Care Home: Ivonbrook Care Home

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What the care home does well Most people told us their needs, or those of their relative, were always met at the home. They said “I’m well looked after” and that the home “provides the care and attention needed by the residents”. People told us there were usually staff available when they were needed. People said staff were “kind and patient” and would “do anything for you”. What has improved since the last inspection? Of the 12 requirements made at the last inspection, 10 had been met and 2 partly met. This had resulted in improvements to care plans, staff training, the environment of the home, and the security of confidential information in the home. The manager had applied for registration with CQC and was approved as the registered manager soon after the inspection visit. What the care home could do better: Ensure that care plans are produced and written using a person centred approach. Ensure that care plans are updated with information about changes in the person’s needs so that those needs are fully met. Ensure that infection control systems and procedures in the home meet the current guidance from the Department of Health so that people are better protected from the risk of infection. Develop the quality assurance system further to ensure as wide a range as possible of views and opinions about the home, and to produce a report to show the findings of surveys and the action taken to meet any issues raised. This will help to ensure that people’s views and opinions are taken seriously and used to improve the service in the home. Develop policies to demonstrate how the requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards will be implemented in the home. This should include how the provider will ensure that staff are conversant with this legislation and their roles and responsibilities. This will ensure that people`s rights are promoted and upheld. Key inspection report CARE HOMES FOR OLDER PEOPLE Ivonbrook Care Home Eversleigh Rise Darley Bridge Matlock Derbyshire DE4 2JW Lead Inspector Rose Moffatt Key Unannounced Inspection 25th November 2009 09:40 DS0000002061.V378559.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. 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 mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ivonbrook Care Home Address Eversleigh Rise Darley Bridge Matlock Derbyshire DE4 2JW 01629 735306 01629 735441 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) David Treasure Mr A Wright, Mrs Glenys Pamela Wright, Alison Treasure Margaret Anne Poole Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit the person named in variation V38675 in the category DE(E) dated 8 February 2007 25th November 2008 Date of last inspection Brief Description of the Service: Ivonbrook is situated in its own grounds in Darley Bridge village, near Matlock, and provides nursing and personal care for up to 40 older people. The home is purpose built and the facilities are on 2 floors. All bedrooms are single rooms; 12 rooms have en-suite facilities. There are 2 lounges, dining rooms and a small quiet lounge area. People in the home have access to a garden. Fees at the home range from £350 - £700 per week. In addition, people pay for hairdressing and private chiropody services. This information was given by the provider on 25th November 2009. Information about the home, including CSCI / CQC inspection reports, is available in the main entrance area of the home. Ivonbrook Care Home DS0000002061.V378559.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 2 star. This means the people who use the service experience good quality outcomes. The focus of our inspection is on outcomes for people who live in the home and their views on the service provided. The inspection process looks at the providers ability to meet regulatory requirements and national minimum standards. Our inspections also focus on aspects of the service that need further development. We looked at all the information we have received, or asked for, since the last key inspection or annual service review. This included: the annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also has some numerical information about the service; surveys returned to us by people using the service and from other people with an interest in the service; information we have about how the service has managed any complaints; what the service has told us about things that have happened - these are called notifications and are a legal requirement; the previous key inspection and the results of any other visits we have made to the service in the last 12 months; relevant information from other organisations; and what other people have told us about the service. We carried out an unannounced inspection visit that took place over 7½ hours on 25th November 2009. The inspection visit focused on assessing compliance with requirements made at the previous inspection and assessing all the key standards. We sent out 10 surveys to people living in the home and received 9 completed responses, 5 of these completed with help from the person’s relative. We sent out 10 surveys to staff employed at the home and received 2 completed responses. There were 26 people accommodated in the home on the day of the inspection visit. 10 people who live in the home, 4 visitors and 3 staff were spoken with during the visit. The manager was available and helpful throughout the inspection visit. Some people were unable to contribute directly to the inspection process because of communication difficulties, but they were observed during the visit to see how well their needs were met by staff. Case tracking was used during the inspection visit to look at the quality of care received by people living in the home. 3 people were selected and the quality of the care they received was assessed by speaking to them and / or their relatives, observation, reading their records, and talking to staff. Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.2 Page 6 What the service does well: Most people told us their needs, or those of their relative, were always met at the home. They said “I’m well looked after” and that the home “provides the care and attention needed by the residents”. People told us there were usually staff available when they were needed. People said staff were “kind and patient” and would “do anything for you”. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.2 Page 7 taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 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 Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Assessment processes had been improved so there was detailed and consistent information about the needs of people in the home. People were confident their needs could be met at the home. EVIDENCE: Most people told us their needs, or those of their relative, were always met at the home. They said “I’m well looked after” and that the home “provides the care and attention needed by the residents”. We looked at the care records for 3 people living in the home. All had an assessment of their needs carried out by staff from the home prior to their Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 Page 10 admission. There was also assessment information from social services and/or hospital staff. We found that some people had been asked if they had a Lasting Power of Attorney in place, or an Independent Mental Capacity Advocate (IMCA) working with them. The manager said they had recently started to ask for this information. There were no assessments of the person’s mental capacity to make decisions about their daily life. The AQAA said that pre-admission assessment forms and care plans had been updated in the previous 12 months. The AQAA gave us information about the needs of people in the home. The AQAA showed there was an admission policy in place that had been reviewed in 2009. Standard 6 did not apply as there were no people receiving intermediate care in the home. Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans had been improved and developed to ensure a more consistent approach to meeting people’s needs. EVIDENCE: Most people told us their care and support needs, including medical care, were always met in the home. Most people said staff usually listened to them and acted on what they said. People said staff were “kind and patient” and would “do anything for you”. A relative said they felt reassured that the person’s nursing needs were met as they were “closely monitored and the GP called in when necessary”. Staff told us they always had up to date information about the needs of people in the home and had relevant training to help them to meet those needs. Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 Page 12 The 3 care records we looked at each had a care plan that had been reviewed every month. 2 of the care plans seen covered all of the person’s individual needs, though more detail was needed in some areas. The other care plan did not cover all of the person’s needs, although information about all of their needs was available in other parts of the care records. The care plans were not always updated when there were changes in the person’s condition or needs. For example, one person had started treatment for an eye infection and although there were details of this in the records of GP visits, there was nothing in the care plan. We made a requirement at our last inspection that care plans must be reviewed to ensure they were up to date and reflective of people’s needs. This requirement was mostly met as the care plans had all been reviewed monthly, but not fully met as the care plans did not always reflect the person’s changing needs. The requirement has been repeated in this report with a short extended timescale. The care plans were not written in a person centred way and were not signed by the person, or their representative, to indicate their involvement and agreement. The care records we looked at each had assessments of the person’s nutritional needs, their risk of developing pressure sores, and their risk of falling. There was also an assessment and plan of how they should be assisted with moving and handling. All of these assessments had been reviewed monthly. One person had an agreement for using bed rails signed by a relative, but no risk assessment for this. We saw records of the input of other healthcare professionals, such as the GP, District Nurse, chiropodist and optician. People told us they saw their GP as necessary. Medication was securely stored. We found satisfactory records of the receipt, administration and disposal of medicines. There were protocols in place for the use of medicines prescribed ‘as required’. Most medication was administered by the registered nurses in the home. Care assistants administered topical creams, such as skin moisturisers. We found some medicines kept as ‘homely remedies’ were out of date. The AQAA said they had improved in the last 12 months by improving care plans and risk assessments and ensuring they were reviewed monthly. They planned to improve by encouraging more involvement of people in the home, or their representatives, in care planning and review. The AQAA told us there were relevant policies and procedures in place that had been reviewed in 2009. Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 Page 13 Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was a range of suitable activities offered, a choice of appetising meals, and enough flexibility in routines to ensure that lifestyle in the home met the needs, preferences and expectations of people living there. EVIDENCE: People told us they could choose how to spend their day and could get up and go to bed when they wanted to. One person was pleased they could have a drink of beer when they liked and could stay in their room when they wanted to. In response to the question, ‘what does the home do well?’ one person said “try to give food we like. Good trips out”. There was a weekly activities program on display that included quizzes, dominoes, trips out, arts and crafts and a church service in the home. There was an activities coordinator employed for 2 days per week plus volunteers Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 Page 15 helping most days with activities. Most people told us there were usually activities that they could take part in if they wanted to. People told us they liked the rural setting of the home and enjoyed watching a herd of deer and other wildlife in the garden. Visitors told us they were always made welcome in the home and could visit at any reasonable time. There were 2 dining rooms in the home, or people could choose to eat in their own rooms if they wanted to. There was a choice of meals available and one person was pleased there was always a non-meat alternative. When we asked people if they had enjoyed their lunch they said “I always do!” and “the meals are very good”. We saw that staff gave sensitive assistance to those people who needed help with eating and drinking. There was no heated trolley to transport meals from the kitchen to the dining rooms and so meals were taken on covered, warmed plates. However, we saw that some meals arrived in the dining room well before people were ready to eat. The AQAA said that they had improved in the last 12 months by asking people about their preferred daily routines and including this information in their care records. They had also employed the activities coordinator since the last inspection. They planned to improve by gathering more information about the background and preferred routines of people in the home. Also, by finding out more about suitable activities for people with dementia. Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The systems in place ensured people in the home were safeguarded and their complaints were taken seriously. EVIDENCE: Most people told us they knew who to speak to informally if they were not happy, and most people knew how to make a formal complaint. People told us they would go to the acting manager or the owner with any concerns and they were confident that appropriate action would be taken. A relative said they “only have to mention something and it will be sorted out straightaway”. The complaints procedure was displayed in the entrance area of the home. We looked at the complaints records and found 2 recorded since the last inspection. The action taken for each one was noted, but not the eventual outcome, and the records were not signed. Compliments were recorded but were not always made available to staff. We found that all staff had received training about safeguarding vulnerable adults since the last inspection. Staff told us they knew what to do if abuse was alleged or suspected. Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 Page 17 We had not received any complaints or safeguarding referrals about the home since the last inspection. The AQAA showed that there were relevant policies and procedures in place that had been reviewed in 2009. The AQAA said they had improved in the last 12 months by ensuring there was a copy of the complaints procedure in each person’s bedroom. Also, by ensuring all staff training in safeguarding vulnerable adults was up to date. Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was clean, well maintained and suitably equipped to meet the needs and preferences of people living there. EVIDENCE: Most people told us the home was usually clean and fresh. They said they liked the homely style of the lounges. One person commented that the décor could be improved in places. To comply with requirements made at the last inspection, privacy locks had been fitted to toilets, air filtration machines had been installed to reduce Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 Page 19 unwanted odours, and a code lock had been fitted to the office door to ensure secure storage of confidential information. The lounges and dining rooms were warm and suitably furnished. There were good views of the garden and people clearly enjoyed watching the herd of deer and other wildlife. The bedrooms seen were personalised with people’s own possessions and were suitably equipped to meet individual needs. There were some areas where the homely style was compromised, such as a large whiteboard with details of staff training in the main corridor, and a large fridge marked ‘staff’ in one of the dining rooms. One lounge had an alcove storage area that looked untidy. We were told that it was planned to curtain off this area. The home appeared clean in all the areas seen and there were no unpleasant odours. There were systems in place to ensure effective cleaning and maintenance. The laundry was suitably equipped. Most people told us they were satisfied with the laundry system and that clothing and bedding were changed regularly. One person said they did not always get their own clothes returned from the laundry. There had recently been an external audit of how well infection control was managed in the home. The home had scored well on this and the manager was working on an action plan to address areas where improvement was needed. We found that soiled laundry was manually sluiced and soaked before washing in the laundry, contrary to current guidance from the Department of Health. We also found that used disposable razors were left in a box in one of the bathrooms, instead of being immediately disposed of after use. There was a potential risk of these razors being re-used. The box was removed during the inspection visit. The AQAA gave details of improvements made to the home since the last inspection, including ensuring all bathrooms and bedrooms had liquid soap and paper towels in place. They planned to improve by continuing the improvements in décor and furnishing. The AQAA showed there were relevant policies and procedures in place and that these had been reviewed in 2009. Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People in the home were protected by satisfactory recruitment procedures and supported by staff with relevant training in sufficient numbers to meet individual needs. EVIDENCE: Most people told us that staff were available when they needed them and that staff usually listened to them and acted on what they said. People said that staff were “very friendly”, “lovely, nothing is too much trouble”, and, “very kind and patient”. There were 26 people living in the home on the day of the inspection visit, 17 of these assessed as needing nursing care. The staff rotas showed that there were always 4 care assistants on duty during the day and 2 at night, plus a registered nurse for each shift. Staff told us there were usually enough staff available to meet the needs of people in the home. We observed that there was always a care assistant available in one of the lounges during the day and there appeared to be sufficient staff available at lunchtime to help people as required. Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 Page 21 We looked at the records of 3 members of staff and a volunteer working in the home. All had the required documents in place, including a Criminal records Bureau (CRB) disclosure and 2 written references. 2 of the staff records did not have a full employment history and 1 did not note the reason for leaving a previous job that involved the care of vulnerable adults. We made a requirement at our last inspection that staff must only start work when all the required information and documents were in place. This requirement was mostly complied with and staff records had improved, but there were some gaps in information. We have repeated the requirement in this report with a short extended timescale. We found that new staff had received an induction training that met Skills For Care standards. Staff training records had improved since the last inspection. We found that most staff were up to date with required training, such as moving and handling and fire safety. Some staff had also had training about caring for people with dementia and about managing challenging behaviour. Of 13 care staff, 6 had already achieved a relevant National Vocational Qualification (NVQ) at level 2 or above. The manager and 3 other staff had received training about the Mental Capacity Act 2005. Staff told us that training had “really improved” in the last year and that “the staff team work well together – it’s a happy atmosphere”. They said they would like more staff meetings – there had been one meeting in 2009. The AQAA said that they had improved in the last 12 months by introducing a skills based induction program for new staff, updating staff training records and ensuring all pre-employment checks were in place before new staff started work. They planned to improve by more staff training, including training about the Mental Capacity Act 2005. Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was well managed with effective systems in place so that the health, safety and welfare of people was promoted and protected. EVIDENCE: Since the last inspection, the manager had made an application for registration with CQC. She was successful in this application very soon after the inspection visit. The manager had worked in the home for several years and had previously been the registered manager of the home. People told us they had Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 Page 23 confidence in the manager and the owners to put right any problems raised. Staff told us the manager was good and “motivates and encourages us”. The AQAA was completed by the manager. The AQAA gave a reasonable picture of the current situation within the home with sufficient evidence to support the comments made. The data section was fully completed. Quality assurance measures included annual surveys completed by people in the home and/or their relatives. The surveys seen did not offer the opportunity to be completed anonymously. There was no report produced of the findings of surveys and of any action taken to address issues raised. We saw monthly reports produced by one of the owners in line with regulation 26. There had been one meeting for people in the home and their relatives in 2009. There was information available in the home about the Mental Capacity Act 2005 and the manager and 3 other staff had received relevant training. The manager was aware of the need to implement new practices to take into account the requirements of the Act. Some people chose to have small amounts of personal money kept safely in the home. We found that the money was stored securely and there were satisfactory records of all transactions. The AQAA showed that all maintenance of equipment and systems was up to date. We sampled records of checks of fire safety equipment and found these were up to date. Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 Page 24 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 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement A system of care plan reviews must be introduced to ensure the care plans in place are up to date and reflective of residents needs. This will help to ensure that people’s changing needs are fully met. The previous timescale was 30/01/09. This has not been fully met and so a time extension has been given. If this extended timescale to meet this requirement is not met, enforcement action will be taken. 31/01/10 Staff must only be confirmed in post following all preemployment checks described by Schedule 2. This will ensure a robust system for recruitment of staff that safeguards people in the home. The previous timescale was 30/12/08. This has not been fully met and so a time extension has Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 Page 26 Timescale for action 31/01/10 2 OP29 19 3 OP8 13(4) 4 OP26 13(3) been given. If this extended timescale to meet this requirement is not met, enforcement action will be taken. Where bed rails are used, there 28/02/10 must be an individual risk assessment in place to ensure that any associated risks are reduced as far as possible or eliminated. There must be effective infection 31/03/10 control systems and procedures that follow current guidance from the Department of Health. This will help to ensure that people in the home are protected from infection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations Care plans should be produced and written with a person centred approach, and should be signed by the person, or their representative, to indicate their involvement and agreement. This will help to ensure that people have care and support in line with their personal preferences. There should be a system in place to regularly check that the use by date of products used as homely remedies has not expired. This will help to ensure that people in the home are protected and are given medicines that are effective. There should be a heated trolley for meals to be transferred from the kitchen to the dining rooms. This will help to reduce the risks to people in the home. The records of complaints should include the outcome of the complaint and whether the person making the complaint was satisfied with the outcome. This will help to ensure a more robust system so that people are confident appropriate action is taken to address their complaints. DS0000002061.V378559.R01.S.doc Version 5.3 Page 27 2 OP9 3 4 OP15 OP16 Ivonbrook Care Home 5 OP33 6 OP33 7 OP33 The quality assurance system should be further developed to ensure as wide a range as possible of views are sought, surveys can be completed anonymously, and a report should be produced to show the findings of surveys and the action taken to meet any issues raised. This will help to ensure that people’s views and opinions are taken seriously and used to improve the service in the home. The admission processes should include: - recording whether the person has made an advance decision on receiving medical treatment, and if they have a Lasting Power of Attorney, Independent Mental Capacity Advocate, or Relevant Persons Representative. - consideration of the persons capacity to make decisions about their daily lives, care and treatment. This will ensure that people are safeguarded and their rights are promoted. Policies should be developed to demonstrate how the requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards will be implemented in the home. This should include how the provider will ensure that staff are conversant with this legislation and their roles and responsibilities. This will ensure that peoples rights are promoted and upheld. Ivonbrook Care Home DS0000002061.V378559.R01.S.doc Version 5.3 Page 28 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastmidlands@cqc.org.uk Web: www.cqc.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) Care Quality Commission (CQC). 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