CARE HOMES FOR OLDER PEOPLE
Westcroft 1 Cleveland Walk Bath Bath & N E Somerset BA2 6JS Lead Inspector
Grace Agu Unannounced Inspection 12th February 2008 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Westcroft DS0000020315.V354919.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. Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Westcroft Address 1 Cleveland Walk Bath Bath & N E Somerset BA2 6JS 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) 01225 466685 01225 443367 Mrs Jean Uter Ms Pamela Anne Ramjutton Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. May accommodate 21 Patients aged 50 years and over requiring nursing care Staffing Notice dated 03/10/1996 Manager must be a RN on parts 1 or 12 of the NMC register May accommodate one named person with Mental Health needs. The registration will revert when this person leaves the Home. Date of last inspection Brief Description of the Service: Westcroft Nursing Home is registered as a Care Home with nursing. It is situated in an elevated position in Bathwick, close to the city centre of Bath. The home is an older property with an extension, set out over three floors. There is a mixture of single and double rooms. One double room has an ensuite facility. There is a passenger lift in the old wing and a chair lift in the new wing: however the home is not suitable for independent wheelchair users and does not enable people that require aids and equipment to move around the home independently. The front entrance has one step into the porch and another step into the foyer; level access is through the side entrance. The home has a large garden to the rear with extensive views over the city. Fees for placement at the home currently range from between £494 - £630, and are determined on an individual basis. Hairdressing, newspapers and chiropody costs incur additional charges. Prospective residents can be provided with information about the home by requesting the home’s brochure from the proprietor - this will detail the services and facilities available at the home. Westcroft DS0000020315.V354919.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 the people who use this service experience adequate quality outcomes. This was an unannounced visit which was undertaken by two inspectors as part of a key inspection over ten hours to review the requirements made at the last inspection and also to review the care practice to ensure that it is in line with the legislation and that best practice is followed at the home. The visit also followed up complaints raised by one relative regarding the care received by their relative whilst living in Westcroft Nursing Home. At the last key inspection 24 requirements and five recommendations were made in relation to various areas of service provision including issues that affect the health and safety of individuals living and working at the home. We visited the home last December on a random inspection to review the requirements and we noted some improvements in the overall service delivery and management of the home. At this inspection, whilst there were several outstanding requirements it was pleasing to note that the home is making efforts for greater improvements to ensure that individuals living in the home are given care that demonstrates good value for their money. We met with the new home manager and the administrator. Whilst touring the building, we spoke with a number of service users, staff members and three relatives. A number of records were viewed. What the service does well:
The home has a statement of purpose, which has information about the service provided, staff training as well as service user accommodation. There is a service user guide, which has information about the home, it’s aims, and fees and services to enable a prospective service user to make an informed decision about the home. Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 6 Good meals are provided for service users and staff ensure meals are not hurried and that residents who are unable to feed themselves are assisted in a respectful and dignified manner. We saw evidence of this on the day of this visit. One of the comment’s card that we received from a relative states, “My brother is well fed and he enjoys the food”. A complaint procedure is in place to enable service users, families, friends and advocates to complain if unsatisfied with the services provided. The environment is well maintained, tidy and safe giving the service users a sense of homeliness and security. What has improved since the last inspection? What they could do better:
At this inspection evidence from observation on the day, feedback from the survey showed that insufficient activities are provided at the home. The Manager must address this concern to enable the service users to remain stimulated whilst living in a care home and eliminate the feeling of boredom. Prospective services users and their relatives / representatives would be more reassured if the home confirms in writing of its ability to meet their needs and ensure that the service users are provided with the terms and conditions of their stay.
Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 7 Furthermore to ensure that service users enjoys a comfortable and warm environment the faulty heating system in the home must be addressed. To ensure that the home manager and any other new staff are aware of their roles and responsibilities appropriate induction system must be put in place. Appropriate individualised risk assessment must be in place for all service users to ensure protection in terms of health and safety. The general cleanliness of the home must improve by ensuring adequate numbers of domestic and laundry staff to ensure that service user are provided with a clean environment where they are happy to live. To ensure that care needs of identified service users are met it would be better to provide appropriate care plans for identified needs and to provide adequate protection. It could be better if there are risk assessments in place following accidents to service users to minimise falls. We observed whilst reviewing medication that limited life medication (insulin) is stored in kitchen fridge. Furthermore we also noted that the recording of the fridge and freezer temperatures were inconsistent. This is hazardous to the medicines stored in the fridge. The home must ensure that a separate medicine fridge is used to store medicines in order to protect the service users’ medicines. Also in order to minimise the risk of food poisoning to the service users staff and visitors, the home must ensure that there is regular recordings of the fridge and freezer temperatures. The home must ensure that identified staff members receive training on protection of vulnerable adult from abuse and manual handling. This so that people using the service are protected from abuse and potential handling injury. All staff to undertake formal moving and handling training. The arrangements around fire safety are poor and must be improved in regard to fire drills and routine checks of fire system and equipment. The communal lounge/dining room would benefit from being updated to provide the individuals living in the home with a better homely environment. Individuals living in the home would enjoy better meals for if the menu has options to enable them to choose what they would like to eat. Furthermore it could be better if the service users are informed when the menu is changed. Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 8 To enable new staff to perform their duties effectively and to protect the service users appropriate induction programme must be put in place. It could be better if there are risk assessments in place following accidents to service users to minimise falls. 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. Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users are properly assessed before admission to the home. However written confirmation has not been provided to the individuals that their needs would be fully met. Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 11 EVIDENCE: The home’s statement of purpose has recently been updated and has detailed information about services and facilities provided at the home. The Service User’s guide is given or sent to the prospective resident or their representative when they visit to look round. Two care files of recently admitted service users contained pre-admission assessments and care plans completed on how the assessed needs were to be met. However there was no evidence of confirmation in writing to the service users that the home is able to meet their needs as required by the regulation. All prospective service users and/or their families are encouraged to visit the home before admission and are informed of one month trial to enable them to decide whether to stay. The new manager told us that person centred training is being organised to enable staff to meet individual needs of people living in the home. Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service Users are respected and treated in a dignified manner and their right to privacy is upheld. Individual care plans must be clearly and comprehensively written to reflect the assessed needs. Medication policies and procedures are in place to protect residents’ health care. Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 13 EVIDENCE: Four care files were reviewed following requirements made at the last inspection. All the care files contained detailed assessment of their needs however; the care plans had limited information in regards to how staff were supported in meeting the needs of identified individuals. Other care files reviewed contained required information to include weight monitoring and were reviewed monthly to reflect an individual’s changing needs. However no evidence was seen to show that service users or their advocates have been involved in the care planning process. It is required that service users and /or their representatives are consulted whilst care plans are developed to ensure that the individual’s health and welfare needs are adequately met. The home had recently employed a new manager and the inspectors were informed that one of her roles is to review the care planning system with the view to making it more detailed in order to reflect individual needs. We noted that in some cases there was evidence of risk assessments in relation to manual handling, nutritional risk assessments and weight records. However, on one care file there was a general risk assessment that has no reflection on the needs of this individual. For one individual who had recently been admitted to the home there was no wound assessment chart completed yet this individual was admitted with leg sores. For this same individual no pressure sore risk assessment had been completed to prevent minimise the risk of this individual developing pressure sores. Furthermore we noted that whilst an individual with bedrails had a risk assessment in place, this individual had three accidents with one that was potentially serious. We discussed this with the new manager and the risk assessment was reviewed and action plan put in place to protect the health and safety of this person. This was noted to be satisfactory on a short-term basis. The new manager stated that the occupational therapist had been consulted to visit the home to reassess all the bed rails and advise the home on best practice. Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 14 The facilities noted in the home and the conduct of staff support the policies of maintaining privacy and dignity at the home. For example the double rooms have curtains used to respect the service user’s privacy whilst assisting them with personal care. Service users spoken with stated that staff respected their privacy and treated them with dignity. One resident stated, “ I am very happy here, staff are respectful and kind, I have a choice of when I get up and go to bed. They answer when I ring the bell. Another person stated, “ I am treated well. One comment card that we received from a relative regarding care provided said “I feel mother is content in the home and enjoys the food and does not have any complaint so her needs are met and so I am satisfied with her care”. The care files viewed contained evidence of visits from other health professionals to include doctors, and chiropodists. Out patient appointments are also organised where appropriate in order to meet the services needs. Records seen from the drug trolley in relation to handling and administering medication were satisfactory. There was a photograph of the resident maintained with each record. The medication was stored in a locked trolley and in a locked cupboard. We observed whilst reviewing medication that limited life medication (insulin) is stored in kitchen fridge. Furthermore we also noted that the recording of the fridge and freezer temperatures were inconsistent. This is hazardous to the medicines stored in the fridge. The new manager stated in the letter sent to the Commission after the visit that the provider had agreed to purchase a separate fridge for service users medication. This will be reviewed at the next inspection. The home has a policy and procedure in the event of death of a service user. Terminally ill service users are cared for in a dignified manner. Service users, representatives are able to stay with the individual if required. Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home enables the resident to maintain contact with families, friends and the local community. However, there are insufficient social and therapeutic activities provided to meet the needs of people living in the home. It also fails to provide service users with choice in respect of meals and meal times. EVIDENCE: Individuals living at the home and relatives spoken on the day confirmed that the home actively support the service users to maintain contact with families, friends and relatives. Three relatives met on the day stated that there are no restrictions at the Home and that they visit their relative regularly. One individual stated that she has friends that visit daily. Another individual stated that her relative visits daily as they live close to the home.
Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 16 Service Users spoken with stated that they have a choice of when to get up and retire. One individual stated “I have a choice to stay in bed if I feel like it.” Another said that they felt able to choose when they got up and went to bed “its up to me”. Whilst walking around the home, we observed that most of the service users sat in their rooms with little or no stimulation. Some people were in the lounge without any form of activity or entertainment all through the inspection. One individual said there had been no activities since the New Year and the record of activities showed none had been organised since the same period. At a discussion with the new manager in relation to service users’ daily activities, she was unable to provide us with any satisfactory reason why this is the case The Manager must ensure that a programme of meaningful activities based on individuals’ capabilities and in consultation with them and /or their representatives is in place routinely to ensure that people that live in the home maintain the level of stimulation that they had before moving to the home. The menu on the day of inspection contained one option however looked nutritious. Service Users spoken with stated that they were not aware of what they were having for lunch. Moreover, we noted that the meal was different from the menu planed for the day. One individual we spoke with said there was “not normally a choice” and that “meals could be better”. The cook told us that she was unable to inform the service users about the change on the day however that was not the norm. It was agreed that the individuals living in the home must be informed of any changes in future and that this would be reviewed in the next inspection. The fridge and freezer temperatures were not taken regularly increasing the risk of food poisoning. The cook stated that a new thermometer and food probe was to be purchased following the recommendation of the Environmental Health when they visited in 7/01/08. Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individuals living in the home are confident that their complaints would be listened to and that the home is able to protect them from abuse. Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 18 EVIDENCE: The Home has a complaints procedure, which is displayed, to enable service users and relatives to make a complaint if they are not satisfied with the services provided. The complaints procedure contained required information to include details of the Commission for Social Care Inspection. The complaint book viewed had one complaint from a relative regarding the person’s dissatisfaction about the care and services provide to her parent whilst she was living in the home. Evidence from the records show that it was satisfactorily resolved. It was also noted from staff files that some other staff members have not attended Abuse training. At a discussion with the new manager, she stated training had been booked and she would ensure that identified staff attend Abuse training as booked. A requirement was made to ensure that staff receive this training for the protection of the service users. There is also a Whistle Blowing Policy to enable staff to report any bad practices without fear of reprisal. The home also has policy and procedure on the Protection of Vulnerable Adults from abuse. There was evidence that the home checks the Personal Identification Numbers of all registered nurses with the Nursing and Midwifery Council (NMC) before commencement of employment and periodically. Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The residents enjoy a pleasant, homely environment, however, it fails to provide service users with a clean and hygienic place to live in. EVIDENCE: The home is situated in an elevated position in Bath wick, close to the city centre of Bath. The home is an older property with an extension, set out over three floors. The front entrance has one step into the porch and another step into the foyer; level access is through the side entrance. The home has a large garden to the rear with extensive views over the city. Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 20 Major changes to the building have not occurred since the last inspection. The home remains suitable for its stated purpose. However there some areas in the home for example the communal area which would require updating. We noted during the tour of the building that the home had a faulty heating system and the area around the lounge was cold. We discussed this with the new manager and it was agreed that that this situation must be addressed to ensure that service users enjoys a comfortable and warm environment The Commission received a confirmation in writing from the home that this has been addressed. A requirement has been issued to ensure that this is not repeated. We will be following this up in our next visit. Whilst walking round the home, we also noted that the general cleanliness of the home was unsatisfactory due to the absence of domestic staff on the day. Furthermore the kitchen floor requires cleaning due to accumulation of dust on the shelves and build up of grease on the worktops. The home’s cook stated that she would ensure that the kitchen is kept clean at all times. A cleaning schedule is in place. The home must organise cleaners on a regular basis to ensure that service users enjoy clean environment and that good standard of hygiene is maintained at the home. The registered nurse told us that the home employs a laundry person five days a week from 3-8pm and that care staff takeover laundry duties before and after those times. The home has basic sluicing facilities there was no visual instructions and prompts for staff to follow to ensure hygiene practice is followed. The laundry facilities and practices were seen to be satisfactory. We were not able to confirm that the laundry person had attended training on Control of Substances Hazardous to Health (COSHH) and infection control to ensure awareness of the principle of hygiene and the procedure to be followed to reduce the risk cross contamination. The home has a policy on Infection Control. Westcroft DS0000020315.V354919.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): 27,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing arrangements in the home must be improved so that the needs of residents can be met in an efficient way and the training of staff needs to be improved to make sure that all staff have the necessary skills and competence to meet the needs of the work they are to perform. The recruitment and selection of staff fails to make sure that as far as possible the health and welfare of resident is protected. EVIDENCE: As noted previously in this report staffing arrangements are adequate taking into account the current occupancy of the home. However the needs of individuals who live in the home are potentially not being met to the full. The domestic and laundry arrangements in the home are not to the degree required and entail care staff undertaking domestic duties detracting from fulfilling care requirements. The focus of care and nursing staff must be on meeting care needs rather then trying to ensure the hygiene standards of the home are met. Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 22 A number of recruitment and training records were looked at they showed that full information had been obtained including two references. Criminal Record Bureau checks had been obtained however for three of five there had been no Pova list checks recorded and in one instance there was no copy of work permit or visa for the individual. We also noted that one recently appointed handyman had no evidence of recruitment documentation to confirm that this individual is cleared to work in a vulnerable adults setting such as Westcroft Nursing Home. The provider stated on the telephone after the visit that the documentation would be sent to the Commission for verification. The information had not been received before this report was completed. Training records showed that individuals had undertaken moving and handling, Safeguarding Adults, First Aid and Food Hygiene. However there were 4 members of staff who had only undertaken video training relating to moving and handling. One member of staff had only undertaken infection control training with no record of health and safety or moving and handling training. Another had only undertaken Mental Capacity Act training. The new manager stated that she received no formal induction in to her role. This practice is not acceptable. The home must ensure that all staff receive adequate induction based on their job description to enable them to perform their duties effectively. Westcroft DS0000020315.V354919.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): 31,32 38 35 36 37 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is no stable leadership at the home home, the home fails to protect service users by lack of generic risk assessments and unsafe health and safety practices. The health and safety of individuals who live and work in the home is potentially at risk because of poor practice in fire safety arrangements. Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 24 EVIDENCE: We met with the new manager, a registered general nurse with experience of working in older people setting. The new manager had been in post for one month and showed good understanding on the needs of the people living in Westcroft Nursing Home. She was very familiar with the inspection process and cooperated with the inspectors throughout the visit. The Commission for Social Care Inspection had received a satisfactory Criminal Record Bureau Check however the application from registered manager was rejected for insufficient documentation. She told us that the documentation has been obtained and the application was re submitted to the Commission. Staff members we spoke with told us that the new manager was approachable and would listen. They were confident that she would make a positive impact in the care provided for the residents. It was clear from the discussions that the manager had clear objectives on how to make improvements to care provision and other services at the home. One service user stated this about the new manager “ we are just getting to know her. She seems good.” The home sent a comprehensive document (Quality management Action list) to the Commission that is expected to evidence how the home had complied with the requirements and methods used to monitor the quality of it services. Whilst this document is very detailed it seemed difficult to understand in terms of finding the required evidence. It was agreed that this document is simplified to make easier to understand and provide the Commission with the required evidence. The new manager told us at a discussion that staff supervision has been commenced and staff we spoke with confirmed that they have received supervision. We note that the home has purchased new accident book and accidents have been recorded. However we are concerned with the numbers of accidents to individuals living in the home. There were no risk assessments in place in some cases to prevent or minimise the occurrence of those accidents. The requirement is repeated in and will be reviewed at the next inspection. The home is reminded that failure to meet requirements may result in enforcement action being taken.
Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 25 Whilst there was a risk assessment in relation to bedrail on of the one bed seen and consent was signed by the individual’s representative, the bedrail fail to meet safety standards. The bedrail was too short for the bed, which meant that the individual is likely to fall out of bed from the lower end of the bed. This concern was confirmed by the entry on one service user’s daily report following an injury sustained on 7/2/08 through unsafe bedrails. This was discussed with the new manager and immediate safety action was taken to prevent further injury to the service user. It was agreed that the action plan was a temporary measure and must be monitored and reviewed regularly and that a permanent measure must be put in place in order to protect the service users. The new manager also contacted the Occupational Therapists during the visit to arrange for assessment of the all the bed rails in the home and was unable to confirm the date to attend. However the manager wrote to inform the Commission that the home was given guidance and advice for use of bedrails from the Bath and North Somerset Primary Care Trust. It is expected that the home would follow this guidance to ensure that service users using bedrails are protected. Records seen confirmed that the work place risk assessment was undertaken by a private company and advice and action to be taken along with time scales had be produced by the company, however the action plan had not been fully implemented. We saw the document and noted that the information was comprehensive and would provide adequate protection to the home if the recommended action plans are fully implemented. Records relating to health and safety specifically fire were looked at and showed that the last recorded fire drill for staff was 12/03/06. Last weekly test of fire system was 10/09/07 and emergency lighting 25/08/07. A fire risk assessment for the environment of the home was in place however this did not include specific individual accommodation. Gas safety inspection last carried out 21/08/07. Last recorded lift inspection 27/07/07. At time of this visit there were concerns about the heating system effectiveness with temperature in part of the home particularly communal lounge was not satisfactory and individuals were clearly cold. This was addressed with the maintenance member of staff who assured the inspectors radiators would be checked the following day. It was unclear whether the boiler system was adequate or that temperature controls were working as required.
Westcroft DS0000020315.V354919.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 3 3 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 2 X X X X X 1 STAFFING Standard No Score 27 2 28 X 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X X 3 3 2 Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 27 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13 Requirement An individuals living in the home must have appropriate risk assessments to protect them from possible injuries. All residents must have a plan of care that sets out their specific care needs and states how these are to be met. These must be completed for all new residents as soon as possible after admission. The plan must be revised as often as is necessary, and kept up to date. Wound care monitoring must include accurate record keeping and meaningful reviews of progress. All staff must attend POVA training and must be able to act appropriately if abuse is suspected, witnessed or alleged. Timescale for action 22/02/08 2 OP7 15 22/02/08 3. OP8 12(1) 22/02/08 4. OP18 13(6) 22/02/08 Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 28 5 OP29 19 Robust recruitment procedures 31/03/08 must be followed at all times and all new staff must be fully vetted before starting work. This must include the following: CRB and POVA First checks (the latter must be received prior to employment starting) THIS IS A REPEATED REQUIREMENT. Staff must receive training 06/03/08 appropriate to the work they are to perform. All staff must receive the training that the home has themselves deemed as mandatory. New staff must receive a structured induction training that meets the ‘Skills for Care’ requirements and this programme is completed within given timescales. Provide service users with activities after consultation based on individual capabilities. Provide evidence in writing to service users that the home is able to meet their needs Ensure that service users medicine (insulin) is stored appropriately. The home must ensure that fridge and freezer temperature are up to date to protect the individuals living in the home from food poisoning 31/03/08 6. OP30 18(1)c 7. OP30 18(1)c 8. 9. 10. OP12 OP4 OP9 16 15 13 22/02/08 22/02/08 22/02/08 11. OP38 23(4)b 22/02/08 12. OP38 13 The home must ensure that the 22/02/08 heating system is repaired in order to protect the service users from cold environment.
DS0000020315.V354919.R01.S.doc Version 5.2 Page 29 Westcroft 13. OP38 13(7) Bed rail risk assessments must ensure that their use is the most appropriate method of maintaining the safety of the residents, and consent for their use must be obtained. The manager to ensure all fire safety procedures are followed. (This refers to frequency of fire drills (as required by Avon Fire service) and testing of fire systems. Review the level of domestic support provided on a weekly basis and ensure that periodic deep cleaning is undertaken Ensure that there are risk assessments in place following accidents to service users to minimise falls. 12/02/08 14 OP38 23 (4) 12/02/08 15 OP27 23 22/02/08 16 OP38 13 22/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. N Refer to Standard Good Practice Recommendations Westcroft DS0000020315.V354919.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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
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