Inspection on 18/12/06 for Whiteacres Residential Care Home

This inspection was carried out on 18th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Whiteacres Residential Care Home 26/01/10

Whiteacres Residential Care Home 30/06/09

Whiteacres Residential Care Home 07/01/09

Whiteacres Residential Care Home 10/07/08

Whiteacres Residential Care Home 30/04/08

Whiteacres Residential Care Home 09/01/08

Whiteacres Residential Care Home 29/10/07

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Whiteacres Residential Care Home 40 Whitehill Road Ellistown Leicestershire LE67 1EL Lead Inspector Keith Charlton Key Unannounced Inspection 18th December 2006 09:55 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 Whiteacres Residential Care Home DS0000068031.V323658.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. Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whiteacres Residential Care Home Address 40 Whitehill Road Ellistown Leicestershire LE67 1EL 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) 01530260415 01530260415 genesishomes2003@yahoo.co.uk Genesis Homes (Essex) Ltd Mrs Melanie Partridge Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (18), Old age, not falling within any other category (18), Physical disability over 65 years of age (9) Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: No one in the category PD(E) may be admitted into Whiteacres Residential Care Home when there are already 9 persons of category PD(E) accommodated in the home. 2. No one in the category OP may be admitted into Whiteacres Residential Care Home when there are already 18 persons of category OP already accommodated in this home. 3. No one in the category DE(E) may be admitted into Whiteacres Residential Care Home when there are already 18 persons of category DE(E) already accommodated in this home. 4. No one in the category MD(E) may be admitted into Whiteacres Residential Care Home when there are already 18 persons of category MD(E) already accommodated within this home. 5. No person to be admitted to Whiteacres Residential Care Home in the categories OP, PD(E), DE(E), or MD(E) when18 persons in total of these categories/combined categories are already accommodated in this home. This is a new registration of an existing service, Date of last inspection and the first inspection of the service under the new Registered Provider. Brief Description of the Service: Whiteacres is a home situated on the main road in Ellistown, a village in the North of the County of Leicestershire. The home can accommodate upto 18 people, and is registered to admit service users within the Dementia (DE) Mental Disorder (MD), Old age (OP), Physical Disability (PD) groups. The home has 18 single bedrooms some having en-suite facilities. A number of bedrooms are under the current regulation size, though this has been recognised appropriately with information contained in the Statement of Purpose. Service user accommodation comprises of 2 lounge areas and a dining room, bedrooms are split between both floors in the home and a passenger lift services both floors of the home. The home is situated on a bus route to Leicester and Coalville, and is closely situated to shops and green areas. The weekly fees range from £319 to £379 per week - this information was provided on the inspection day. There are additional costs for expenditure such as hairdressing, private chiropody, toiletries, newspapers, and the social fund that pays for outings, outside entertainments etc. 1. Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting three service users and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection. The Registered Manager was on her day off for the first day of the inspection so it was conducted with the Deputy Manager in charge. Planning for the Inspection included reading the notifications of significant events sent to the Commission for Social Care Inspection and the last Inspection Report, as the service is still managed by the same Registered Manager. There have been no complaints made to the Commission for Social Care Inspection since the new registration of the service. The Inspection took place between 9.55 and 15.00 and included a selected tour of the home, inspection of records and direct and indirect observation of care practices. The Inspector spoke with five service users (though this was limited for some owing to the difficulty with communicating with service users with a high level of mental frailty) four staff members, and one visitor. The Inspection was concluded on 20/12/06 with the Registered Manager. What the service does well: Service users said that staff were friendly and helpful towards them, reported that staff welcome visitors and they thought some of the food provided to them was good. Staff were observed to be generally friendly towards service users. Service user needs were well covered regarding medical authorities being involved where necessary following illness or injury. Care Plans contain the past life history of service users if service users/their representatives agree to supply this information. This helps staff see service users as people with a valued past and assists in talking with them. Service users generally spoke positively about the activities arranged by staff, which provided interest and stimulation for them. Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 6 Staff thought they were valued in their performance of their jobs and staff training is encouraged by the Registered Manager in order to equip staff to meet service users needs. The Registered Manager has a positive attitude in seeking to improve the care standards in the service and was receptive to ideas as how to improve the service for service users. Facilities have been improved and there is ongoing redecoration of facilities. What has improved since the last inspection? What they could do better: The Registered Provider needs to ensure that the welfare of service users is protected at all times, as there were staff without statutory Criminal Records Bureau, which meant service users were exposed to staff who may have posed a risk to them if they had criminal convictions or cautions. The Commission for Social Care Inspection issued an Immediate Requirements Notice for the Registered Provider to rectify this situation. Staffing levels need to be reviewed as there are only two staff available for service users care from 8am to 10am, which does not provide essential supervision needed for some service users with challenging behaviour, which then does not provide proper protection for service users and staff. Staff must always be aware of service users care needs; this would include ensuring that staff encourage and prompt in a low key manner rather than being too forceful and directive at times, ensuring a full assessment of needs on admission, Care Plans need to have full details of the care requirements of service users regarding Risk Assessments so that the proper care is always given, and staff being aware of all the Care Plans and the Policies and Procedures of the service. Providing signs to facilities would assist service users who have dementia, in that they can identify facilities clearly. Some comments were made by service users and staff that there should be more outings and more walks. Staff always need to carry out medication procedures properly, have full training on all essential care issues, and have a full understanding of the Vulnerable Adults procedure. Staff were not always seen to use proper Moving and Handling procedures to ensure safe practice for service users. There needs Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 7 to be a more thorough review of safe working practices, including the need to protect service users from burning from hot radiators. There needs to be a review of the food to ensure that food with flavour and of good quality produce is always served. 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. Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process is managed so that service uses receive a satisfactory assessment, thereby ensuring that their main health and welfare needs can be met. EVIDENCE: No service users could remember anyone from the home coming to see them prior to admission to discuss their care needs, saying they could not remember that far back. The Registered Manager stated that prospective service users will be seen in their own setting prior to admission where possible and can visit the home to see whether it suits their needs. An assessment was inspected and whilst it contained relevant information as to service users needs it did not include all aspects of needs, as per the National Minimum Standard. The Registered Manager said the form would be reviewed Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 10 to cover all care issues in this standard. There were also assessments on file from Social Service Departments available, which outlined service users needs. The home does not offer intermediate treatment facilities. Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are not always well looked after regarding their personal care, or always treated with respect, which will affect their day to day sense of feeling valued, though are generally looked after in respect of their health. EVIDENCE: Service users said that staff would call the doctor if they were not well and they made medical appointments for their regular health checks. Service users care plans were inspected and included records of the service users care needs. There was written evidence that service users/their representatives were given the choice to be involved in the setting up and reviewing of the Care Plan. Care Plans contain the past life history of service users if service users/their representatives agree to supply this information. Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 12 This helps staff see service users as people with a valued past and assists in talking with them. Risk assessments were kept and set out within a risk assessment framework though these were not detailed and need to be reviewed so that they state the specific risk and how it needs to be managed. This was further evident when the inspector observed Moving and Handling practices whereby a service user was being inappropriately lifted by staff. The Registered Manager said that she would take this up with staff and organise refresher training. Care Plans did not clearly set out medical checks, e.g. dental needs as regards routine dental checks, or whether the service user needed a chiropodist, and there was no information regarding daily living wishes. Therefore care plans were not detailed enough for staff to deliver consistent and appropriate care. The Registered Manager said these issues would be followed up. Accident records were viewed which showed that medical services were called if there had been injuries to residents. The Registered Manager was asked to look at the Infection Control policy to ensure that staff coming to work with infections do not pass them on to service users. Service users said staff were friendly. The inspector observed that in general staff were friendly though there were instances where a staff member was too directive in trying to get a service user to take a tablet when she was eating and did not want the medication at that time, and some staff were too directive in telling service users what to do rather than explaining and encouraging in a respectful way. The Registered Manager said she was aware of this manner for some staff and would take this up further. The inspector also observed good practice where staff were explaining and encouraging in a friendly manner at the service user’s pace. The visitor the inspector spoke with said he thought the staff were caring and friendly and did a good job. A Senior Care Assistant confirmed that only senior staff issue medication and have undertaken medication training. The Registered Manager confirmed this. Some gaps in medication record sheets were noted, where medication had been supplied but not signed. The Registered Manager said she had carried out audits of medication and was frequently reminding staff of the importance of signing the record after medication had been issued, and agreed to take this matter further with the staff. It was noted that a service user may able to self medicate some of her medication, which would assist to maintain independence, as per the policy of the service. The Registered Manager confirmed that it was the practice of the service to promote self medication if the service user was able to safely carry Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 13 this out and this service user would be assessed and asked if she wanted to do this. Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users do not always have the opportunity to lead a full and active lifestyle, which restricts important stimulation for them, though they can generally exercise choice. The food supply is not always tasty, which means service users are disappointed with this essential part of daily life. EVIDENCE: Service users said that there were usually enough activities and they enjoyed them, though they would like more outings and walks out with staff. The Registered Manager said this would be followed up and staffing levels reviewed to facilitate this. Service users and staff said staff escort service users to the nearby shops and working mens club, if there is time. No activities were observed to be on during the inspection. The Registered Manager said she would highlight activities to be offered by staff on a daily basis, and look into specific training to provide relevant activities for service users with dementia. Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 15 The Registered Manager said someone came in to do reminiscence sessions with the service users. This situation is commended. It was also discussed that service users mat benefit from having memory boxes filled with important items of interest and used to discuss events from the past, so as to provide more stimulation. The Registered Manager said service users and relatives are able to take part in Residents Meetings, held every six months. Minutes of meetings evidenced this as taking place. The Registered Manager needs to review this frequency to see if it would be more useful for service users and relatives to have more frequent meetings to air views and suggestions. Both service users and a relative stated that visitors are always welcomed to the home by staff and no one reported any restrictions. Service users said that there were no rules – they said they could rise and retire when they wanted. One service user said she went to the local stroke club on a weekly basis. It was noted in the records that a staff member had highlighted that some staff were getting service users up very early. It was shown also that the Registered Manager took appropriate action to ensure this practice was stopped and that service users can get up when they choose. There were a variety of views regarding the food in that service users said it could be both very good or lacking in taste. The Registered Manager said she was aware of the problem and is taking action to ensure that food is always tasty and the meat is of good quality. Menus were inspected and found to have choice for the main meal though only a choice of one desert which and needs extending to provide more variety. Food records need to be more detailed to include the vegetables served so this variety can be properly monitored. It is recommended that the cooks attend service users meetings so that they can receive direct feedback from service users and answer any questions. It is also recommended, as part of the Quality Assurance Survey, that service users are asked on a one to one basis what meals they want and for menus to be provided based on their choices. The inspector tasted the food. It was broadly satisfactory though the beef grill and sausage were basic processed foods and the food lacked flavour. Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements for receiving and responding to complaints are generally in place though refresher staff training on the Adult Protection procedure is needed to result in the full protection of service users welfare. EVIDENCE: Service users generally said that they thought that if there was a problem then the Manager or Senior staff would sort it out. A Complaints Book is kept. The last recorded complaint was four years ago. The Registered Manager confirmed this. The Complaints Procedure is generally satisfactory but does not give the complainant the opportunity to go to the Commission for Social Care Inspection at the initial stage, as per the National Minimum Standard. It also states that all complaints need to be put into writing, which would be very difficult for a service user with dementia or mental health difficulty. The Registered Manager said these issues would be followed up. Care staff spoken with were unaware of the full procedure regarding of which Agencies to contact if the in house arrangement failed. The Registered Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 17 Manager said staff have received training on the proper procedure but these issues would be followed up and a short procedural statement drawn up and provided to help staff to follow the correct procedure. Since the new registration of the home there has been an incident in October 2006 which was not reported to the Social Service Department under the Vulnerable Adults procedure, which highlights the need to have comprehensive staff training on this issue. This is an ongoing issue, which is subject to investigation. Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Facilities are seen to be comfortable by service users and are currently undergoing improvement. Odour control is generally good. EVIDENCE: Service users said they were satisfied with their rooms, which the inspector observed to be personalised with items of resident’s furniture, pictures and photographs in them. The maintenance person was seen to be working redecorating a bedroom and said that the home was being refurbished. The Registered Manager confirmed this and said the programme would also replace carpets in six bedrooms. Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 19 The inspector recommended that the Registered Manager look into providing signing to the environment to assist service users with dementia, e.g. same colour doors for bathrooms etc. She said that would be done. Odour control was of a good standard. There was only one bedroom where the carpet was odouress, (the Registered Manager stated she had referred the service user to the District Nurse in order to alleviate this). The Registered Manager said she would ask the cleaner to clean this room. Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels are not maintained to a safe level to meet service users needs. Recruitment procedures need to be in place to meet service users needs and properly protect them. Staff training systems are generally good though need strengthening to protect service users from the challanging behavior of other service users. EVIDENCE: There were comments that there was not enough staff to take service users out. There has also been a recent challenging behaviour incident, which highlighted the need to ensure there is sufficient staff available to protect the Health and Safety of service users and staff. At the time of the incident there were two care staff on duty on the floor, which meant that proper supervision of service users with challenging behaviour cannot always take place as they are undertaking a variety of other tasks. The Registered Manager said that with this incident staff were present but could not have stopped the incident occurring. Nevertheless, having sufficient staff at identified areas of risk will help prevent incidents such as these occurring or developing into more serious incidents. Staff training on challenging behaviour is also required to ensure staff know how to deal with these situations. Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 21 The staffing rota demonstrated only two staff on duty from 8am to 10am, one care assistant and one senior staff on duty. (The Commission for Social Care Inspection would also expect that the Registered Manager is not fully included into the necessary staffing compliment as she has Management duties to perform, and not only care tasks). For all other day time/evening periods there are at least two care staff plus a senior staff member. There are two care staff awake on night duty. Staffing needs to be reviewed to ensure that service users are properly protected and their needs are met. This is especially important, as there are currently three service users with challenging behaviour, which demonstrates the need for ongoing supervision. This revised rota needs to be sent to the Commission for Social Care Inspection. Staff said there had been training in the last twelve months. Records were seen by the inspector that demonstrated this, coupled with information seen arranging more training. There was also evidence of proper induction training for new staff. The Registered Manager was recommended to devise a Training Matrix to identify key issues that staff need training in (to quickly access who needs training in any relevant issues) – e.g. first aid, challenging behaviour, moving and handling, health and safety, medication, dementia, training on service users conditions – stroke care, diabetes, parkinsons disease etc. Staff said they were encouraged to undertake National Vocational Qualification level 2 training and the Registered Manager stated that the National Minimum Standard regarding of 50 of care staff with National Vocational Qualification level 2 had been exceeded with over 80 of care staff with this qualification. Recruitment records were inspected and found in some areas to be poor placing residents at risk of harm. Criminal Records Bureau /Protection of Vulnerable Adults checks were not in place when staff commenced employment, and some written references not in place at this stage. An Immediate Requirements Notice was served for this to be quickly rectified by the Registered Provider. This stated: (i) The registered provider must apply for a POVA First/Criminal Records Bureau check in respect of all future members of staff and any current members of staff without such checks. (ii) The registered provider must review staffing arrangements at the home to ensure that at all times any current members of staff without POVA First/Criminal Records Bureau checks do not work unsupervised. The Registered Manager said she now fully understood the proper procedure and would be immediately implementing this. Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 22 Since the Immediate Requirements Notice was issued the Registered Provider has replied stating that the necessary action has been taken and that it will be complied with in future. Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are not fully in place to protect the health and safety of service users. EVIDENCE: Service users said that they thought the Registered Manager ran the home well and that she was approachable and thoughtful. The Registered Manager has a National Vocational Qualification level 4 and has also achieved the Registered Managers Award. Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 24 There was evidence on staff records that staff are appropriately supervised and supported. Annual appraisals are also carried out. Staff Meetings have been held and were well recorded but there had only been one meeting in the past fourteen months. The Registered Manager agreed to have more meetings to support staff and ensure practice issues were regularly discussed. There is a Health and Safety folder with Risk Assessments for safe working practices though this appears basic with a simple note that there were no identified risks. Other Risk Assessments for safe working practices are needed, e.g. use of ladders, any work needed regarding the lift, the need for window restrictors etc. The Registered Manager is to check this issue with the Environmental Health Officer so that it comprehensively covers all workplace risks. A Quality Assurance system was in place for 2006. This had been supplied to service users, relatives and other stakeholders, e.g. the hairdresser, people supplying activities etc and a summary of the outcome had been comprehensively presented, as to any action that needed to be taken. It is recommended the results are included in the Statement of Purpose. Service user monies records were found to be properly kept with running balances, and two signatures were recorded so that transactions are witnessed. Fire Precautions: a fire door was found to be locked in the dining room, which compromised fire safety in that this blocked a fire exit. Staff quickly rectified this in that the door was unlocked and another safety handle affixed instead. A staff member was asked the fire procedure and was fully aware of the whole procedure. All system testing was on required schedules for emergency lighting, fire bell testing, and fire drills. There was also a fire risk assessment on file. The hot water temperature was checked in a bathroom and found to be 44c, close to the National Minimum Standard of 43c; within the recommended safe temperature limits of 43c. There was evidence on file of regular hot water temperature checks carried out. Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. 2. 3. Standard OP10 OP18 OP27 Regulation 12 13 18 Requirement That the Registered Provider ensures that service users are always shown respect by staff. That all staff receive refresher Adult Protection Training and are fully aware of this procedure. Staffing levels need to be reviewed and increased to ensure that service users needs are met and there is protection of service users from challenging behaviour. The revised rota needs to be sent to the Commission for Social Care Inspection. The registered provider must apply for a POVA First/Criminal Records Bureau check in respect of all future members of staff and any current members of staff without such checks. This was left as an immediate requirement at the time of this insepction. The registered provider must review staffing arrangements at the home to ensure that at all times any current members of staff without POVA First/Criminal DS0000068031.V323658.R01.S.doc Timescale for action 21/12/06 19/02/07 19/02/07 4. OP29 19 24/12/06 5. OP29 19 20/12/06 Whiteacres Residential Care Home Version 5.2 Page 27 6. 7. OP29 OP38 19 13 Records Bureau checks do not work unsupervised. This was left as an immediate requirement at the time of this insepction. Statutory staffing checks must be in place before staff commence employment. The Health and Safety systems in the home must protect the welfare of service users from harm. This includes protection from burning and unsafe Moving and Handling practices. 19/12/06 21/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP7 OP9 Good Practice Recommendations Care Plans need to be more thorough regarding clearly explaining risks and how they can be minimised, and including the daily living wishes of service users. It is recommended that the Registered Manager institute a more rigouress audit trial for medication to ensure that gaps in recording the issuing are swiftly followed up. The food supply is in need of review to ensure it is always has flavour and the meat supply of good quality. Facilities need to be signed to help orientate service user with disabilities OP15 OP19 Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Whiteacres Residential Care Home DS0000068031.V323658.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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