Inspection on 11/07/08 for Warley House

This inspection was carried out on 11th July 2008.

CSCI found this care home to be providing an Adequate service.

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

Warley House 18/08/09

Warley House 12/07/07

Warley House 20/07/06

Warley House 16/01/06

Warley House 17/08/05

Warley House 26/11/04

Warley House 01/06/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

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 27/11/2008.

CARE HOMES FOR OLDER PEOPLE Warley House Warley Road Scunthorpe North Lincolnshire DN16 1PL Lead Inspector Kate Emmerson Key Unannounced Inspection 11th July 2008 09:30 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 Warley House DS0000002881.V368371.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. Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Warley House Address Warley Road Scunthorpe North Lincolnshire DN16 1PL 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) 01724 861507 warlhome@globalnet.co.uk Barton Medical Services Limited Tracey Anne Borrill Care Home 39 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (39) of places Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP and Dementia - Code DE (E) The maximum number of service users who can be accommodated is: 39 12th July 2007 2. Date of last inspection Brief Description of the Service: Warley House is a Care Home providing personal care and accommodation for thirty-nine older people, twenty of whom may have a diagnosis of dementia. They provide a day care service for up to five people per day. The home is situated in a housing estate in Scunthorpe some distance from the town centre and local amenities, although it is on a local bus route. The home is currently undergoing a redecoration and refurbishment programme. There is an enclosed garden at the rear of the property and a separate house within the grounds, which has been developed into a laundry. Warley House consists of a two-storey building serviced by a passenger lift and stairs. The home has twenty-one single and nine shared bedrooms, none of which have en-suite facilities. The home has four sitting rooms and a large dining room. There is also a smaller quiet dining room on the upper floor but it tends to be used as a training room for staff. Just inside the main entrance is another smaller seating area, which is part of a thoroughfare but attracts some people, who want to sit and watch what goes on. The home also has a designated smoking room and a staff sleep-in flat. The home has five assisted bathrooms and sufficient toilets appropriately sited throughout the home for ease of access. The home charges between £354 and £416 per week. The home also charges third party top-up fees of £26.89 for publicly funded people. In addition people are expected to pay for hairdressing, private chiropody treatments, toiletries and newspapers/magazines. More up to date information on fees and charges can be obtained from the manager of the home. Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. The Inspection took place over two days in July 2008. Prior to visiting the home the survey questionnaires were sent to the home for people who live in the home and for the staff. None had been returned on writing the report. During the visit we spoke to people living in the home, the manager, and care workers to find out how the home was run and if the people who lived there were satisfied with the care and facilities provided. We looked at assessments of need made before people were admitted to the home, and the home’s care plans to see how those needs were met while they were living there. Also examined were medication practices, activities provided, nutrition, complaints management, staffing levels, staff training, induction and supervision, how the home monitored the quality of the service it provided and how the home was managed overall. We checked with people to make sure that their privacy and dignity was maintained, that people could make choices about aspects of their lives and that the home ensured they were protected and safe in a clean environment. We observed the way staff spoke to people and supported them and checked out with staff their understanding of how to maintain people’s privacy, dignity, independence and choice. Information received by the Commission over the last few months was also considered in forming a judgement about the overall standards of care within the home. The home had been requested to complete an Annual Quality Assurance Assessment prior to the inspection but at the time of writing the report this had not been received. The manager had had a period of leave and this together with the disruption of project managing the redecoration had interrupted the usual management of the home and some of the management systems had not been fully maintained. The manager and the area manager worked with the Commission to make sure that immediate concerns relating to health and safety in the home were addressed. In future there must be more robust project management to keep the disruption to management of the home to a minimum. Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Whilst there are activities in the home which some people seemed to enjoy others commented that there ‘wasn’t a lot going on’ and indicated that they thought that the activities were too childish. Whilst interests were recorded at assessment this information did not influence the activities on offer in the home and this area could be improved. The management of the home had been seriously affected by the refurbishment and some important checks had not been completed, this could have put people’s health and safety at risk. They must make sure that they plan projects better in future so that the home can continue to be managed safely. Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 7 Whist there was nothing to indicate that people’s needs were not being met the effectiveness of the care provided was not monitored and evaluated in detail; this means that people’s changing needs may not be noticed. 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. Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3, standard six does not apply, as the home does not provide intermediate care. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs were assessed and although there were some gaps in this process these had not impacted on the care provided. People hadn’t always been provided with a contract/statement of terms and conditions, which meant that people did not have full information about the service to be provided. EVIDENCE: Four care files were examined in detail. These evidenced that assessments of need and associated risks were usually completed prior to people being admitted to the home and that copies of assessments/care plans completed by care management were obtained. In one case, although the home had not completed their own assessment they had used the information provided by Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 10 care management and the hospital to develop a care plan and had completed relevant risk assessments. In another they had completed a basic assessment of need but they had not identified and recorded at the assessment the needs associated with the person’s memory loss. However a detailed care plan had been completed. There was some evidence in the files to show that the manager formally wrote to people or their representatives following assessment to confirm the home was able to meet the needs of the person. However in one case this had not been fully completed in the person’s correct name. There was evidence that people were issued with a contract or statement of terms and conditions, although these had not been fully completed in two cases. The home charges additional fees (third party top-ups) for people whose care is publically funded, the manager gave an assurance that this was always paid by a third party. One person spoken to was aware that an assessment of their needs had taken place and that a care plan had been formulated to meet their needs. The home does not accept intermediate care placements so standard six does not apply to this home. Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health and social care needs were met. However there were some deficiencies in care planning and monitoring of the care provided to ensure that risks to health and welfare were minimised as far as possible. People’s privacy and dignity were not always protected. EVIDENCE: The records of care provided to four people were examined. Overall the care plans were detailed and set out people’s preferences in how care was to be delivered. Staff demonstrated an understanding of individual’s needs and likes and dislikes. Whilst there was a low incidence of pressure sores in the home there were some deficiencies in care planning and monitoring of the care provided to Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 12 ensure that risks were minimised. Although risk assessments had been completed and equipment provided specific care plans detailing the daily care requirements had not been completed. Staff had some understanding of the needs of people at risk of pressure sore development but there was inconsistency when describing care requirements of individuals living in the home. When asked staff could not state when care to relieve pressure had last been provided and although records of the time care had been provided were in place they were inconsistently completed to be an effective tool. Evaluations of the care plans were evident but were limited to a date and signature and gave no insight as to the effectiveness of the care plan in meeting people’s needs. There was evidence that some people had signed agreement to their care plans. Some people spoken to knew they had care plans, whilst others said they had no interest in reading their individual plans. From discussions with people and examination of documentation and observation it was evident that people living in the home were supported in personal care tasks by staff that respected their privacy and dignity. Due to the needs of the people living in the home none of them were administering their own medications. The home uses a Monitored Dosage System for medication and only senior care workers administer medication. Although staff spoken with could describe what they should do if there was an error with medication, the medication policy and procedure did not include guidance on practice in the case of medication errors. This is recommended. A medication round was observed and random selections of medication records in relation to receipt, administration, storage and stock control were examined and found to be appropriate and effective. Controlled Drugs were stored in a controlled drugs cabinet and an appropriate register was in use. The quantities of controlled drugs in stock matched the balances recorded in the register. Overall the people who used the services were complimentary about the staff and care received. However whilst staff were observed to have good interactions with people living in the home there were some aspects of care in the home, which need to be addressed to protect privacy and dignity. One person stated that they were in a double room and there was no curtain to ensure that privacy could be protected. The manager stated that this was because the room had recently been redecorated and she arranged for this to be refitted. However this should have been completed prior to people being placed back in the room and staff assisting with care tasks in this room should have reported this. One staff member was observed to carry out care tasks in silence when assisting a one person to the table. This evidenced that staff Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 13 were not always proactive in ensuring privacy and dignity was maintained. Training in this area was provided in induction training but refresher training is recommended. Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are enabled to keep in contact with family and friends and people receive a healthy, varied diet according to their assessed needs and choices. People have access to recreational and social activities, but further improvement in this area is needed to ensure everyone living in the home experiences a full life with opportunities to take part in varied activities according to their assessed needs and preferences. EVIDENCE: The home did not employ an activity coordinator the manager stated that it was the whole teams responsibility to provide activities in the home. Staff confirmed that they were expected to do activities in the home and that staff groups were organised to do this. One staff member stated that there was not a lot of interest in activities in the home. There was some evidence in some cases that people’s needs and interests were taken into account in assessment and care plans but this information was not used to determine the types of activities offered. Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 15 One person living in the home said ‘there isn’t a lot to do here, that’s the problem, and there are not enough staff to do activities, sometimes there is a lot on and then not a lot’. One said ‘ I play dominoes’ and another said ‘you do noughts and crosses that you throw on the floor, its all right, going back to when you were kids though’. The manager stated that they employ a private company to provide a motivation group once a month; one person said the motivation group ‘was a change I enjoyed it’. People spoken to who were able to express an opinion said they felt staff listened to them and said they were able to exercise choice in aspects of their life and daily routines. In discussion staff displayed a good knowledge of individual resident’s needs and likes/dislikes and records contained information about people’s religious observances and social interests. A priest and local vicar visited the home on a regular basis. People spoken to said visitors could come at anytime and could be seen in private. The home provided three meals a day and a light supper. Staff were observed offering people choices of meals sometimes by showing them the choices plated up if this was more appropriate for the person due to limits in their ability to communicate. Meals were well presented and available in different portion sizes and seconds were available. There was a very good atmosphere in the dining room. Staff were observed to sit next to people who needed support to eat their meal and support was provided in a sensitive manner. People spoken to say that the home provides a good standard of meals, which people enjoyed. Comments included ‘the food is very good’, ‘there’s nothing wrong with the food’ and ‘I like Grace’s custard, she makes it thick’. The home caters for people on low fat and diabetic diets. The manager said other specific dietary needs would be accommodated where this was needed. Staff were observed giving people liquidised food that had been mixed together. It was recommended to the manager that different types of food be served individually, even if liquidised, so that people can experience different textures and flavours in their meal. The manager stated that should be the normal practice in the home and she spoke to staff about this. On the second day of the inspection there was a change in practice. Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 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. A satisfactory complaints procedure was in place however complaint records were not maintained in sufficient detail to evidence that complaints were always appropriately managed. People were protected from abuse. EVIDENCE: There had been two complaints about the home made to the Commission since the last inspection carried out in July 2007. One related to misuse of peoples money and was referred to the Local authority, see below and another relating to staffing levels, which was referred to the providers for investigation. Complaint records held by the home were not always complete with regard to details of the complainant and the actions taken following receipt of the complaint. The home could not therefore evidence that complaints were always managed appropriately. The home’s policy and procedures were not being followed in terms of the information to be recorded. The way that the home stored the information relating to complaints was inappropriate in that Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 17 this was not in line with the home’s policies and procedures and confidentiality could not be maintained in its current format. The complaints procedure was displayed in the entrance to the home although some of the details were not up to date. Staff spoken to say they had no complaints about the home and felt confident to raise issues of concern if they arose with the manager. People spoken to who live in the home said they knew who to report concerns or complaints to. They were positive about the service they received. One said ‘it’s all right, I wouldn’t want to go anywhere else’ and another said ‘I like here very much’. When asked about abuse, what it was and what they would do if they suspected or saw or suspected any abuse staff stated that they would report it to the manager or senior care worker. Examination of a sample of individual staff training records showed staff had been provided with training in safeguarding adults. There had been one safeguarding referral made to the local authority in August 2007 regarding misuse of people’s monies. This was investigated and unsubstantiated. The manager was now following good practice when recruiting new staff to ensure that people living in the home would be protected. Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24, 25 and 26 People who use this service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are provided with a clean home and extensive redecoration and refurbishment was being undertaken. Some issues relating to management of the refurbishment project and general maintenance of the home may put people’s health safety and comfort at risk. EVIDENCE: A tour of the home was completed with the manager. An extensive refurbishment programme was underway at the time of the inspection and there was limited access to some facilities for people who lived in the home. For example there was only one of the four bathrooms functioning and this still required decoration. Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 19 Whilst there was major refurbishment being undertaken for which the providers should be commended, the quality of the work and attention to health and safety was disappointing. For example new carpets had been fitted in corridors but fire doors did not close and where fire signs had been removed for painting these had not been refitted some three weeks after the work had been completed. Bedrooms had been redecorated but sinks had been left in rooms which were stained and taps were dripping and wardrobe doors had been painted but they were unable to closed. Privacy curtains had not been replaced in shared bedrooms prior to people moving back into the rooms. We requested a fire officer visit to the home during the inspection when it was discovered the fire doors would not close. The fire officer undertook a full audit of the home. We left immediate requirement notices with the home for them to complete work that was necessary to ensure people’s health, and safety would be protected. The home had completed the work to meet these requirements by the second day of the inspection. During the tour of the home other issues were raised • The internal lift door curtain used to protect people from entrapment in the metal framework had been removed and not replaced leaving people at risk of injury. An immediate requirement was left for this and a temporary curtain had been fitted by the second day of the inspection. The manager was advised that people must be accompanied at all times in the lift until the correct curtain is fitted. • One bedroom was very odorous • There was no hot water to taps in six bedrooms on the first floor Many people had furnished their rooms with a range of personal items, to reflect their own individual choice and taste. One person said that their bed was so comfortable they could ‘stay in it all day’. Some bedroom doors had privacy locks and some of the bedrooms had lockable facilities. However the fire officer stated that some locks needed to be changed, as they could not be easily opened from the outside in an emergency. Following the inspection the management provided an action plan, which indicated that: • Two bathrooms were now fully functioning and the other bathrooms would be complete by 8 August 2008 • New taps and sinks would be fitted where required by 15 August 2008 • New bedroom locks would be fitted by 31 July 2008 The manager said she had obtained a grant from the local authority and this money had been used to refurbish the dinning room. This was now a very pleasant area. Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 20 Staff in interview confirmed adequate supplies of protective clothing. Equipment provision was also discussed and staff said there were appropriate mobility aides in the home to enable resident’s needs to be met. Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 21 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 this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home did not provide sufficient evidence that staffing levels met minimum guidelines although peoples basic care needs were met. Staff were trained and competent. Recruitment practice was generally satisfactory. EVIDENCE: The roles and responsibilities of staff are clearly defined and in discussion with the inspector staff demonstrated understanding of the management and reporting structures for the home. The manager of the home stated that the Residential Forum Guidance is used to calculate staffing hours however the manager had no evidence of this as she informed us that head office complete this calculation and provide her with staffing numbers to be adhered to. The home did not have any formal method of determining dependency in line with the residential forum guidance and determined this from local authority funding level of the placement. The manager provided information that of thirty-three residents, nine were high dependency and the rest were medium. At this level the residential forum guidance indicates that the home should provide 664.80 waking care staff Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 22 hours. Information provided by the manager indicated that 573 waking care staff hours were provided. This may indicate that the home does not provide sufficient care staff. Staff spoken to said there were generally enough staff on duty to enable people’s needs to be met. Evidence from discussions with residents during the visit confirmed that they were generally satisfied with the care they received. Comments included ‘I like all the staff’ and ‘the staff are very good’ but one said that ‘ there are not enough staff to do activities’. The manger said the home had an equal opportunities policy and procedure, although the inspector did not examine this. Feedback from the manager, staff and information in personnel and training records showed the procedure is followed when employing new staff and throughout the home’s working practices and staff’s access to training. Employment records for two staff members appointed since the last inspection were examined. Records were generally in good order and relevant and all the required checks had been obtained before staff started work. New staff were provided with an induction and the manager had an induction programme which meets Skills for Care Common Induction Standards specification. A workbook is provided as part of the induction and there was evidence that this is completed. In one case the workbook had not been provided until sometime after the staff member had started work the manager stated that his was due the staff going on holiday early in her employment. A new staff member confirmed that they had been provided with induction in to the home but had not completed any moving and handling training. The home had a training plan and examination of a sample of staff records evidenced that mandatory safe care, general and service specific training was covered and certificates were in place to support recent training courses the staff had accessed. Training consisted of in-house training, distance learning and external facilitators. Specialist training in dementia care was provided inhouse and the manager had collated health and social care information in a resource folder for staff information. An overview of the training was maintained although the information provided was not fully up to date and did not show dates of when training had been provided or was due. Further information was provided after the inspection, which showed when, training had been provided and when this was due. The home had a good National Vocational Qualification training programme for staff. The manager stated that twelve of the twenty-two staff had achieved level 2 or above and the rest were working towards the qualification or were enrolled to on the course. This exceeds the target of 50 of care staff trained to level 2 or above, which is a very positive achievement. Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 23 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 this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service An experienced manager manages the home. There had been disruption to the management of the home, which had impacted on the management of health and safety in the home. Procedures to ensure the risk of fire was minimised in the home had not been fully maintained. The manager worked well with the Commission and the Fire Officer to address issues immediately and minimise risks. EVIDENCE: The manager is experienced and has completed a National Vocational Qualification at level 4. Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 24 The manager had had a period of leave and this together with the disruption of project managing the redecoration had interrupted the usual management of the home and some of the management systems had not been fully maintained. The manager had not returned the Annual Quality Assurance Assessment as requested by the Commission. This is a legal requirement and must be provided. The home had achieved the local authorities Quality Development Scheme Gold Award. The home only keeps a limited amount of money within the home for residents. Samples of records were checked and these were found to be in good order. A staff supervision programme was in place and all staff had a named supervisor. A random selection of records was checked and staff records showed they receive regular supervision. The staff confirmed this. There are a range of policies and procedures in place for health and safety. Safe working practices were maintained by the provision of training to staff in the form of moving and handling, basic food hygiene, basic first aid, infection control and fire safety. Training records evidenced that the majority of staff had received this training although fire training was due for all. One staff member who had trained to provide the moving and handling training had not had the required refresher training. This is required before she can provide any further training. Following the inspection the management provided written information that all staff would receive fire training in the week commencing 28 July 2008. Maintenance certificates were in place and up to date for moving and handling equipment within the building. Maintenance certificates had not been filed since May 2008 making it difficult to assess if all maintenance checks had been completed as due. The manager assured the inspector all checks were up to date this was confirmed in writing following the inspection. Accident books were filled in appropriately. Risk assessments were seen regarding moving and handling and daily activities of daily living. Records showed that the fire alarm had not been checked since 29 May 2008 and weekly checks had not been completed on a regular basis back to January 2008. Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 25 The manager tested the fire alarm during the inspection and fire doors on the ground floor corridor and first floor corridor were not working correctly. The fire officer completed a full audit of the home and advised the manger on a schedule of works to be completed. We gave the home immediate requirement notices to ensure that risks in the event of a fire could be minimised and these were met within the time scales. The manager provided evidence at a later date that a private company had been visiting the home to service the system on a monthly basis the last date being the 26 June 2008. Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 26 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 X 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 2 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 1 X 1 X 2 X 2 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 3 X 2 X 3 3 X 2 Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5 (1) (b) Requirement Timescale for action 01/10/08 2. OP12 16(2) m and n The registered person must ensure each resident be given a personalised statement specifically relating to the care, accommodation etc that they will receive for the fee being paid. This should be supplied, at the latest, at the point at which someone takes up residence in the home. It is important that fee information is widely available at an early stage to support people to make informed choices. Further information about this can be found in the revised Care Homes Regulations. (Previous timescale of 30/09/07 not met) The registered person must 01/10/08 ensure that all people living in the home are provided with a range of appropriate meaningful activities, which are suited to their assessed needs and preferences. This will help to ensure residents do not get bored and that they have access to activities that are suitable for them. (Previous timescale of DS0000002881.V368371.R01.S.doc Version 5.2 Warley House Page 28 3 OP18 17(2) 4 OP19 13(4) 23(2)(c) 5 OP19 OP21 23(2)(b) 6 OP26 16(2)(k) 7 OP27 18(1)(a) 8 OP33 24 43 23(4) 9 OP38 30/09/07 not met) The registered person must make sure that complaint records include details of the complainant and the actions taken following receipt of the complaint. This is to evidence that complaints are managed appropriately. The registered person must provide evidence that the lift has been fitted with the correct internal curtain. Until this has been provided staff must accompany all persons using the lift to protect their health and safety. The registered person must send written confirmation that all identified maintenance work to bathrooms, taps, sinks and locks have been completed. The registered person must make sure that the home is kept free from unpleasant odours for the comfort of the residents. The registered person must review staffing levels in the home to ensure that they are meeting Residential forum Guidelines this to make sure that staffing levels meet minimum guidelines for the dependency of the people accommodated in the home. The registered person must ensure that the Annual Quality Assurance Assessment is completed and returned. The registered person must make sure that the fire alarm systems are tested on a weekly basis and that records to evidence this are maintained. This is to protect people’s health and safety in the event of a fire. 01/10/08 14/09/08 01/10/08 01/10/08 14/09/08 14/09/08 11/07/08 Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations The registered person should ensure that in all cases people’s needs are fully assessed and recorded so that full information is available to make sure that peoples care needs can be met in the home. The registered person should ensure that care plan evaluations are recorded in more detail to assist in monitoring the effectiveness of the care provided to meeting people’s needs. The registered person should ensure that care plans are more specific in detailing the care requirements of those with pressure sores and that the care is monitored and evaluated so that the care provided is effective in minimising the risk of pressure sores. The registered person should further develop the medication policy and procedures to include the processes to be followed in the event of a drug error to ensure consistency of practice. The registered person should provide refresher training to staff in promoting and protecting peoples privacy and dignity. 2 OP7 3 OP8 4 OP9 5 OP10 Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Warley House DS0000002881.V368371.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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