Inspection on 18/12/08 for Welby Croft

This inspection was carried out on 18th December 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 20/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Welby Croft Crossing Road Chapel-en-le-frith Highpeak Derbyshire SK23 9RY     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Susan Richards     Date: 1 8 1 2 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 37 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 37 Information about the care home Name of care home: Address: Welby Croft Crossing Road Chapel-en-le-frith Highpeak Derbyshire SK23 9RY 01298812797 01298815379 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Argyle Residential Home Ltd Name of registered manager (if applicable) Mrs Pauline Andrew Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 24. 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 category: Old age, not falling within any other category - Code OP Date of last inspection Brief description of the care home Welby Croft is a family run converted two storey house with a modern ground floor level extension, providing personal care and support for up to twenty four older persons. It comprises of twenty two single and one shared room, with eleven of the single rooms each having an en suite facility. The home offers a variety of communal rooms, including a dining room lounge,conservatory, library and kitchen dining room for residents use. A hair dressing salon is also provided. It is located on the north east Care Homes for Older People Page 4 of 37 care home 24 Over 65 24 0 Brief description of the care home outskirts of the town of Chapel en le Frith in the High Peak with good access to local facilities and set in landscaped gardens with access and seating provided for people. Care and support is provided from a team of care, hotel services staff and with administrative support, led by a registered manager. A creative therapist also provides support for people to engage in occupation, leisure and social activities in and outside the home on a flexible sessional basis throughout the week. Care Homes for Older People Page 5 of 37 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is one stars. This means the people who use this service experience adequate quality outcomes. For the purposes of this inspection we have taken account of all the information we hold about this service. This includes our annual quality assurance assessment questionnaire (AQAA), which we ask the home to complete on an annual basis in order to provide us with key information about the service. We also received survey returns from a number of people who use the service and who have a interest in it. At this inspection there were twenty three people people accommodated plus one person who was in hospital. We used case tracking in our methodology, where we Care Homes for Older People Page 6 of 37 looked more closely at the care and services that two people receive. We did this by talking with them, talking with staff about their care, observation of staff interactions with them, looking at their written care plans and associated health and personal care records and by looking at their private and communal accommodation. We spoke with staff about the arrangements for their recruitment, induction, training, deployment and supervision and we examined related records. The registered manager, Pauline Andrew was not present and we were assisted by Anne Andrew, responsible individual representing the company ownership, who we have referred to as the provider in this report. We spoke with the provider about the arrangements for the management and administration of the home and we examined associated records. All of the above was undertaken with consideration to any diversity in need for people who live at the home. At the time of our visit all people accommodated are of British white backgrounds and of Christian religion. As at the date of this inspection, the range of fees charged per week is, Four hundred and forty pounds per week for people who are privately funded. Three hundred and sixty four pounds per week for people whose care is funded via local authority arrangements and with a top up fee as agreed with that individual. What the care home does well: What has improved since the last inspection? What they could do better: Ensure people are provided with the key written information they need about the service, which should also be made available in suitable alternative formats as may be necessary to ensure equality of access for people. Ensure that the arrangements for the storage of peoples medicines accords with recognised guidance and requirements. Care Homes for Older People Page 8 of 37 Ensure that where a person chooses to manage their own medicines that a recorded risk assessment is undertaken to determine their capacity, ability and safety to do so and which is regularly reviewed. Develop written needs assessment and care plans to more effectively account for individuals capacity to make key decisions about their lives, including the care they receive in accordance with the principle of the Mental Capacity Act 2005. So as to best promote peoples rights to make key decisions about their lives and the care they receive and determine their best interests. Ensure that the homes medicines policy provides staff with details as to the procedure they must follow in the event of any verbal instruction from a GP for changes to a persons prescribed medicines. Ensure that peoples views specified during this inspection process and from the homes satisfaction surveys, including concerning meals provided, heating in their own rooms and promoting their privacy, dignity and choice are considered and acted upon. Take prompt and necessary action as specified in this report, to ensure that all staff employed at the home are fit to do so, thereby more effectively safeguarding people from potential harm and or abuse. Ensure that individual staff induction records are kept. Ensure the health and safety of service users based on assessment of vulnerability of and risks to their safety with regard to potential environmental risks as specified in this report. And provide a written record of such risk assessment and take any action that may be necessary as identified from those risk assessments. Ensure the regular servicing and maintenance of hoist equipment in the home, so as to prevent unnecessary risks to the health and safety of residents and staff that may arise from failure to ensure this. Ensure that all accidents resulting in injury to any service user are reported in writing to the Commission without delay and also compliance with Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1985. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 37 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 37 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People may not be best informed about the home and the services it aims to provide. Overall, peoples needs are mostly accounted for, although some aspects of their personal safety and risk together with their individual capacity to make key decisions relating to these are not always best accounted for. Evidence: In our annual quality assurance questionnaire completed by the home, they told us that they ensure a comprehensive approach to peoples admission to the home, in terms of visits and information provided. At this inspection we saw that the statement of purpose for the home is that of the previous registered provider and that there is no service guide in place. Care Homes for Older People Page 11 of 37 Evidence: Some people that we spoke with said felt they would benefit from provision of a service guide and some, who had lived at the home for a longer time, told us that they were given a brochure from the previous registered provider. People told us they felt their needs were mostly met by the home, although one person that we case tracked who was more recently admitted there, expressed considerable anxiety as to whether their needs would be met, particularly relating to their nutritional requirements. We spoke with staff about these and looked at their recorded needs assessment, including for their nutrition. We saw that these refered to a nutritional plan devised from limited information provided by their nearest relative. There was no record as to their stated personal preferences relating to these and there was no trigger or scoring system for their nutritional risk assessment to assist in determining the need for a referral to a dietician. See also healthcare section of this report. Another person that we case tracked told us that overall their needs were met and we saw that these were reasonably well recorded and included their preferred daily living routines, lifestyle preferences and likes and dislikes. We saw from speaking with that person and looking at their needs assessment records that they had chosen to manage their own medicines, which they kept in their own room and had signed their consent for this. However, there was no recorded risk assessment in place to ascertain their individual capacity and safety to do so. See also healthcare section of this report. We discussed the need to ensure this is provided with key staff. Care Homes for Older People Page 12 of 37 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. For the most part peoples health care needs are accounted for. Although medicines practises do not always accord with recognised guidance and directives, which may compromise peoples health and welfare and unnecessarily potentiate the risk of misuse. Evidence: In our annual quality assurance questionnaire completed by the home, they told us that peoples health care needs are well met, that they are treated with respect and sensitivity and that they are making improvements by reviewing peoples written care plans. At this inspection two people told us that they usually received the care and support they need. Although three people said that this varied. Comments received included reference to staff being under pressure and some being more conscientious than others. Care Homes for Older People Page 13 of 37 Evidence: Most people told us that staff usually uphold their privacy and dignity and are respectful towards them. Although comments received from two people told us that staff may not always be discreet when approaching people in communal areas to assist them to the toilet, particularly where they may have hearing difficulties and also sometimes in ensuring that toilet doors are properly closed when in use. During our visit we observed staff to be courteous at all all times with people and to be respectful in their approaches with them. All told us that they receive good medical care. One person told us that they independently accessed outside healthcare practitioners of their choice, which they preferred to arrange themselves and that they also managed their own medicines. We looked at the arrangements for these and found that their decisions to do so were recorded within their written care plans, although with no reference to their actual capacity make those decisions. Also as referred to under Section One of this report, there was no recorded risk assessment in place with regard to their capacity and ability to manage their own medicines, which they kept in their own room. And we saw that they were not provided with suitable lockable storage facilities for these, which are contrary to recognised guidance concerned with medicines storage and also to the homes own medicines policy. Another person whose care we looked at more closely told us they had specific dietary requirements linked to their medical condition and personal preferences. Their written care plan referred to guidance provided by their nearest relative regarding foods to provide for them, although this was very limited. Also, as stated under Section One of this report, their nutritional risk assessment did not have a trigger to identify the need for possible referral to an outside dietetic health care professional for advice. In all other respects peoples care plans were reasonably well written and in accordance with their assessed needs, including their emotional welfare. They included peoples preferred daily living and personal care routines, including sleep and rest and also identified goals aimed at maintaining peoples independence as far as possible. When we looked at the arrangements for the handling and management of peoples medicines by the home, we saw that some of these were not stored in accordance with recognised guidance and legal requirements. Homely remedies were left out in a plastic tub on top of a filing cabinet in the office and internal and external preparations were not stored separately in the metal cupboard provided. Residents monies were also stored there and not in a separate, dedicated safe keeping facility. We also saw that the window to the room where medicines are kept was not opaque glass and did not provide for restricted opening and the temperature of the room was very hot. Care Homes for Older People Page 14 of 37 Evidence: There is no refrigerator provided for the purposes of storing medicines, although we were advised that there was no stock of medicines requiring storage in a refrigerator. We also saw that a specified medicine that must be stored as controlled drug was not kept in a cupboard that is certificated for this purpose. This is contrary to recognised guidance and legal requirements and the homes own medicines policy. Staff responsible for the management and handling of peoples medicines told us about their training for this and we saw certificates of their training, which told us they should be competent to do so. Overall medicines administration records were properly kept. However we saw two areas where improvements were necessary. These were in respect of hand written instructions recorded onto a medicines administration record sheet, which was not signed and dated by the person recording these nor countersigned by a witnessing staff member. Also where a verbal instruction was given by a persons GP to discontinue a medicines. This verbal instruction was not recorded and there was no policy guidance for staff to follow with regard to any such verbal instructions. We discussed the above matters with the provider who was present throughout our inspection visit and who agreed to action these. Care Homes for Older People Page 15 of 37 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall, peoples daily living preferences and lifestyles at the home meet with their expectations, although regular consultation with them as to their satisfaction with meals and menus and other aspects of their daily recreation, may further benefit. Evidence: In our annual quality assurance questionnaire completed by the home, they told us that they provide a varied activities programme, with a creative therapist providing sessional activities and with frequent trips out into the local community and weekly spiritual praise. They also tell us peoples friend and families can partake in meals at the home with prior notice and that they intend to continue to develop opportunities for people to engage in activities in and outside the home. At this inspection we saw that information about activities is displayed on the residents noticeboard and also by way of a monthly planner, including entertainments. And during the morning most people were getting ready to go out for Christmas lunch, which on return they said they had very much enjoyed. People told us about some of the trips out during the summer, which included one to the Cat and Fiddle, highest pub in England. Care Homes for Older People Page 16 of 37 Evidence: During our tour of the home, we saw there is a very comfortable, cosy and well equipped library room, a hair dressing salon and pleasant views over well kept gardens and the open countryside from many rooms in the home, including the library room. People told us that there are usually actvities they can join when the creative activities therapist comes in. These include arts and crafts, quizzes, gentle exercise and nail care. Some people were satisfied with current arrangements, but some felt that these could be offered more frequently. Two people told us that staff often put on the TV without consulting residents and sometimes put childrens TV on. People whose care we looked at more closely told us they were supported in bringing their own personal possessions into the home and invited us to look at their rooms. One person spoke at length about the ways in which the home supports them to make choices and to maximise their independence, although we saw from looking at their needs assessment and care planning records that there was no formal process in place to account for their actual capacity to make substantial key decisions about their lives. See Section One, Choice of Home section of this report. People told us that they usually enjoy the meals at the home, although a few people said that menus had been reviewed and felt that since, the quality and quantity of food had reduced. Some were dissatisfied that the menu had been removed from display along the the fruit bowl, with no consultation with people, although at our visit the menu was returned, which people were pleased about. The menu did not offer an alternative, although the cook said that they would always provide something else for those who requested this. Feedback from people tells us that they may not be aware of this and some said they would not wish ask as this may cause inconvenience. Records of actual food provided were not kept, so we could not see where alternatives where offered. Lunches were served to around six people on the day of our inspection, who had chosen not to join the Christmas lunch trip. These were presented well. People chose where to eat and were assisted by staff where required. Tables were attractively set to a high standard. One person told us that she felt unsafe in the dining chair as she was used to having a chair with arms. This was brought to the attention of staff. The provider told us of their plans to further develop the rear garden area to enable people to make greater use of during the summer months. Care Homes for Older People Page 17 of 37 Evidence: People told us that there are always activities they can join as they choose. Some have newpapers delivered to the home and all told us that their families and friend are made welcome, although some were not aware that they could join meals with them. There is no written information provided advising of this service. Care Homes for Older People Page 18 of 37 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home takes complaints seriously and people may be assured that any complaints they raise will be acted on, although people could be better informed about how to complain. Previous failures in staff recruitment practises do not best ensure peoples protection from potential abuse or harm. Although the action that the provider has told us they are taking is satifsactory in principle and should ensure people are more effectively protected. Evidence: In our annual quality assurance questionnaire completed by the home they told us that they display their complaints procedure and swiftly deal with any complaints receive and within twenty eight days. At this inspection, most people told us that they usually knew who to speak with if unhappy although most said they did not know how to make a formal complaint. We saw however, that the complaints procedure is displayed in the entrance area to the home, although, as previously stated in this report, no written service information is provided for people on their admission, including about how to complain. We looked at the homes complaints record and discussed this with the provider. We Care Homes for Older People Page 19 of 37 Evidence: saw that one complaint is recorded since their registration, which is currently being investigated. In the complaint, reference was made to to a fall and subsequent injury sustained by a service user. We saw by looking at specific records that we asked for that this accident and injury was properly recorded within the homes internal documentation, at the time of its occurence. However, a written notification of this accident was not forwarded to the Commission nor to the local authority Environmental Health Officer in accordance with legislation that requires this. (See Management section of this report, where we have referred to this and made a specific requirement that the provider must comply with). Staff spoken with were conversant with the homes complaints procedure and their role and responsibilities concerned with dealing with complaints. They also told us about recent training they had received concerned with recognising abuse and safeguarding people form abuse. However, although they were conversant with internal procedures to follow in the event of the suspected or witnessed abuse of any service user, most did not understand the role of external agencies. Particularly social services, as the lead authority concerned with safeguarding people and external procedures to follow, should this be necessary. We asked to look at the homes policy and procedures concerned with safeguarding people. The provider was not able to locate this, but advised that it may require review. Information provided in the annual quality assurance questionnaire from the provider told us that this was in place, although last reviewed in May 2008, under the previous registered provider. We also found from talking with staff and examining records that many staff employed under the previous registered provider and who continue to be employed at the home, do not have confirmed POVA or criminal records checks undertaken. (See staffing section of this report where we have made a specific requirement that the provider must meet in respect of this). We have written separately to the provider raising our serious concerns about this and telling them what they must do. The provider has given us their written assurance that they will take the necessary action to ensure that these are achieved. We have also asked them for some further information relating to this, including to let us know in writing when matters raised are complied with. Care Homes for Older People Page 20 of 37 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall, people benefit from a home that is clean, comfortable, homely, well decorated and furnished and which for the most part suits their needs. Although some potential environmental risks are not sufficiently accounted for, which may not always best ensure peoples safety. Evidence: In our annual quality assurance questionnaire completed by the home, they told us that the home is clen, well furnished and decorated with a range of lounge facilities and well established beautiful gardens with seating for people to access. They told us about some of the improvements they have made since their registration in August 2009, which tells us they have undertaken a considerable amount of substantial upgrading, maintenance, repair and renewal of the home. They tell us that over the coming months they aim to continue with this programme and told us the areas they intend to cover. This tells us that they are making considerable investment to achieve this. At this inspection we saw that overall the home was clean, comfortable, homely, warm and well lit, well furnished and decorated and reasonably well equipped. People told us Care Homes for Older People Page 21 of 37 Evidence: they were satisfied with their environment, which they said for the most part, suited their needs. We saw a number of additional facilities were provided, which gave people increased choice and pleasure. These included well kept attractive gardens with seating, a snug relaxing library room, a separate hairdressing facility and a kitchen with drinks and snack making facilities and table and chairs for people to use with their visitors. However, some people raised that the home is sometimes cold, particularly peoples own rooms. And that they cannot regulate the radiators in their own rooms, mostly in the older part of the building, with some older radiators and exposed pipework becoming scalding hot to touch. During our tour of the building we found radiators and exposed hot water pipes in peoples own rooms in the older part of the building, which were scalding hot to the touch. There were no recorded risk assessments in place in respect of these. We observed that many first floor windows, including those recently replaced did not have window restrictors fitted and there were no recorded risk assessments in place in respect of this with regard to the vulnerability of and risk to service users. One person whose care that we looked more closely at, had a recorded decision in their care planning records that they did not wish to have a window restrictor fitted, but with no recorded risk assessment provided. We also saw from our observations and discussions with the provider that there are no recorded risk assessments in place as to potential vulnerability of and risk to service users that may arise from various stairs and steps located from the middle lounge and some corridor areas. We have referred to the above environmental risks in the Management section of this report and made a number of requirements there about these. We also saw that bars of soap and domestic type hand towels were provided for hand washing purposes in communal bathing and toilet areas, with no dispensible soap or disposable paper towels. And that many bathrooms have carpeting as opposed to hard flooring, which does not promote good infection control. Discussions with staff and examination of records indicated that there have been no recent outbreaks of infection in the home. However, with the exception of planned replacement of bathroom flooring to more suitable, there is no infection control auditing system or management plan in place to reduce potential risks here. We discussed the above with the provider, who agreed to action these areas. Care Homes for Older People Page 22 of 37 Evidence: Care Homes for Older People Page 23 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are usually met from the numbers and skill mix of staff. People may not be effectively protected from previous staff recruitment policy and practises, although the action assured by the registered provider to address this should better ensure peoples safety. Evidence: In our annual quality assurance questionnaire completed by the home they told us that staff is effectively recruited, trained and deployed and also about some of the improvements they have made or aim to make, including appointment of a deputy and developing staff training ararrangements. At this inspection people told us that staff is mostly available when they need them and staff told us that there is usually sufficient staff to enable them to perform their role and to meet peoples needs. Although comments were received from both indicating that there are key times during the afternoon and evening when staff availability is considerably reduced. Examination of staff duty rotas reflected this and showed us that that there are two key periods during the afternoon and evening for around where care staff numbers are Care Homes for Older People Page 24 of 37 Evidence: reduced to two care staff for the twenty three people accommodated. Examination of accident and complaints records showed only one recent complaint following an accident resulting in an injury to a service user. However, this occurred during the evening and was unwitnessed. The provider advised us that a recent review of staff records showed that most staff employed originally by the previous registered provider, and who continue to be employed at the home do not have relevant CRB or POVA checks confirmed. They advised that these are undertaken for all new staff starters under their employ, but that they had not taken any action to ensure that these are provided for staff who do have have these in place. Examination of staff records and discussions with staff also confirmed this to be so. We told the provider about our serious concerns in that all staff must have evidence of satisfactory CRB and POVA checks confirmed, together with fully completed application forms and at least two references. We have put those concerns in writing to the provider telling them what they must do to ensure these is achieved and they have given us their written assurance as to the action they will take to comply with this. We have also asked them to provide us with further written confirmation to tell us when this is achieved. Discussions with staff told us that some may not have received a full induction in accordance with nationally recognised standards and may also not have provided full documentary evidence for the purposes of their recruitment, including the provison of a written application form and two references. Examination of their records, commenced under the previous registered provider, showed us that none had a record of their induction and some did not have completed application forms or two references provided. Staff told us about the training they have undertaken and also training planned and discussions with the provider and examination of their records told us that training arrangements are satisfactory, with a training plan in place. Around sixty percent of staff have achieved at least NVQ level three with arrangements in place to enable progression with these. Care Homes for Older People Page 25 of 37 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is reasonably managed and run, although some potential environmental risks to service users are not effectively accounted for, which may not be in peoples best interests. Evidence: In our annual quality assurance questionnaire completed by the home they told us that the home is well managed. They told us about some of the improvements they have made and are continuing to develop, which include a review of management and administration systems, the introduction of regular staff meetings and a satisfaction survey sent out to all service users, relatives and visiting health care professionals in order to inform their service planning and development. They also gave us some statistical information in the questionnaire relating to the servicing and maintenance of equipment at the home. Some of this indicated that there may be areas that were not up to date. However, certificates were provided at Care Homes for Older People Page 26 of 37 Evidence: our inspection visit which showed us that these had been satisfactorily undertaken, with the exception of hoist equipment. The provider assured us that this would be actioned. At this inspection the registered manager, Pauline Andrew was not on duty and we were assisted by the responsible individual for the company who we have referred to in this report as the provider. We saw some of the returns from the recent satisfaction survey circulated to people who use the service or who have an interest in it. Feedback in these gave an overall indicator that people feel care for, valued and secure and live in a home from home and cheerful and comfortable environment. We also saw that similar themes were emerging in terms of improvements that people felt could be made. These included some areas that are also identified under the relevant outcome sections of this report , such as heating and meals. We could see that action already taken by the home with regard to some of the matters arising, such as return of menu display, development of activities and provision of information about these. Discussions with the provider told us that results of the survey are not formally published and shared with the people who complete these. We looked at the homes systems and arrangements for the management and handling of peoples monies, which for those who wish are for safekeeping purposes only. These are mostly satisfactory, with the exception of the storage arrangements as detailed under the Healthcare section of this report and with clear records kept in respect of each persons monies held. In the Environment section of this report we refer specifically to the lack of recorded risk assessments in respect of individuals vulnerability and safety with regard to risks from exposed hot surfaces of radiators and pipework in the home, provision of window restrictors where these are not in place and the safety of the environment relating to stairs arising from the middle lounge and steps from corridor areas. One person whose care and service provision we looked more closely at independantly used the chair lift provided from the middle lounge to access their own room on the first floor, which they appeared to competently do on the day of our inspection. However there was no recorded risk assessment in place in respect of this. Staff spoken with described satisfactory arrangements for ensuring safe working practises by way of training and provision of equipment and we saw that cleaning materials were safely stored. Care Homes for Older People Page 27 of 37 Evidence: We spoke with staff about the homes procedures for dealing with and responding to accidents and incidents that may occur in the home and also about their responsibilities in dealing with these. Staff were mostly conversant with these in terms of internal procedures to follow, although a recent accident resulting in an injury to a service user was not reported in accordance with the Reporting of Injuries, Diseases and Dangerous Occurrences regulations 1985, RIDDOR. And a written notification of this was not provided to the Commission as is required. (See also Complaints section of this report). Care Homes for Older People Page 28 of 37 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 29 of 37 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 29 19 Ensure that you obtain in respect of each person employed, the information and documents as specified under Schedule 2, 1 to 7 of this regulation. To ensure that staff working in the home is fit to do so and to safeguard people from harm and abuse. 31/03/2009 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 4 The homes statement of purpose must be reviewed and updated. To ensure it provides accurate information, including as to the current registered provider. 31/03/2009 2 1 4 A written service guide must 31/03/2009 be produced in accordance with that specified under this regulation and a copy supplied to each existing and prospective servcie user and to the Commission So as to provide people with the information they need Care Homes for Older People Page 30 of 37 about the service and to assist them in choosing to live at the home. 3 3 13 A recorded risk assessment 31/03/2009 must be in place in respect of any service user who wishes to manage their own medicines. The format of which, must accord with recognised practise. So as to identify any potential risks to their health and safety. And, to determine the need for a management plan aimed at reducing or eliminating any such risks that may be identified from that assessment. 4 3 13 Approaches to the recorded risk assessment of individuals nutritional needs must be developed to provide a trigger, which ensures that where necessary advice is sought from outside dietetic healthcare professionals. So as to ensure that peoples risk assessed needs are effectively accounted for. 5 9 13 Medicines must be properly stored in the home in that, Lockable storage must be provided where people choose to retain and manage their own medicines in their own rooms. 30/04/2009 31/03/2009 Care Homes for Older People Page 31 of 37 Medicines must not be stored openly and must be kept in the appropriate metal storage cupboards A cupboard that complies with the Misuse of Drugs Safe Custody regulations must be installed for the storage of controlled drugs at the home. The window in the medicines room must be of opaque glass and of restricted opening. Medicines storage cupboards must not be used for the storage of any other items. So as to ensure that medicines are stored safely and to reduce the risk of harm or misuse. 6 16 22 A copy of the homes complaints procedure must be supplied to each service user and in a format which is suitable for that person. So as to ensure that people are suitably informed about how to complain. 7 26 13 Bars of soap and domestic 31/03/2009 hand towels must not be left out for communal use. Dispensible soap and disposable paper hand towels must be provided in all communal handwashing 31/03/2009 Care Homes for Older People Page 32 of 37 areas, such as bathrooms and toilets. So as to make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the home. 8 38 23 Arrangements must be made to ensure the regular servicing and maintenance of hoists that may be used for the purposes of moving and handling service users. So as to ensure that equipment provided at the home for use by service users or persons who work at the home is maintained and in good working order. To minimise potential risks to service users and staff that may arise from equipment that is not regularly serviced and maintained. 9 38 37 Accidents or incidents that 28/02/2009 may occur in the home resulting in the injury of any service user, must be reported in writing to the Commission without delay. So as to ensure that all accidents resulting in injury to any person reported in accordance with this regulation and to ensure peoples health and safety. 10 38 13 The health and safety of 31/03/2009 people accommodated at the 31/03/2009 Care Homes for Older People Page 33 of 37 home must be ensured based on assessment of vulnerability of and risk to service users that that may arise from, Hot surfaces of exposed radiators and pipework in the home, inlcuding their own rooms, Non provision of window restrictors to first floor windows, Individuals independentin use of the stair lift, Individuals access to the stairs arsing from the middle lounge and steps from corridors. These must be have regularly recorded reviews with action taken as may be necessary. So as to ensure that any unnecessary risks to the health and safety of service users are identified and so far as possible eliminated, and That all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. Care Homes for Older People Page 34 of 37 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 3 Individual needs assessments must be developed to include individuals capacity to make key decisions about their lives in accordance with the Mental Capacity Act 2005. The temperatures of the room where medicnes are stored should be regularly monitored to ensure ambient temperatures are maintained, which accord with that necessary for medicines storage. The homes medicines policy should be developed to include guidance for staff to follow in the event of any verbal instruction from a GP in respect of changes to their prescribed medicines. Where medicines instructions are hand written on to the MAR chart, these should be signed and dated by the person writing them and countersigned and dated by a witnessing staff member. The home should regularly consult with people as to whether the arrangements for health and personal care to ensure peoples privacy and dignity are respected at all times. With particular regard to personal care giving, including nursing, bathing, washing, using the toilet. The home should regularly consult with people about their routines of daily living and preferences, including meals provided to establish their satisfacton with these and to ensure they meet with their expectations. Pipe work and raidiators should be guarded or have guaranteed low temperatures surfaces. Central heating radiators should be controlled in the service users own rooms. The home should obtain a copy of the Department of Healths Essential Steps guidance in respect assessing and implementing good infection control measures, including internal auditing to enable the home to measure its own success in achieving these. The registered persons should review and monitor staffing levels during the afternoon and evening to ensure they are sufficient to promote peoples safety and supervision needs. And should consider the use a formally recognised tool for the determination of staffing levels at the home such as the Department of Healths Residential Forum staffing tool. 2 9 3 9 4 9 5 10 6 12 7 8 9 25 25 26 10 27 Care Homes for Older People Page 35 of 37 11 29 The provider should ensure that we receive the information we have asked for in our letter of 09 January 2009 relating to our immediate requirement and serious concern letter issued on 19 December 2009 by the due date and as requested in that letter. Results of satisfaction surveys should be collated and published for the information service users and any others involved in their completion. The registered manager should ensure peoples health and safety by ensuring compliance with relevant leglislation including, Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1985. 12 33 13 38 Care Homes for Older People Page 36 of 37 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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