CARE HOMES FOR OLDER PEOPLE
Valley Court Valley Road Cradley Heath West Midlands B64 7LT Lead Inspector
Jean Edwards Unannounced 7 September 2005
th 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 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 E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Valley Court Address Valley Road, Cradley Heath, West Midlands, B64 7LT Telephone number Fax number Email 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 E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 7th March 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 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. Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection visit was 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 unannounced inspection in March 2005, reports of events and incidents from the home and records held at the home. The visit commenced at 7:45am and lasted until 4:50pm. During the visit the inspectors spoke to the majority of the 66 residents who are currently living at the home, with longer discussions taking place with the residents and/or their relatives, whose care was looked at in depth. The Deputy Manager, trained nurses and senior carers took an active part in the inspection process. The Inspectors toured the building, looking in particular at the laundry, treatment rooms, and communal areas of the home and a sample of residents’ bedrooms, with their permission. What the service does well:
The organisation has responded to the previous inspection report with a comprehensive action plan, which gave dates for the required improvements to be put into place. There is satisfactory progress in a number of areas, however a number of improvements required at the last inspection visit are still to be put in place. Residents are encouraged by staff to treat Valley Court as their own home and to be as independent as their disabilities allow. Residents are able to make their own choices and can take an active part in meetings and surveys if they wish. Views can be freely aired about the running of the home. Some comments from a recent survey are: everyone is friendly, I am happy here, they are all very good - all staff are friendly and helpful and we all have privacy when we require it. The meals are thoughtfully and well prepared, and the menus are pre-planned and each persons preferences are recorded each day. In addition members of staff were seen to ask residents what they preferred at each mealtime. Special diets are prepared and served in a way, which tempts people to eat. A relative comments, quality of food is excellent - all residents have wide variety of food, prepared and cooked to perfection by kitchen staff. Members of staff are available at mealtimes and are able to sensitively offer people help and assistance, as they need it.
Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 6 Valley Court has a more stable staff group; many have worked at the home for some time and know the residents well. They are caring, committed and flexible, often willing to work extra shifts. Comments from residents and relatives about the staff include, the staff are wonderful, very respectful and friendly - they would like to spend more time chatting and helping residents but this can only be achieved with more staff. During the visit staff demonstrated a dedicated approach to their work; they clearly know residents’ likes and dislikes and how to meet their needs. They are keen to share views and answered any questions in an open and honest manner. This inspection was conducted with full co-operation of the Registered Manager, staff and residents. The atmosphere throughout 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?
The staff make sure that all areas of need are thoroughly assessed before people are admitted to the home. For example there are now full details recorded about each persons mobility, weight, sleep pattern, likes and dislikes. There are detailed care plans in place for each resident; further information has been included to cover all areas of care needed. The majority of personal plans now contains details about social interests, alternative communication methods where needed, and preferred daily routines. Personal plans are signed by residents and/or their representatives and they are reviewed on a monthly basis on the residential unit, though these improvements need to be fully completed on the nursing unit. Action has been taken to improve the way medication is stored, administered and recorded and the home now has a rigorous medication system, which safeguards residents well being, with only a few minor improvements still to be made. The Home has improved security and now all visitors are requested to identify themselves, enter their details in the visitors book and they are appropriately escorted around the premises. The complaints guidance for staff has been improved with the production of a flowchart to follow. The home has received one complaint since the last inspection visit, which has been successfully resolved.
Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 7 The communal toilets and some bathing facilities throughout the home have been redecorated and refurbished as necessary, creating a cleaner, brighter environment for residents. The home has held discussions with residents as to provision of facilities in their bedrooms, for example whether they want one or two comfortable chairs, writing tables and so on. Additional chairs have been provided in bedrooms or are available in communal areas to be used in bedrooms for visitors, as required. The decisions reached are recorded in each persons care plan. An audit of all bedrooms has taken place to identify and rectify minor repairs required. An audit of bedding, pillows, sheets and towels has also taken place and a replacement programme has made sure that all items are now at an acceptable standard. There is a general improvement to carpets in communal areas, some have been steam cleaned to a satisfactory standard and others have been replaced, for example Balmoral dining room carpet. The number of domestic staff on duty on a daily basis has been increased to maintain satisfactory standards of cleanliness and infection control throughout the home. Some comments from relatives and residents were positive about the level of cleanliness, whilst others commented that it still needed to be improved in some areas, giving an example of a residents bedroom. The organisation has submitted a formal application for the registration of the acting manager to the CSCI satellite office, which has recently been successfully processed. The home has implemented its own surveys to obtain the views of residents, relatives, and visitors as to how they think the home is performing. Results now need to be collated, published and acted upon. There are improvements to some areas of health and safety in the home, such as improved access to high level medication cupboards in the treatment room on the residential unit, with control measures, steps, put in place, to provide a safe system of access for staff. What they could do better:
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; this is an outstanding requirement from previous visits. The Registered Manager must make sure that each persons susceptibility to develop pressure sores is accurately assessed and regularly reviewed to be consistent with any special pressure relieving equipment, especially if this is already in place. Records of the care provided to treat any pressure sores must be more detailed. This especially applies to the residential unit.
Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 8 The Registered Manager must ensure that the all healthcare screening processes and records are regularly reviewed and accurately show the current situation for each person, especially where weight loss is noted. Any resident with significant weight loss over a period of time must be referred to the GP and dietician in good time for advice and support Although the home has made very good progress to improve the systems relating to medication in the home, there are a few required improvements from previous visits, not fully in place. For example any unclear directions for dosages must be discussed with the doctor and/or the pharmacist. The home has not yet fully resolved the excessive temperatures recorded at times, in the treatment rooms. The home must ensure that medication is stored at temperatures below 25 C at all times. Minor improvements are also required for the completion of medication records. The home has a programme of redecoration, maintenance and repair, however this must be expanded to include all areas, facilities and equipment. Although staffing levels appear generally adequate there are a number of comments from residents and relatives, which indicate that there are not enough staff to provide timely care, stimulation and outings. Examples of comments are, staff very good - a few more permanent staff would help the sometimes overworked staff, there are too many occasions when they are short staffed, staff shortages - could play more stimulating games and residents are bored or asleep in the afternoons - occasional outings would be great. The registered manager must review the numbers of staff on shift, including the numbers of nurses to provide nursing care. Consideration must be given to residents needs and wishes and appropriate numbers of staff must be available at all times. 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 organisation must make that there are monthly monitoring visits and reports about the conduct of the home by the nominated representative on a consistent basis. 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. 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 E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 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 standard(s) 1,2,3,4,5 Information about the running and performance of the home is not made proactively available. 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. The home uses assessment tools, which means that residents’ needs are assessed to ensure that care needs will be met. Despite the lack of documentary evidence, introductory visits and trial stays are encouraged by the home, ensuring that people have time to make decisions, which are right for them. Standard 6 is not applicable. This home does not provide intermediate care. EVIDENCE: Although the home has an updated statement of purpose and service user guide, neither is available in the home. There is no copy of recent inspection reports in evidence in the public parts of the home. There is little evidence from discussions with residents and families that documented information about the home is given to them.
Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 11 There is an outstanding requirement for the homes contract / terms 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 is insufficient evidence that each person has an appropriate contract / terms and conditions, which is appropriately signed and dated. Examination of a sample of residents’ case files demonstrates that the home has obtained the referral agency’s assessment of needs and in most cases a care plan. There are copies of Sandwell Authority’s single assessment information for people admitted from the Sandwell area. In addition the home has a comprehensive assessment tool, which is now generally well completed with all relevant information. Evidence from informal discussions with residents and families is that the home does offer an opportunity to visit before an admission takes place. Prospective residents and their families visited the home during this inspection visit. However there is no documentation relating to introductory visits on each persons case file. Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 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 standard(s) 7,8,9,10 The care planning system in place is inconsistent and does not adequately provide staff with the information they need to satisfactorily meet residents needs. Although the health needs of residents are generally well met with evidence of good multi disciplinary working taking place on a regular basis, records are not satisfactory. The home has made good progress to improve the arrangements for administration of medication, which generally safeguards the people living at the home. EVIDENCE: There is a there is a care plan in place for each person, based on his or her assessed needs, and though there are improvements in the level of information and guidance, they are not sufficiently detailed and comprehensive. Plans have yet to be improved and expanded to include details for the care for people with Diabetes and other complex needs, such as peg feeds and indwelling catheters. For example expanded care plans must give staff explicit guidance about the monitoring arrangements, especially relating to diet, skin, eye, foot care, continence management etc. There is no oral care plan or catheter care plan in place for a resident with a peg feed and has a catheter. Some of the residents’ care plans sampled contains records of the persons preferences for their daily
Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 13 routine, for example rising, retiring, and bathing, however these are not consistently completed. There is some evidence that care plans are developed in conjunction with the resident and their relatives, however four of the sample of plans assessed had no signatures in place to indicate agreement. Risk assessments in place and appropriately recorded health care screening assessment tools for each person are variable across the home. There are no tissue viability assessments for residents on the residential unit and there are some areas of risks, which have not be assessed. For example, there are no risk assessments relating to risks of chocking, frequent falls or aggressive behaviour. There is generally satisfactory evidence that residents are weighed on admission and regularly weighed each month. From the sample of residents case files assessed, two people have lost significant amounts of weight, (LM) 1st 6lbs in 6 months and (AP) 4kgs in one month, there is no evidence that referrals have been made to the GP and community dietician for advice and support. There is some documentary evidence relating to the health care checks provided for older people, though these not consistently completed and are satisfactory to demonstrate that all regular checks have been offered, whether or not they had attended or what the outcome has been. It is a matter of concern that recently a request was made for a GP to visit a resident who was unwell; instead the GP made a diagnosis and prescribed medication over the telephone. Subsequently the resident deteriorated and required admission to hospital. The home has a duty to ensure residents receive appropriate medical attention as needed and failures by other health professionals are reported to the relevant authorities. The content of the daily notes has generally improved, however staff need to be made aware of inappropriate usage terms and labels such as aggressive. Medication is administered by the registered nurses on the nursing unit and by senior carers on the residential unit. Completion of medication records (MAR sheets) has generally improved. There are no gaps on the residential unit, though there are five gaps on MAR sheets on the nursing unit. The fluctuating fridge temperatures have been resolved and are now satisfactory. There is no room thermometer in the nursing treatment room and monitoring arrangements need to be in place to ensure that medication is stored below 25 C at all times. There are a small number of requirements outstanding from previous inspections, mainly relating to updating medication procedures, such as the homely remedy policy. Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 14 There is evidence that support is given to residents to be appropriately groomed and dressed. There are records of each person’s preferred name, and staff address residents in a respectful manner. Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 This home makes some planned and spontaneous activities available on a regular basis, though not all residents are aware of them or are able to take advantage of socially stimulating opportunities. There is good contact maintained with family and friends for the majority of residents. The meals at Valley Court are good, offering both choice and variety and catering well for special dietary needs. EVIDENCE: Residents and relatives spoken to generally feel that there are not sufficient staff on duty at all times and that they do not have time to spend talking to them and to enable them to enjoy regular activities and outings. The home employs an activities co-ordinator for five days each week and there is a structured weekly activities programme, time is divided between the residential and nursing units. There are a small group of residents who enjoy the activities and bingo provided. There is a lack of consistent evidence available to demonstrate that all residents have been consulted as to their preferred activities, hobbies, and outings. Half of the sample of case files assessed had completed sections or logs of hobbies, interests, or preferences for activities.
Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 16 Efforts are made to involve people in fund-raising for the residents benefit and recently the summer fayre raised £750. New garden furniture, benches and bird table / bath has been provided to encourage people to sit outdoors in the warm weather, with only limited success. There is a visiting policy, which welcomes visitors. A considerable number of people visited during this visit. One person expressed her appreciation of the way her mothers birthday is celebrated at the home. Security is now improved with all visitors requested to sign the visitors book and escorted around the home, as necessary. The home has a rotating weekly menu, which offers a wide and varied choice of meals. There is a range of options for each meal. menus are displayed in each dining room and care is taken to record each persons daily preferences. Catering staff take pride in preparing and cooking as much fresh food as possible and presenting the food to look appetising. Members of care staff offer sensitive assistance to people needing help or feeding. People consulted are very complimentary about the food provided. Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 17 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 standard(s) 16,18 The home has a generally satisfactory complaints system with evidence that residents and relatives feel that their views are listened to and acted upon. Arrangements for protecting residents are not yet satisfactory and may not safeguard them from risk of harm or abuse. EVIDENCE: The home has received one complaint since the last inspection visit in March 2005, this has been satisfactorily resolved and the response was made within the 28 day timescale. The complaints procedure has not yet been updated as previously required and the only format available is in written form, which may not be the most suitable format for everyone living at or visiting the home. 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 a training course relating to the protection of vulnerable adults and responding to challenging behaviours. Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,22,24,25, 26 The management have a good understanding of the areas in which the home needs to improve with considerable planning in place indicating how this improvement is going to be resourced and managed. The standard of the décor within this home is generally good with evidence of improvement through continuing maintenance. Although large, this is a generally homely and comfortable environment for residents. EVIDENCE: Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 19 Valley Court is a purpose-built property, currently providing accommodation for up to for 69 older people requiring residential or nursing care. The home continues to be refurbished, redecorated and repaired on an ongoing basis. The décor, fixtures and furniture are generally completed to high standards. The property stands in its own grounds, with car parking at the front, and generally well-tended grounds to the sides and rear. The deputy care manager and a small number of staff on the residential unit have improved garden and patio area, however this needs on-going maintenance and the maintenance person / gardener is employed for just two days each week. 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. In addition to the en suite facilities there are a number of communal toilets situated throughout the home, close to communal areas. 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. It is evident that improved standards of cleanliness continue to be pursued and there were no discernable malodours. The laundry is separately staffed and well organised. There are two industrial washing machines and two tumble driers and an ironing press. Good infection control measures are in place. Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Good progress has been made over recent years in creating more stable substantive staffing levels and residents now receive improved consistent care. The standard of vetting and recruitment practices is generally good, though improved records are needed to safeguard the residents. EVIDENCE: Although assessment of staffing rotas demonstrates that the home continues to maintain generally satisfactory staffing levels, comments throughout the visit indicate residents needs are not always met in they ways they would like. This is not a reflection on the care practice of staff employed. The nursing unit currently has a high number (10 bedfast) of highly dependent residents and the overall number of nurses available has reduced. 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. The Home has a staff team of 41 people including care staff, domestic staff, laundry staff, catering staff, 1 activities co-ordinator, 1 gardener / maintenance staff (p/t), 1 administration staff, 6 registered nurses (2 full time / 4 P/T), and the Registered Manager. The staff team is now relatively stable. Three staff have left the home’s employ since the last inspection visit in March 2005, for valid reasons. There are currently 4 staff vacancies.
Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 21 One senior member of staff has been dismissed for gross misconduct. The home must demonstrate compliance with all aspects of employment law, including rights of appeal. The Home operates generally robust recruitment practices. Random samples of staff files examined had some omissions, which must be rectified. For example two files have no recent photographs, and there are no copies of signed contracts or job descriptions. As a matter of good practice interview questions and answers, signed and dated should also be held on file. Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,37,38 The systems for resident consultation at Valley Court are generally good with a variety of evidence that indicates that residents’ views are both sought and acted upon. EVIDENCE: Ms Joan Green, appointed as acting manager in September 2004, has recently successfully completed the CSCI registration process to become the Registered Manager at Valley Court. She is a RGN (Registered General Nurse), with significant management experience. She has many years of nursing experience, including nursing homes. There is evidence that she continues to update her training and personal development. The previous requirement for the home to produce an annual development, with continuous self monitoring, evidencing the involvement of residents, representatives and other community stakeholders, has not yet been fully met.
Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 23 However it is very positive that a documented survey for residents and relatives has been circulated, the results now need to be collated and acted upon. There is no current evidence of the organisations unannounced visits to the home on a monthly basis, comprehensive audit reports to the home and the CSCI office, Halesowen in compliance with regulation 26 have not been provided over recent months. The visits and reports must be recommenced on a consistent monthly basis. Record keeping at the home continues to improve, achieving better standards, with minor improvements required at this visit. A sample of mandatory training records, fire safety and maintenance documentation examined identified deficits. For example there is insufficient evidence that all staff have received 2 fire training sessions and 2 fire drills in a 12 month period and there are no records for a number of electrical items in residents bedrooms to demonstrate that they have been PAT tested. The Manager must ensures that all staff receive mandatory training commensurate with their roles; fire training, drills twice each year, moving and handling, first aid, food hygiene, health and safety and infection control training, commensurate with duties undertaken. The accident records examined are satisfactory. There have been 78 accidents involving (Residential) residents and 17 accidents involving (Nursing) residents since March 2005. The Manager and Deputy Manager undertake a regular documented accident analysis, which is used to identify trends and instigate reviews / reassessments and corrective action as required. Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 24 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 2 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3
COMPLAINTS AND PROTECTION 2 x 2 2 x 3 3 3 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 Standard No 16 17 18 Score 2 x 2 3 x 2 x x x 2 2 Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4 5 Requirement To ensure that the statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: and a summary of this information is included in the home’s service user’s guide. (Timescale of 31/10/04 Not Met) 1) To ensure that the statement of purpose and service user guide are available in the home at all times. 2) To provide documentary evidence that the statement of purpose, service user guide and complaints procedure have been made available to residents and their families. 3) To ensure that the most recent inspection reports are available in the home at all times. To review the contract / terms and conditions using the publication from the Office of Fair Trading: Guidance on Unfair Terms in Contracts in Care Timescale for action 31/10/05 2. 1 4 5 31/10/05 3. 2 5(1) (b) 31/10/05 Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 26 4. 2 5(1) (b) Homes (Timescale of 31/10/04 Not Met) 1) To ensure each person is issued with an appropriate document - contract / terms and conditions (for residents funded by the local authority), with the details of who is responsible for paying fees and responsibilities for any breaches 2) To ensure that there is an upto-date signed and dated copy of the contract / terms and conditions on each residents file To provide documented evidence that prospective service users and/or their representatives are involved with the pre-admission assessment. (Timescale of 31/10/04 Not Fully Met) To expand the standard letter used to confirm that the home can meet the residents needs to include the details of the assessed identified needs, in compliance with Reg 14(1)(d) To provide documentary evidence of introductory visits, detailing outcomes 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. (Timescale of 31/10/04 Not Fully Met) To continue the process of obtaining documentation for Service User case records as identified in Regulation 17(1) Schedules 3 and 4. (Timescale of 31/10/04 Not Fully Met) To ensure that all plans are signed by service users/and/or their representatives and reviewed monthly (nursing) 31/10/05 5. 4 14(1) 31/10/05 6. 4 14(1)(d) 31/10/05 7. 8. 5 7 14(1) 15(1) 31/10/05 31/10/05 9. 7 15(1) 17(2) Schedules 2 and 4 31/10/05 10. 7 15(1) 31/10/05 Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 27 11. 7 15(1) 12. 7 15 (1) 13. 7 15 (1) (Timescale of 31/10/04 Not Fully Met) To complete all service user plans with details of Preferred term of address Preferred rising and retiring times Preferred bathing times (Timescale of 31/10/04 Not Fully Met - nursing) To provide additional detail in service user plans relating to: Oral care Diabetic care Agreed limitations on choice, freedom or decisionmaking (Timescale of 31/10/04 Not Fully Met) 1) To provide explicit details and guidance for all aspects of care as part of each persons plan, for example: Continence management / promotion Management of agitated / aggressive behaviour Peg feeds 2) To ensure that all areas of risk are assessed, with documented staff guidance as part of each persons plan, for example: Risks of choking/asphyxiation / increased falls (LM) To ensure that service user care plans are updated to identify any changes in need (Timescale of 31/03/05 Not Fully Met) 1) To devise and implement a care plan, risk assessment and risk management guidelines for the service user identified in assessment information as presenting with aggressive behaviour (Timescale of 31/03/05 Not Met) 31/10/05 31/10/05 31/10/05 14. 7 15 (1) 31/10/05 15. 7 15 (1) 3110/05 Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 28 16. 8 12(1) 15(1) 2) To ensure that appropriate measures are in place to meet the needs of any service user with behaviour which challenges the service (Timescale of 31/10/04 Not Met) 1) To provide documentary evidence of specialist pressure relieving equipment provided, as part of each persons plan 2) To provide detailed documentary evidence of: - Oral care provided - Personal care provided - turns / change of positions 3) The home must not accept diagnosis and prescriptions for medication over the telephone 4) The registered persons must ensure that GPs fulfill all requests to visit residents requiring medical attention The registered manager must ensure that: All files contain tissue viability / pressure sore risk assessments (Timescale of 31/03/05 Not Met on Residential Unit) To provide the Commission for Social Care Inspection with a detailed and comprehensive action plan to include timescales for action to improve the control and administration of medication in the following areas: 1. To devise and implement a documented protocol and identify parameters for abnormal BMs (blood sugar monitoring results) (Timescale of 30/04/05 Not Met) 2. To expand me homely 31/10/05 17. 8 12(1) 15(1) 31/10/05 18. 9 13 (2) 31/10/05 Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 29 medication policy (Timescale of 30/04/05 Not Fully Met) To ensure that both units have: 3. An approved homely remedies list and a homely remedy policy. (Timescale of 30/04/05 Not Met) 4. To enhance the selfmedication policy to address how staff will monitor residents’ compliance with medication. (Timescale of 30/04/05 Not Fully Met) 1) To ensure that the specimen 31/10/05 signature list is up-to-date 2) To ensure that there are two signatures to witness hand written MAR sheets 3) To keep the room temperature in the treatment room on the nursing unit under review to maintain the temperature below 25° C. 4) To ensure that variable dosages are accurately recorded on MAR sheets, e.g. one tablet or two To ensure the final wishes for all residents (nursing unit) are discussed and recorded 1) To encourage user led activities, which may occur spontaneously for staff to follow and participate (Timescale of 31/10/04 Not Fully 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
Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 30 19. 9 13 (2) 20. 21. 11 12 12(1) 16(2)(m) (n) 31/10/05 31/10/05 22. 12 16(2) 17(2) activities, taking note of refusals. (Timescale of 31/10/04 Not Fully Met) 1) To complete details of hobbies 31/10/05 / interests and an activities audit for each person, which is then kept under review, particularly for less able people 2) To ensure the activities log is completed for each person 1) To include details of supper on meals taken records 2) To provide sugar free ice cream for LM and any other residents needing to follow a diabetic diet 1) To amend the contact details on the complaints policy from NCSC to CSCI (Timescale of 30/04/05 Not Fully Met) To ensure that the complaints procedure is made proactively available in formats suitable for personal capabilities 1) To review and expand the restraint policy / procedure, including references to staff trained in physical intervention and appropriate documentation of any incidents (Timescale of 31/10/04 Not Fully Met) 2) To obtain staff training relating to protection of vulnerable adults, dealing with challenging behaviour, use of physical intervention (Timescale of 31/10/04 Not Fully Met) 1) To review and expand the physical intervention policy 2) To review and expand the violence and aggression policy 3) To review and revise the missing persons policy (more 23. 15 12(1) 17(2) 31/10/05 24. 16 22 31/10/05 25. 16 22 31/10/05 26. 18 13(6) 31/10/05 27. 18 13(6) 30/11/05 Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 31 than two years old) replacing terms such as NCSC with CSCI 4) To make advocacy information proactively available To produce a documented 31/10/05 programme of (planned) routine maintenance and renewal of the fabric and decoration of the premises (Timescale of 31/10/04 Not Fully Met) To review the storage space on 30/11/05 the nursing unit and identify appropriate storage for the large numbers (14) wheelchairs, Zimmer frames, hoists, screens To provide the Commission for 30/11/05 Social Care Inspection with a detailed and comprehensive action plan to include timescales for action for the following areas: 1) To progress the repair/replacement of carpets in communal areas which are heavily stained or have worn joins (Timescale of 31/05/05 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 Not Fully Met) 3) To progress the redecoration of the quiet lounge on the residential unit, especially the stained ceiling and replace the missing light shade Timescale of 31/05/05 Not Met) 4) To progress the repair the motor, which is required for the
Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 32 28. 19 23(2) 29. 19 23(2) 30. 19 21 24 23(2) 31. 20 23(2) fans in bathrooms, toilets, and en suites to work effectively (Timescale of 31/05/05 Not Fully Met) 1) To rectify the worn joins in the carpet in the dining room on the nursing unit 2) To rectify the curtain which is off the rail in the dining room on the nursing unit 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 (Timescale of 31/05/05 Not Fully Met) 1) To provide a nurse call point in the lounge in the nursing unit 2) To replace the cord for the nurse call point in bedroom 49 To repair the radiator panel in the reception area To investigate and resolve the poor water pressure in bedroom 29 1) To continue to improve levels of cleanliness throughout the home in response to comments from some residents and relatives 2) To ensure that the laundry cleaning schedule is completed and signed after tasks are carried out 1) To review staffing levels throughout the home, in conjunction with an assessment of the residents dependency and occupancy levels particularly on 30/11/05 32. 22 16(2) 23(2) 30/11/05 33. 22 23(2) 31/10/05 34. 25 23(2) 31/10/05 35. 26 13(4) 31/10/05 36. 27 18(1)(c) 31/10/05 Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 33 the nursing unit 2) To undertake an 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 awaiting lengthy periods for attention 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. 37. 29 17 (1) 19 (1) 31/10/05 38. 29 17 (1) 19 (1) 39. 29 17 (1) 19 (1) 40. 29 17 (1) 19 (1) 2) To ensure that account is taken of the guidance regarding POVA (Protection of Vulnerable Adults) clearances required for any persons, including volunteers, with checks implemented as required. (Timescale of 31/10/04 Not Fully Met) To continue with the process of 30/11/05 obtaining all information required for staff files to meet the documentation identified in Regulation 17(1) Schedule 2 and 4. (Timescale of 30/11/04 Not Fully Met) To ensure staff files include the 30/11/05 following: - A recent photograph - Two sources of identification - An accurate job description - Copy of the signed and dated contract of employment - Evidence of qualifications, signed by the registered manager to indicate that originals have been seen To ensure that POVA/CRB 31/10/05 certificates are stored separately
Version 1.40 Page 34 Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc to main personnel files 41. 29 17 (1) 19 (1) To obtain information for agency staff working at the home relating to: - Personal information - POVA/CLB clearance - Training undertaken To ensure that any future disciplinary action demonstrates full compliance with current Employment Law Legislation To provide documentary evidence that all new care staff have been registered to undertake a TOPSS accredited induction within six weeks and foundation training within six months 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 (Timescale of 31/10/04 Not Fully Met) To collate and formally respond to the recent resident / relative survey The organisation must ensure that the nominated representative resumes regular unannounced monthly visits on a regular basis to assess the conduct of the home, with copies of written reports to the home and the CSCI office, Halesowen To provide staff training relating to report writing, with particular guidance about the use of terms such as aggressive To designate a person at the Home to take overall 31/10/05 42. 29 17 (1) 19 (1) 17 (1) 19 (1) 31/10/05 43. 29 30 30/10/05 44. 33 24 30/11/05 45. 46. 33 33 24 26 30/11/05 31/10/05 47. 37 17(1) 18(1)(c) 30/11/05 48. 38 13(4) 30/11/05 Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 35 18(1)(c) 49. 38 13(4) 50. 38 13(4) 18(1)(c) responsibility for Health & Safety, with appropriate training accessed as soon as practicable (Timescale of 31/10/04 Not Fully Met) To ensure the health & safety and welfare of Services 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 Not Fully Met) To arrange accredited risk management training for all persons involved in undertaking risk assessments as soon as is practicable or engage the services of a ‘competent’ person to provide documented risk assessments, with control measures and risk management strategies. (Timescale of 31/10/04 Not Fully Met) To provide documentary evidence that approved risk assessment awareness training has been arranged for all staff to be delivered within an identified timescale. (Timescale of 31/10/04 Not Fully 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. 2) To ensure that documented risk assessments and risk management strategies relating 30/11/05 30/11/05 51. 38 13(4) 30/11/05 Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 36 52. 38 23(4) to the service users and the environment are reviewed, expanded and implemented. (Timescale of 31/10/04 Not Fully Met) 1) To forward copies of the recent West Midlands Fire Service report and Environmental Health inspection reports with the homes responses, to the CSCI satellite office, Halesowen (Timescale of 31/05/05 Not Met) 2) To ensure health and safety posters are updated with the name of the responsible person in the Organisation (Timescale of 31/05/05 Not Fully Met) 1) To ensure that All staff receive 2 fire training sessions and 2 fire drills in any 12 month period, as a matter of priority, with documentary evidence submitted to the CSCI office, Halesowen by the 31/10/05 2) To ensure that the new member of staff KP receives the following mandatory training as a priority: - Fire training / drill - Moving and handling - Use of hoists - Food hygiene 3) New members of staff must not undertake duties until appropriate training has been undertaken 4) To ensure that staff do not wear jewellery, watches, nail polish and that they have short nails and appropriate flat ‘covered in’ footwear. To undertake a risk assessment relating to the use of the toaster 30/11/05 53. 38 13(4) 23(4) 31/10/05 54. 38 13(4) 31/10/05
Page 37 Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 55. 38 13(4) / cooker in the dining room on the nursing unit 1) To provide a bedrail risk assessment / evidence of regular checks for all rooms where they are in use (NR - 15/705) 2) To ensure that all portable electrical appliances in residence bedrooms receive an annual PAT check, with documentary evidence available To ensure that all accidents / incidents are appropriately recorded e.g. NR (5/9/05) 31/10/05 56. 38 17(1) 31/10/05 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. 4. 5. 6. 7. Refer to Standard 18 22 27 27 29 29 29 Good Practice Recommendations That staff signatures are obtained to demonstrate awareness of the multi-agency policy/ procedures for the protection of vulnerable adults 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 a 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 That staff files are reorganised and structured, with the use of an index/checklist and dividers That documentary evidence of the interview data, questions and answers and persons involved in the interview is held on personnel files 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
E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 38 8. 29 Valley Court 9. 10. 11. 33 35 38 That the Registered Manager reviews, dates and signs or policies procedures and good practice guidance That Service Users’ temporary financial accounts held by the Home are independently audited on a regular basis That staff signatures are obtained to demonstrate their awareness of policies and procedures, especially relating to the protection of vulnerable adults Valley Court E55 S4829 Valley Court UN V248199 070905 Stage 4.doc Version 1.40 Page 39 Commission for Social Care Inspection Mucklow Office Park West Point, Mucklow Hill Halesowen B62 8BR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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