Inspection on 03/05/07 for Vivian House

This inspection was carried out on 3rd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Vivian House 04/10/06

Vivian House 21/09/05

Vivian House 21/04/05

Vivian House 21/09/04

Vivian House 14/04/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Vivian House Brunswick Street Morley Leeds West Yorkshire LS27 9DL Lead Inspector Valerie Francis Key Unannounced Inspection 09:30 3rd May 2007 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 Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Vivian House Address Brunswick Street Morley Leeds West Yorkshire LS27 9DL 0113 253 0309 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) W & S Red Rose Healthcare Limited Mrs Jennifer L J Mills Care Home 24 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (24) of places Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 2006 Brief Description of the Service: Vivian House is a large detached property set in its own grounds. Over a period, the house has had a 2-storey extension added. It is situated on the outskirts of Morley, but within easy reach of all the amenities in the centre of Morley, there is convenient bus service to surrounding areas. The home provides care for 24 older people. Within this number the home is registered to provide care for 16 people with dementia. Accommodation is provided on 2 floors, which are serviced by a lift, there is also a stair lift available in the older part of the building. There are 22 single bedrooms and 1 shared bedroom. Bathing and toilet facilities are available on all floors, and 6 of the single bedrooms have an en-suite toilet. The ground floor also contains a choice of sitting area and a large dining room, which overlooks gardens to the front of the building. The current charge is £365- £400 per week. This includes all meals and accommodation. Residents pay extra for their hairdressing (£6.00 & £23.00) and any personal newspapers or magazines and for personal toiletries. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk Information about the home is gathered from a variety of sources, one being a site visit. Additional site visits called random inspections may be made that will concentrate on specific areas such as health care or nutrition. One inspector carried out this inspection on 3rd and 4th of May 2007 and was at the home from 09: 30am until 5.30pm on the first day, a further visit was made at 5pm until 6.30pm on the 4th. The purpose of this inspection was to assess all the key standards (the key standards are identified in the main body of the report); to assess progress in meeting any requirements made following the previous inspection and to assess how the needs of people living in the home are being met. The methods used at the inspection included looking at care records, talking to people who use the service, observing care practices in the home, talking to staff and management, looking at the environment and looking at other paperwork including staff records. The home was sent a Pre Inspection questionnaire prior to the inspection this provided some information to the CSCI in advance of the inspection. Survey cards were sent to the home for residents and their relatives. Twelve people who use the service and four relatives returned their survey cards to the CSCI area office. The inspector spoke to visitors, staff on duty, the manager and the registered person. A tour of the building was made on both days. Comments from the survey cards are included throughout this report. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 6 Feedback was given to the manager the deputy and the registered person at the end of the inspection. Since the inspection the manager has written to the CSCI with an action plan to deal with the requirements discussed during the inspection. The gas, electric and PAT safety checks have now been carried out copies of the certificates were sent to the CSCI office. The manager said a format to record Risk assessments for Nutritional, moving and handling, skin integrity was in place, and each person will be assessed by The 31st May 2007, with a copy on their files. Systems were said to be in place for the recording of risk assessments for daily living, monthly evaluation and six monthly reviews. Plans have been put in place to ensure that relatives are involved in pre assessments for the prospective people who want to use the service. Families are to be invited to six monthly review meetings. I would like to extend my thanks to everyone who contributed to the inspection and for the hospitality during the visit. What the service does well: Survey information from relatives of people who use the service said “ I am happy with the care and attention given to my mother “ the staff are kind and friendly”. “ I always feel welcome”. On person spoke to said “ I get on well with staff and my mother is well looked after, and am going to put my name down to live here it is that nice and friendly”. One person who lives at the home said, “I am happy they are nice to me.” The atmosphere at the home is calm and relaxed. The staff demonstrate knowledge and understanding of the client group. Families and friends are made very welcome at the home and are also supported by the manager and her staff. There is a plentiful supply of hot or cold drinks for residents throughout the day. Staff are proactive in encouraging people to eat and drink. The staff made positive comments about the provider who they said was “always willing to provide them with any thing that would improve the care of the people who use the service.” And was readily available to support them. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 7 One person said “any concern raised by people response is quick and family informed. And their relative is cared for in an establishment which a genuine friendliness.” What has improved since the last inspection? What they could do better: Written information about the home did not clearly identify how the home meets the needs of people with dementia so that people seeking a home, and their families, have the information they need to decide if the home will be able to meet their needs. The manager is advised to request better quality information from other referral agencies before carrying out her own assessment. Care plans were not person centred, and therefore did not identify the specific needs such as likes and dislikes. For example there was no information in care plans to show how the home would continue to meet social needs. General risk assessments are carried out, but there was no plan of action to minimise the identified risk. There were no indications that nutritional, pressure sore, falls risk assessments were carried out. So that any person identified at risk would have a care plan which would show how these risks would be minimised/managed. Some consideration should be given for staff to undertake a course that would provide them with more information on safe handling of medicine. Some consideration should also be given to include the cook in such training so that she is fully aware of any food that may have some effect with the medication the people were taking. There was no evidence of jugs of juice and water available in the lounges for those who could help themselves. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 8 The manager was advised that the complaints procedure must be readily available so that any one coming into the home has the information, if they wish to make a complaint. The Visitors WCs had bars of soap and terry towels in use, advice was given that in order that infection control is not compromised the use of paper towel and liquid soap in the dispensers should be used. Some chairs in communal sitting rooms were dirty and showing signs of wear and tear. Plans were in place for the replacement of furniture. The quiet room used by the people and their visitors was found to be cold, it was evident that the portable heater seen was being used. The inspector advised that portable heaters must not be used and efforts must be made to ensure all radiators are working. The manager dealt with this quickly, and the heater was removed and radiator switched on. Some bedrooms carpets were torn and fraying and the wash hand basin vanity unit surrounds were showing water damage and needed replacing. In the kitchen, cupboards needed replacing, the worktops were showing signs of wear and tear, and the whole area needed through cleaning. The manager/proprietor was aware of the issues raised. Since the inspection the registered proprietor has contacted environmental health for advice about the planned new kitchen. Although it would appear that there is enough staff available to the people who use the service, the manager and the registered person must review the staffing level over the twenty four hours. People’s varied needs and the lay out the building must be taken in to consideration, to making sure there are enough care staff available and whose time is spent meeting the needs of the people who live in the home. No copies of letters inviting people to attend an interview or letters offering a post were in seen. This is recommended as good recruitment procedure. Staff, including domestics should receive effective training on infection control as a matter of urgency to reduce the risk of cross infection in the home. If possible a member of staff should be designated to carry out health and safety checks and record any identified risks in the environment. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 9 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 10 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 Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. People who use the service experience good quality outcomes in this area this judgement has been made using available evidence including a visit to this service. The Statement of Purpose had recently been reviewed. However the written information did not clearly identify how the home meets the needs of people with dementia so that people seeking a home, and their families, have the information they need to decide if the home will be able to meet their needs. All people who use the service have their needs assessed before they are admitted to the home. EVIDENCE: Although the home’s Statement of Purpose has written information about the services and facilities available, additional information is needed which states how the care needs of people with dementia will be met. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 12 Two relatives spoken to were aware of the home’s information pack which they said they had been given prior to their people/relative moving into the home. Although the inspector was told that visits by people who use the service is encouraged there was no record to indicate that this had happened before they moved in. The manager said a copy of the Service User Guide is given to people who use the service. People who use the service were asked but none were clear if they had a copy of the document. Since the last inspection the home has a new assessment form, which the manager intends to use for the next person wanting to move into the home. Two pre admission assessments were inspected of people who had recently moved in to the home and all showed that assessments had been carried out before admission. The manager said she tries to get a copy of the “Easy Care “multi agency assessment. This was said, in the main, to be out of date and did not reflect the person’s needs. Relatives are encouraged to take part in the assessment process, by providing the home with a social history of the person to help the staff provide more person centred care. The manager is advised to request better quality information from other referral agencies before carrying out her own assessment. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area, this judgement has been made using available evidence including a visit to this service. Care plans provide staff with some good information showing how people’s privacy and dignity is respected. However care plans are not person centred. Overall medication practices are safe and the home follows safe guidelines for returning unused medication to the pharmacy. EVIDENCE: Three care files were looked at which included some good information from the pre assessment. The plans however did not include enough detail to make them person centred, to make sure that the diversity of peoples’ needs were taken into consideration at all times. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 14 Although there was information on previous hobbies, there was no information to show how the home would continue to meet social needs. General risk assessments are carried out, but there was no plan of action to be taken to manage and minimise the identified risk. There was no risk assessment for daily living, moving and handling and pressure sores despite the use of pressure relieving equipments seen in use. It was clear that relatives were involved in the care planning process. None of the people whose files were seen had had a nutritional risk assessment carried out, which would provide staff with information about the individual nutritional needs and in some cases might lead to input from a dietician. When a risk has been identified after a risk assessment, there must be a plan of action to show how this would be managed/minimised. Care plans were not person centred, and therefore did not identify the specific needs such as their likes and dislikes. From discussion with staff it was indicated that they are involved in the admission process, and they are given a copy of the assessment information for the person coming into the home. So that they have some information that would enable them to start the process of caring for these people before a care plan is in place. The manager administered the evening medication at the time of the inspection. The inspector was told that all staff who administer medication had had some training by the dispensing chemist. During discussion with staff who administer medicine, it was noted that they were knowledgeable and competent to carry out their role, and the medication systems were correctly followed. Advice was given that some consideration should be given for staff to undertake a course that would provide them with more information on Safe Handling of Medicine. Some consideration should also be given to include the cook in such training, so that she is fully aware of any food that may have some affect with the medication the people were taking. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area this judgement have been made using available evidence including a visit to this service. The staff respect the choices of people who are able to express their views but more could be done for the unmet needs of those people who are less settled. The home provides a programme of activities, which aims to provide interest and diversion for the whole group. This could be improved by drawing on peoples’ past life experiences and skills to adopt a more focussed approach for individuals and those people with dementia. EVIDENCE: One member of staff has been assigned to carry out recreational social activities with the people who use the service. There is an activities plan, which involves the use of outside agencies for entertainment in the home. There were photographs on the notice boards of people on trips out. Social needs are also assessed as part of the pre assessment process, however, more effort is needed to make sure that people who have a dementia Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 16 have the opportunity to take part in meaningful activities that take into account their interests, hobbies and abilities. Staff understand the importance of people who use the service maintaining contact with family and friends. Relatives said they are always made welcome and informed of anything that affects their relative. There is a room where people can meet with their friends or relatives in private. During the visit people were occupying themselves watching TV or chatting with other people and staff. A member of staff during the morning was seen engaging people in an exercise game of throwing a ball to each other. Since the inspection the manager has looked for a suitable course for the member of staff who does activities to enhance her skills to carry out activities with people, taking into account the people with dementia. Meals are served in the dining room with options for people to have their meals in their own room, or in one of the lounges. The dining room tables are arranged in small group settings that encourage conversation and makes meal times a social occasion. The cook has a record of peoples’ likes and dislikes of food. The six-week menus are planned with the input of people living in the home. Although there was no choice of food on the menu the manager said that people could have something different if they did not like what was on offer. The cook has a list of alternative food, which can be offered. The manager said some of the food offered is finger foods, such as fish fingers, potato croquets, for people who may not remain seated to eat a meal. People are reminded each day what was on the menu and it is at this time alternatives are offered. All the people spoken to said they enjoyed the food. Any person who needed assistance at meal times was given this discreetly and with courtesy. Drinks were on offer at regular intervals. Staff assisted those who were not able to help themselves but there was no evidence of jugs of juice and water available in the lounges, for those who could help themselves. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area this judgement have been made using available evidence including a visit to this service. People who use the service and relatives concerns are listened to and acted upon. People who use the service are protected from abuse. EVIDENCE: Although the complaints procedure was not displayed in the home, during discussion with relatives visiting and from survey information it was clear that people knew who they would speak to if they had a complaint. The manager was advised that procedure must be readily available so that any one coming into the home has the information if they wish to make a complaint. A copy of the complaint procedure is available in the service user guide. Some people said they had never had to complain but would go to the manager if they needed to. There was evidence that the manager has dealt with complaints received at the home in a proper and sensitive manner following the home’s procedure. The manager is aware of her responsibility to report any serious complaints to the CSCI. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 18 Staff were familiar with the adult protection procedures and most have received training on abuse and the protection of vulnerable adults. The home has an Adult Protection Procedure and a whistle blowing policy procedure. Staff spoken to were clear what is abuse and they had no problem using the procedures if needs be. A new member of staff, who had not received this training, was clear of her role and what she would do if an allegation was brought to her attention. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience adequate quality outcomes in this area this judgement has been made using available evidence including a visit to this service. People live in an environment that is being constantly improved, to provide people with a safe, homely and well maintained home. EVIDENCE: An inspection was made of the environment, some bedrooms, all communal sitting rooms, toilets and bathrooms. The registered person escorted the inspector around the home, during such time, several issues were noted and brought to the attention of the registered person. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 20 Several bedrooms were inspected, these were found to personalised to different standards, but it was obvious that people had the opportunity to bring with them furniture, fitments and memorabilia, of their past life and family photographs, which were displayed. The visitors Wc’s had bars of soap and terry towels in use, advice was given that in order that infection control is not compromised the use of paper towel and liquid soap in the dispensers should be used. Some chairs in communal sitting rooms were dirty and showing signs of wear and tear. On the first day of the inspection the small sitting room on the first floor was found to subjectively cold, a portable heater was in place, this was brought to the attention of the manager and registered person. The inspector advised that portable heaters must not be used and effort must be made to repair the radiator in this room. This matter was resolved by the next visit the portable heater was removed and radiator turned on. Some bedrooms carpets were torn and fraying the wash hand basin vanity unit surround were showing water damaged and needed repairing or replacing. The wall of one of the bedrooms with ensuite facilities had damp patches, the hot water when tested in three bedrooms was found to be very hot, the registered person took action and since the inspection has fitted thermostatic valves to hot water pipes, in these rooms. In several bedrooms where odour control was a problem, carpets had been replaced with a vinyl floor covering, the type mainly used for kitchens and bathrooms. On the inspection of the kitchen several issues were noted, the kitchen cupboards needed replacing, the worktops were showing signs of wear and tear, the whole area needed through cleaning. The manager/proprietor was aware of the issues raised and is planning to extend the building, and at such time the kitchen will be re-sited and replaced. The outdoor patio area offers an area that is secure, giving people with dementia free access from the building into a secure area out to the garden to avoid undue restriction of their movements. Not all exit doors were alarmed, but following a recent incident plans were in place to fit them all with an alarm. The bathing facilities are to be improved by replacing the bath on the ground floor with a new assisted bath. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 21 The laundry was small but clean and tidy. Personal clothing appeared well cared for. The inspector was given a copy of the home’s maintenance plan for repairs and replacement through the building, and any matter relating issues raised at this inspection were to be address as part of the plan. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area this judgement have been made using available evidence including a visit to this service. The numbers and skill mix of staff meet residents’ needs. Residents are protected by the home’s recruitment procedures. In the main, staff are trained and competent to do their job. EVIDENCE: The rota at the home for over twenty four hours showed from 8.30am to 4.30pm there are four care staff and from 4.30pm to 9.30pm three members of staff. The person in charge is included in the shift numbers. The cook works from 8.30 am to 2.30pm. Staff undertaking the evening shift have to organise and serve the evening meal, which would take away one of the staff from caring for people. Although it would appear that there are enough staff available to the people who use the service, the manager/registered person must review the staffing level over the twenty four hours, making sure there is enough care staff available, and their time is spent meeting the needs of the people. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 23 The varied needs of people who use the service and the lay out of the building must also be given consideration when looking at the staffing levels. The home has domestic staff on duty daily from 9:00am to 2:30pm. There are two awake care staff are on duty during the night from 9:30pm to 8:30am with on call back up if needed. At 7:00am an additional care worker joins the night staff, making three staff available to people until 8:30am when three other staff will come on duty. All staff spoken to had no concerns about the staffing levels to meet people’s needs. However, it was noted during the inspection that staff time was spent doing some domestic work such as laundry, whilst the people who use the service were seen sitting doing nothing. From discussions and survey information it was indicated that staff were stretched and did not always have the time to spend with the people living at the home. The home has 50 of the care staff with a N.V.Q National Vocational Qualification, with plans in place for a further 3 to start NVQ Level 2. Records relating to recruitment of the two recently employed staff were seen. CRB (Criminal Record Bureau) checks had been done. Application forms were in place with interview notes, two references were seen for both staff. This is good practice. However, no copies of letters inviting people to attend an interview or letters offering a post were in seen. This is recommended as good recruitment procedure Staff commence induction training when they start their employment. Training such as moving and handling, principles of care, fire awareness are completed first. Staff’s training records are documented on the home’s training plan with information on their individual files. There was on going Health and Safety training which included manual handling training and basic food hygiene. Staff had also attended courses such as role of the care worker, medication administration and dementia awareness training, which they said made them feel better equipped to care for anyone with dementia. Some staff had done courses on infection control, but the domestic had not undertaken such a course; the manager said plans were in place for them to undertake such a course, which would help them in their role in the home. There are plans in place for further training such as Elder Abuse, Nutrition & Health. Night staff also attended these courses. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 24 Staff had a good understanding of their role. Since the inspection, the key workers group is now headed by one of the management team at the home, whose role it is to oversee the care staff who are key workers for individual people. During discussion with staff they indicated that they felt well supported by the management team. Staff have regular one to one supervision with the manager or the deputy, where they can discuss any issues, including their personal devolvement. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35 & 38. People who use the service experience good quality outcomes in this area this judgement have been made using available evidence including a visit to this service. The home is well managed; the interests of the people who use the service are seen as important to the manager and staff. Staff are properly supervised. Peoples’ financial interests are safeguarded. Health, safety and welfare are promoted. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 26 EVIDENCE: People who use the service and their relatives said they are pleased with the home’s management and the care they were getting. They said they found the manager approachable. The manager is registered with the CSCI and was at the time completing NVQ level four in care and the Registered Manager Award (R.M.A). Staff spoke positively about the management team. All staff spoken to confirmed that they have regular supervision and really enjoy this time. They said it is useful and effective. The manager said she works flexibly to enable her to give night staff one to one supervision. The manager has shown good leadership skills by assessing what needs to improve at the home, prioritising this and working alongside staff to make sure it gets done. There is a Quality Assurance questionnaire in place, which asks for comments from residents, relatives and professional visitors to the home. The manager analyses this information and has produced action plans to make sure of improvements in the service. No regulation 26 Monthly visits are carried out; the registered provider visits the home regularly, sometimes daily. Financial procedures in the home make sure that each person’s money is kept separately. People have access to their money at all times. The manager said some people over spend and most of the time relatives owe the home money despite being given information that they must ensure that money is available for people to use. All transaction for monies held on behalf of people is recorded. Staff meetings take place monthly. Night staff are invited to attend the meetings. However, if they can’t the manager holds a meeting with them to make sure communication is kept up. Accident reports are completed for any accidents or incidents. These are analysed on a monthly basis to identify any patterns or trends. Although health and safety checks are carried out, at the time of the inspection it was noted that several check were out of dated, and there were no record that a Gas safety, Electric and PAT checks had been carried out. However since Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 27 the inspection these checks have been carried out with copies of the certificates sent to the CSCI area office. Discussions were held with staff about infection control. Most had done training on infection control. However when question about sluicing, it was apparent that hand sluicing was being carried out for badly soiled bedding despite having a washing machine with a sluice cycle. There was no procedure for cleaning up bodily waste and it would appear from discussion with staff that infection control could be compromised. Although there were risk assessments in place for the premises some potential risks had not been assessed, such as the marble fire hearth, which is a potential hazard to the people living at the home. During the second visit of the inspection one person fell almost hitting her head on the corner of the Hearth, which could have caused a bad injury. The registered person was advised to assess the fireplace and put in place what steps would be taken to manage and minimise the identified risk. The manager said the registered provider assesses the premises. However the Health and safety of the building must continually be assessed to make sure that people who use the service and staff are safe. If possible a member of staff should be designated to carry out health and safety checks and record any identified risks in the environment. A copy of the homes polices and procedures are made available to staff in the office and are discussed at the staff meetings. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 4 3 X 3 X X 2 Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 (1) (c) Requirement The registered manager must make sure that the statement of purpose has information how the needs of people with dementia will be met at the home. Care plan for people who use the service must be person centred, identifying their likes and dislikes. Risk assessment must be carried out, with an action in a care plan how the identified needs will be minimised/ managed. Hand washing facilities must be improved to prevent the risk of cross infection at the home. This timescale was agreed at the last inspection 01/12/06. The manager must review staffing level throughout the twenty four hours, to make sure that there is enough care staff available to people at all times. The registered provider and manager must make sure that risk assessments are carried of for all areas of the building, equipments and any potential DS0000042865.V335288.R01.S.doc Timescale for action 30/06/07 2. OP7 13 & 15 31/07/07 3. OP7 13 30/06/07 4. OP26 13(3) 30/06/07 5. OP27 18 31/07/07 6. OP38 23 30/06/07 Vivian House Version 5.2 Page 30 7. OP19 23 8. OP38 23 8. OP38 18 (1)(c) (i) risks affecting people who use the service and staff. A plan of action must be in place for any identified risk, which must be reviewed regularly. The issues relating to the premises that were brought to the attention of the registered provider must be address as per the timescale given in the home’s improvement plan. The registered manager and proprietor must make sure that issues about the kitchen, that affect infection control is address. The manager must make sure that all staff especially the general domestic staff have training on Infection Control. 31/08/07 30/06/07 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP3 OP9 OP17 Good Practice Recommendations The manager should ensure that the home is provided with better quality information from other referral agencies, before carrying out her own assessment. The manager should give due consideration for the staff who administer medication and the cook to undertake an in depth course on the safe handling of medicine. The home’s complaint procedure should be readily available to visitors to the home, who may wish to make a complaint. Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Vivian House DS0000042865.V335288.R01.S.doc Version 5.2 Page 32 - 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. 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