vulnerable adult abuse (POVA) register. The home is required to make improvements to a number of areas of health and safety practices and records, with evidence provided to the Commission for Social Care Inspection. Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 8 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.V284651.R01.S.doc Version 5.1 Page 9 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.V284651.R01.S.doc Version 5.1 Page 10 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 Service users can be assured that they have the required information in order to make a choice about living at Valley Court. The home has not yet updated contracts/terms and conditions of occupancy, this has the effect that residents and their advocates may not have the best information regarding their rights and entitlements and any agreed restrictions EVIDENCE: The registered manager has made improvements to the home’s statement of purpose; it now includes all of the required information and is displayed along with the service user guide and complaints procedure. This information is displayed in the lounge areas on both the nursing and residential sides of the building. The manager is currently in the process of distributing the service user guide and complaints policy to each service user for their information. Copies of the last inspection report were also seen on display. There is an outstanding requirement for the home’s contract / term and conditions to be revised and updated taking account of the Office of Fair Trading publication “Unfair Terms in Care Homes Contracts”. At present there Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 11 is insufficient evidence that each person has an appropriate contract / terms and conditions, which is appropriately signed and dated. Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 The care planning system in place is inconsistent and does not adequately provide staff with the information they need to satisfactorily meet residents needs. The home has made good progress to improve the arrangements for administration of medication, which generally safeguards the people living at the home. EVIDENCE: Each of the residents has a care plan generally based upon their assessed needs. There have been improvements to the care plans, the home is now recording some elements of service users preferred routines, such as rising and retiring times and their preferred form of address. There is some evidence that care plans are developed in conjunction with residents however some of the plans seen had not signatures in place to indicate agreements. Discussion with residents also reinforced this point when they indicated that they had no knowledge of the care that has been planned for them. “I don’t know what they do for me but I do know that they look after me”, “I didn’t know they write things down, that’s probably how they know what to do for me then”. Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 13 Risk assessments are in place for each resident looking at pressure sore risk development, nutrition screening and moving and handling issues. These are generally reviewed on a monthly basis but in some cases did not reflect the changing needs of residents. For example one residents pressure sore risk assessment had been reviewed on a monthly basis but did not reflect the fact that they had developed a grade 2 pressure sore, there was a care plan in place for this resident but when read in detail it did not provide an accurate picture of the level of care and treatment that they required. Residents who require bed rails on their beds to keep them safe did have risk assessments in most cases however these risk assessments need to have more detail so that potential risks are highlighted and staff must ensure that they are reviewed on a regular basis, again to reflect residents changing needs. Medication has not been assessed in full but progress was looked at in relation to previous requirements from September’s inspection. The home still needs to develop protocols that address blood sugar monitoring practices. The treatment room temperature fluctuates between 26 – 27oC the home needs to address this so that all medicines are stored at appropriate temperatures. Some of the service users have medicines on a “as required” basis the home currently does not produce a care plan that outlines the circumstances when this type if medicine should be administered or how to monitor it’s effectiveness. For example one resident is prescribed Diazepam on a PRN basis there is currently no care plan that indicates the circumstances when this medication will be needed by the resident or how to monitor its effectiveness. There are adequate facilities for cold storage of medicines, it is observed that liquid antibiotics are being stored appropriately but staff need to ensure that an “opening” date is recorded when the bottles are opened. Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Good contact is maintained with family and friends for the majority of residents and there is evidence that residents are supported to exercise control and make decisions about their lives. EVIDENCE: There is evidence that the home encourages residents, wherever possible to retain their independence to retain some control over their own financial affairs. Decisions regarding the management of residents financial arrangements are generally well documented. The home needs to proactively provide information about independent advocacy services. There is evidence from the tour of the premises and assessment of residents case files that people are encouraged to bring their personal possessions into the home if they wish, subject to health and safety considerations. These decisions are generally documented as part of the admission process. However the inventories held on the sample of individuals files assessed are not all complete and are not all appropriately dated and signed. Although it is positive that there is a proforma in place for the audits of bedroom facilities, the samples assessed are not accurate and kept up-to-date. For example records show that there are two comfortable chairs in residents bedrooms, when in fact there is only one in the bedrooms viewed. Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 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 home has a complaints system, however complaints are not always listened to and sufficient action is not always taken to look into them. Arrangements for protecting residents have improved but are not yet satisfactory and may not safeguard them from risk of harm or abuse. EVIDENCE: The home has a complaints procedure, which is contained in the statement of purpose and service user guide and is displayed in the home. However the procedure needs to be reviewed and updated to demonstrate full compliance with all elements of the Care Homes Regulations 2001 and National Minimum Standards for Older People. The registered person has not yet developed alternative formats for the complaints policy / procedure to ensure that it is provided in suitable formats for all residents to be able to understand and use it. The homes of complaints log, examined during the visit shows that there have been no complaints recorded since the inspection visit in September 2005. There has recently been a series of allegations of physical abuse of residents on the nursing unit. Members of staff at the home, including the deputy manager and registered manager, have responded swiftly to inform the Sandwell social services as the lead agency for the protection of vulnerable adults, the police, the CSCI, and relatives. Appropriate action has been taken to suspend members of staff potentially involved, without prejudice, to allow an investigation to take place to safeguard both residents and staff. All Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 16 agencies involved have commended the home for their actions and ongoing cooperation in following multi-agency procedures. Assessment of the homes policies and procedures relating to the protection of vulnerable adults, dealing with aggression, use of physical / non-physical intervention; whistle blowing and missing persons, identified the need for further revision and expansion. The manager must continue to regularly raise staff awareness of non-physical intervention strategies through supervision sessions and training. Progress needs continue to demonstrate that all staff have attended an approved training course relating to the protection of vulnerable adults and training must be provided relating to responding to challenging behaviours. Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 The management have a good understanding of the areas in which the home needs to improve, however there is currently insufficient planning in place indicating how this improvement is going to be resourced and managed. Although large, this is a generally homely and comfortable environment for residents. 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, and generally welltended grounds to the sides and rear. 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 Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 18 bathrooms identified a previous visits to be in need of adaptation have yet to be completed. During the tour of the premises a sample of residents’ bedrooms were viewed, with their permission. These are furnished appropriately according to the needs of each person. The bedrooms are tastefully decorated and it is evident that people are encouraged to personalise their rooms with their own possessions, pictures, mementos and furniture. A number of bedrooms have been redecorated since the last inspection visit. There is evidence that the home continues to be refurbished, redecorated and repaired on an ongoing basis. However a home of this size needs on-going maintenance and the maintenance person / gardener is employed for just two days each week. There is currently no documented audit and programme of maintenance, repair, replacement and redecoration available. This is an outstanding requirement. The tour of the premises identifies the following to be improved: The new resident in bedroom R18 has clean but a lumpy pillows and a pro pad mattress. The registered person must provide comfortable pillows and an appropriate mattress Assessment of the kitchen identified the following areas to be improved: Worn and damaged colour-coded chopping boards - to be replaced colour coded catering knives - to be provided damaged/ rusting waste bin in kitchen - to be replaced potato masher - suitable for task to be provided drinking beakers, placed in a bowl on the nursing unit, the majority of which are plastic and stained and some have baby motifs must be discarded and replaced with assisted crockery (in a material which upholds dignity) under which are age appropriate The lower areas in the dry store in the kitchen area of dusty and grimy and must be thoroughly cleaned During the visit it has been noted that there are no supplies of soap in the visitors toilet or in five communal toilet or bathing facilities on the ground floor of the residential unit. Staff state that soap dispensers have been reported as faulty at least a week ago. The lack of readily available supplies of liquid soap means that staff are unable to follow good practice guidelines for hand washing and residents are placed at risk of preventable infections. The registered person must ensure that there are supplies of liquid soap in all communal toilets and bathing facilities readily available at all times. Interim supplies of liquid soap have been provided at all locations identified during this visit. Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 Only limited progress has been made in addressing staffing shortages and as a result residents do not receive consistent care. The standard of vetting and recruitment practices is satisfactory, though improved records are needed to provide adequate safeguards for the residents. EVIDENCE: Assessment of staffing rotas demonstrates that the home is struggling to maintain satisfactory levels of substantive, trained, experienced competent staff across all units of the home. The homes staffing situation is worsened by the necessary suspension of three members of staff, whilst a vulnerable adults investigation takes place, and the home is even more heavily dependent on the use of agency staff. Comments throughout this visit indicate residents needs are not always met in they ways they would like. Care records are always not well completed and demonstrate that there is a lack of continuity in providing care particularly for the most dependent residents. Although the nursing unit currently has four vacant beds there continue to be a number of highly dependent residents and the overall number of substantive trained nurses available has reduced further since the last inspection, with the resignation of the former registered manager, who was undertaking work as an RGN and the relocation of the senior trained nurse to be the deputy manager responsible for the residential unit. Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 20 As identified at the previous inspection visit the registered manager must review staffing levels on a regular basis, using Department of Health Residential Forum Staffing Tool, taking account of the occupancy and dependency levels of residents accommodated, and provide adequate number of all designations of staff at all times. This must be actioned as a matter of priority. The Home operates generally robust recruitment practices. However assessment of a random sample of staff files identifies that the previous omissions, have not yet been rectified. The registered person must ensure that all members of staff receive the all required mandatory training commensurate with their duties as follows a minimum 2 fire training / drills in any 12 months, moving and handling, use of hoists, food hygiene, infection control, risk assessment and in addition training relating to protection of vulnerable adults, behaviours which challenge the service and Dementia training. Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 32,35,36,38 The management of the home is not consistently providing clear leadership and communication systems are always effective, with all staff clear of their roles and responsibilities. The standard of records and management of health and safety and control of infection at this home does not fully safeguard residents. EVIDENCE: Residents, staff and visitors consulted feel that the management team of the home are generally approachable, supportive and people feel that they are able to air their views in an open manner. However there have been comments during the visit indicating that action to deal with minor concerns are not always taken for a satisfactory resolution. The areas of activities and staffing have been particularly mentioned. There are clear lines of accountability within the home, with Joan Green, the Registered Manager in day-to-day control of the home and a recently relocated Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 22 senior nurse, appointed as deputy manager responsible for the residential unit. She acknowledges the settling in period and the need for her to familiarise herself with the residents and staff on the residential unit. There is a designated Responsible Individual from the organisation, who is now providing monitoring through monthly unannounced Regulation 26 visits and reports to the home and CSCI office, Halesowen on a consistent basis. Formal supervision and support must be provided to the registered manager on a regular basis. The registered person must continue to make progress to fully meet the requirement to implement a comprehensive system of self-evaluation, with an annual development plan. The Home currently provides support for a number of residents to manage their finances, providing temporary safekeeping for small sums of money. A random sample of balances and records assessed are satisfactory, with two signatures and individual receipts. There is an outstanding good practice recommendation for an independent audit of residents finances held by the home to take place on a regular basis. During this visit it has been noted that care staff are not always following infection control guidelines and have been noted to be wearing the same disposable gloves and aprons to deal with personal care of more than one resident, which does not demonstrate good infection control practice. Improvements are also required to ensure that yellow clinical waste bags are disposed of in a secure container in a secure area and action must be taken to ensure that there are sufficient collections of clinical waste to avoid overflowing containers. A sample of fire safety and maintenance documentation examined is generally satisfactory. Good progress has been made to ensure that all members of staff have received fire training, with 49 members of staff attending one of 35 training sessions. However during the tour of the premises was noted that painting and decorating materials have been stored under the stairwell on the rear ground floor of the Sandringham unit. These have been removed and relocated to a secure area at the inspectors request. The registered person must ensure that the areas under the stairs in the home are kept free from any combustible materials at all times. The accident records examined are satisfactory. There have been 74 accidents involving (Residential) residents and 17 accidents involving (Nursing) residents since September 2005. Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 23 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 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X 2 X 2 STAFFING Standard No Score 27 2 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 2 X X 2 X 2 2 Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 24 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 OP2 Regulation 5(1)(b) Requirement Timescale for action 01/05/06 2 OP2 5(1)(b) To review the contract/terms and conditions using the publication from the Office of Fair Trading: Guidance on Unfair Terms in Contracts in Care Homes (previous timescale of 31/10/04 and 31/10/05 not met) 1) To ensure each person is 01/05/06 issued with an appropriate document – contract/terms and condition (for residents funded by the local authority), with the details of who is responsible for paying fees and responsible for any breaches 2) To ensure that here is an up to date signed and dated copy of the contract/terms and conditions on each residents file (previous timescale of 31/10/04 and 31/10/05 not met) To provide documented evidence 01/05/06 that prospective service users and/or their representatives are involved with the pre-admission assessment (previous DS0000004829.V284651.R01.S.doc Version 5.1 3 OP4 14(1) Valley Court Page 25 4 OP4 14(1) 5 OP7 15(1) 6 OP7 15(1) 17(2) sch 2&4 6 OP7 15(1) 7 OP7 15(1) 8 OP7 15(1) 9 OP7 15(1) timescale of 31/10/04 not met) To ensure that the homes assessment pro forma is fully completed, dated and signed by the assessor and the resident or their representative To expand service user plans to include more detailed and specific information / statements / short and long term goals and monitoring arrangements, in order to meet all of the National Minimum Standards (previous timescale of 31/10/04and 31/10/05 not fully met) To continue the process of obtaining documentation for service user case records as identified in Regulation 17(1)(2) Schedules 3 and 4 (previous timescale of 31/10/04 and 31/10/05 not fully met) To ensure that all plans are signed by service users/and/or their representatives and reviewed monthly (nursing) (previous timescale of 31/10/04 and 31/10/05 not fully met) To complete all service user plans with details of - preferred bathing times (previous timescale of 31/10/04 and 31/10/05 not 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 and 31/10/05 not met) To provide explicit details and guidance for all aspects of care as part of each person’s plan for DS0000004829.V284651.R01.S.doc 01/05/06 01/05/06 01/05/06 01/05/06 01/05/06 01/05/06 01/05/06 Valley Court Version 5.1 Page 26 example: - Continence management / promotion - Management of agitated / aggressive behaviour - PEG feeds to ensure that all areas of risk are assessed, with documented staff guidance as part of each person’s plan for example: asphyxiation / increased falls (previous timescale of 31/10/05 not met) 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) 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 To devise and implement a care plan, risk assessment and risk management guidelines for the service user identified as presenting with aggressive behaviour (previous timescale of 31/03/05 and 31/10/05 not met) To ensure that appropriate measures are in place to meet the needs of any service user with behaviour which challenges the service (previous timescale of 31/10/04 and 31/10/05 not met) The registered manager must ensure that: All files contain accurate tissue viability / pressure sore risk DS0000004829.V284651.R01.S.doc 10 OP7 15(1) 01/05/06 11 OP7 15(1) 01/05/06 12 OP7 15(1) 01/05/06 13 OP7 15(1) 01/05/06 14 OP8 12(1) 15(1) 01/05/06 Valley Court Version 5.1 Page 27 assessments To ensure that tissue viability / pressure sore risk assessments are completed in full and regularly reviewed to demonstrate service users changing needs (previous timescale of 31/03/05 and 31/10/05 not met) To provide documentary evidence of specialist pressure relieving equipment provided as part of each person’s plan To provide detailed documentary evidence of: - Oral care provided (previous timescale of 31/03/05 and 31/10/05 not met) 1) To ensure that all residents are weighed on admission have part of a baseline assessment 2) To refer any residents who are having repeated or frequent falls to Sandwell Falls Prevention Service To devise and implement a documented protocol and identify parameters for abnormal BM’s (blood sugar monitoring results) (previous timescale of 30/04/05 and 31/10/05 Not Met) 1) To ensure that the specimen signature list is up to date (residential unit) (Previous timescale of 31/10/05 not met) 2) To ensure that there are two signatures to witness hand written MAR sheets (Previous timescale of 31/10/05 not met) Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 28 15 OP8 12(1) 15(1) 01/05/06 16 OP8 13(1) 01/05/06 17 OP9 13(2) 01/05/06 18 OP9 13(2) 01/05/06 3) To keep the room temperature in the treatment room on the nursing unit under review to maintain the temperature below 25oC. (Previous timescale of 31/10/05 not met) 4) To ensure that variable dosages are accurately recorded on MAR sheets, e.g. one tablet or two (Previous timescale of 31/10/05 not met) 5) To ensure the authorisation for changes to MAR sheets is clearly indicated and that any changes are dated, signed and witnessed 13(1) To ensure that the Activities of 17(2) Daily Living (ADL) forms are signed by staff and that these forms accurately reflect the entries on the separate checklists used to record personal care given 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 and 31/10/05 not met) 19 OP10 01/05/06 20 OP12 01/05/06 21 OP12 16(2) 17(2) 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 and 31/10/05 not fully met) 1) To complete details of hobbies 01/05/06 / interests and an activities audit DS0000004829.V284651.R01.S.doc Version 5.1 Page 29 Valley Court for each person which is them kept under review, particularly for less able people (Previous timescale of 31/10/05 not fully met) 2) To ensure the activities log is completed for each person (previous timescale of 31/10/05 not fully met) To ensure that ALL visitors to the Home are requested to identify themselves, enter their details in the visitors book and are appropriately escorted, as necessary 1) To ensure that residents inventories and audits of bedroom facilities are accurate and kept up-to-date 2) To proactively provide information about independent advocacy services 1) The registered manager must ensure that the homes complaints policy / procedure reflect all of standard 16 2) To ensure that the complaints policy / procedure is provided in suitable format for all service users to be able to understand (previous timescale of 31/10/05 not fully met) 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 and 31/10/05 not fully met) 2) To obtain staff training relating to the protection of vulnerable adults, dealing with challenging behaviour, use of Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 30 22 OP13 13(4) 01/04/06 23 OP14 17(2) Sch 4 01/06/06 24 OP16 22 01/06/06 25 OP18 13(6) 01/05/06 26 OP18 13(6) physical intervention (previous timescale of 31/10/04 and 31/10/05 not met) 1) To review and expand the missing persons policy (more than two years old) replacing terms such a NCSC with CSCI (previous timescale of 31/10/05 not fully met) To make advocacy information proactively available (previous timescale of 31/10/05 not fully met) 1) To produce a documented programme of (planned) routine maintenance and renewal of the fabric and decoration of the premises (previous timescale of 31/10/04 and 31/10/05 not met) 2) To submit a copy of the planned programme to the CSCI office, Halesowen by 01 May 2006 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 not met) 1) To renovate or replace all stained and damaged comfortable chairs in the communal lounge on the nursing (Windsor) unit 2) To renovate or replace the damaged furniture (e.g. cantilever tables) in the communal lounge on the nursing (Windsor) unit 01/05/06 27 OP19 23(2) 01/05/06 28 OP19 23(2) 01/05/06 29 OP19 23(2) 01/06/06 Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 31 30 OP24OP21 OP19 23(2) 3) To rectify the worn joins in the carpet in the dining and lounge areas on the nursing unit 1) To progress the repair/replacement of carpets in communal areas which are heavily stained or have worn joints (timescale of 31/05/05 and 30/11/05 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 and 30/10/05 not fully met) 01/06/06 31 OP22 23(2) 32 OP15OP22 16(2)(g) 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 and 30/11/05 not met) To replace / provide the following catering items: 01/06/06 01/05/06 33 OP24 23(2) 1) Worn and damaged chopping boards 2) colour coded catering knives 3) damaged/ rusting waste bin in kitchen 4) potato masher - suitable for task 5) drinking beakers, which are age appropriate on the nursing unit (in a material which upholds dignity) To provide comfortable pillows 01/05/06 and an appropriate mattress for DS0000004829.V284651.R01.S.doc Version 5.1 Page 32 Valley Court 34 OP25 23(2) 35 OP26 13(4) 36 OP27 13(4) the new resident in bedroom R18 To investigate and resolve the 01/05/06 poor water pressure in bedroom 29 (previous timescale of 31/10/05 not met) To continue to improve levels of 01/05/06 cleanliness throughout the home in response to comments from some resident and relatives (previous timescale of 31/10/05 not met) 1) To sure that all staff follow 01/05/06 infection control guidelines and use disposable gloves and aprons appropriately 2) To ensure that there are supplies of liquid soap in all communal toilets and bathing facilities readily available at all times 3) To ensure that yellow clinical waste bags are disposed of in a secure container in a secure area 4) To ensure that there are sufficient collections of clinical waste to avoid overflowing containers 5) To thoroughly clean the lower areas in the dry store in the kitchen area To recruit sufficient numbers of 01/06/06 staff, including trained nurses, to ensure that the home is not continuously dependent on agency staff 1) To review staffing levels 01/05/06 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 37 OP27 18(1)(a) 38 OP27 18(1)(a) Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 33 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 not fully met) 39 OP29 17(1) 19(1) To review and update the disciplinary and grievance procedures and staff contracts in view of the introduction of the protection of vulnerable adult abuse (POVA) register (previous timescale of 31/10/05 not met) To continue with the process of 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 not met) To ensure staff files include the following: - A recent photograph - Two sources of identification - An accurate job description - copy of the signed and dated contract of employment - evidence of qualification, signed by the manager to indicate that originals have been seen (previous timescale of 30/11/05 not met) To obtain information for agency staff working at the home relating to: - personal information - POVA/CRB clearance - training undertaken (previous timescale of 31/10/05 not met) To provide documentary evidence that all new staff have DS0000004829.V284651.R01.S.doc 01/05/06 40 OP29 17(1) 19(1) 01/05/06 41 OP29 17(1) 19(1) 01/05/06 42 OP29 17(1) 19(1) 01/05/06 43 OP29 17(1) 19(1) 01/05/06 Page 34 Valley Court Version 5.1 44 OP33 24 45 OP37 17(1) been registered to undertake Skills for Care accredited induction within six weeks and foundation training within six months (previous timescale of 30/11/05 not met) To produce an annual 01/06/06 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 and 30/11/05 not fully met) To cease the use of tippex on 01/05/06 any records required to be kept by the Care Homes Regulations / Schedules To ensure that all records are completed legibly and accurately in black ink 1) To designate a person at the Home to take overall responsibility for health and safety with appropriate training accessed as soon as practicable (previous timescale of 31/10/04 and 30/11/05 not met) 2) To ensure the health and safety and welfare of service users and staff especially that risk assessments are carried out for all safe working practice topics and that significant findings of risk assessments are recorded; and that staff receive training and updates to meet TOPSS specifications (timescale of 31/10/04 and 30/11/05 46 OP38 13(4) 18(1)(c) 01/06/06 Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 35 not met) 3) To provide documentary evidence that approved risk assessment awareness training has been arranged for all staff to delivered within an identified timescale (timescale of 31/10/04 and 30/11/05 not met) 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 and 30/11/05 not met) 2) To ensure that documented risk assessments and risk management strategies relating to the service users and the environments are reviewed expanded and implemented (timescale of 31/10/04 and 30/11/05 not met) 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 not met) 49 OP38 13(4) 2) To provide Dementia training To provide a bedrail risk DS0000004829.V284651.R01.S.doc 47 OP38 13(4) 01/06/06 48 OP38 13(4) 23(4) 01/05/06 01/05/06 Page 36 Valley Court Version 5.1 50 OP38 13(4) assessment / evidence of regular checks for all rooms where they are in use To ensure that the areas under the stairs in the home are kept free from any combustible materials (decorating materials have been relocated during this visit) 16/03/06 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 2 3 Refer to Standard OP7 OP9 OP10 Good Practice Recommendations That consideration is given to the use of the term problem relating to an identified care need That staff must not use a tick to indicate administration of creams on MAR charts That unnamed tights and continence nets left in the ground floor linen cupboard on Balmoral unit be returned to original owners or if that is not possible they should be discarded That staff must not use correction fluid when writing on service users documentation That staff signatures are obtained to demonstrate awareness of the multi agency policy/ procedures for the protection of vulnerable adults. That the organisation follows the multi-agency procedure for the protection of vulnerable adults diligently and only takes actions which are agreed by the lead agency and police to instigate internal investigations and any disciplinary procedures 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 rotas identify service user dependencies and occupancy levels and that regular documented review of staffing levels using the staffing tool, is conducted That the number of maintenance and gardening hours provided is increased to maintain satisfactory standards at the home DS0000004829.V284651.R01.S.doc Version 5.1 Page 37 4 5 6 OP8 OP18 OP18 7 8 9 OP22 OP27 OP27 Valley Court 10 11 OP29 OP29 12 13 14 15 OP29 OP33 OP35 OP37 16 17 OP38 OP38 That staff files are reorganised and structured with the use of an index/checklist and dividers That documentary evidence is obtained to confirm that each new member has been issued with an individual copy of the General Social Care council – Code of Practice and Conduct That professional references have evidence of their origin, such as the company stamp or headed paper That the Registered Manager reviews, dates and signs all policies procedures and good practice guidance That service users temporary financial accounts held by the home are independently audited on regular basis That serious consideration be given to providing the home with IT equipment to generate and maintain satisfactory records and access to up-to-date practice and legal guidance That staff signatures are obtained to demonstrate their awareness of policies and procedures, especially relating to the protection of vulnerable adults That commode pots are numbered so that they are returned to room of origin, which improves infection control measures Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 38 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. Extracts may not be used or reproduced without the express permission of CSCI Valley Court DS0000004829.V284651.R01.S.doc Version 5.1 Page 39 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!