Care and Social Services Inspectorate Wales. Care Standards Act Inspection Report. Hermitage Residential Home

Transcription

1 Care and Social Services Inspectorate Wales Care Standards Act 2000 Inspection Report Hermitage Residential Home The Hermitage Salop Road Welshpool SY21 7EP Type of Inspection Focused Date of inspection Tuesday, 13 October 2015 Date of publication Monday, 9 November 2015 Welsh Government Crown copyright You may use and re-use the information featured in this publication (not including logos) free of charge in any format or medium, under the terms of the Open Government License. You can view the Open Government License, on the National Archives website or you can write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or psi@nationalarchives.gsi.gov.uk You must reproduce our material accurately and not use it in a misleading context.

2 Summary About the service The Hermitage is registered with the Care and Social Services Inspectorate Wales (CSSIW) to provide care and accommodation to up to thirty three older people with personal care needs. The home is a large town house with two purpose built extensions situated in the town of Welshpool within easy reach of the amenities. The registered providers are Janette Nelson and Stephen Griffiths. Currently the manager is not registered with CSSIW. However he is now in a position to complete his application as he is now achieved his Qualification Credit Framework (QCF) in Leadership and Management at level 5 and has registered with the Care Council for Wales (CCW). What type of inspection was carried out? We (CSSIW) carried out this inspection as part of the annual inspection programme. The home had a baseline inspection in June 2014 followed by a focused inspection in December 2014 designed to ensure there continued to be no negative impact on people using the service as a result of not having a registered manager. On this occasion we carried out an unannounced focused inspection which means we concentrated on the experiences of people using the service. For the purposes of gathering information for this inspection we used the following methodology: We examined the information we hold as part of our monitoring role and that regarding our communications with the registered persons since the last inspection. We carried out an unannounced visit to the home over a period of four hours. During our visit we: Examined in detail the care records of four people using the service Spoke to four people using the service Examined the records of three staff members who had been recruited during the past twelve months. Spoke informally to care staff, a house keeper and the cook on duty Observed practice, both informally and through the use of the Short Observational Framework for Inspectors (SOFI 2) tool for a period of thirty minutes. This tool assists inspectors to understand the quality of experiences of people using the service through interactions with staff. Discussed issues with the acting manager and registered persons during and following our inspection visit. What does the service do well? We did not see any areas of outstanding practice to report at this inspection. What has improved since the last inspection? The home has achieved compliance with Regulation 9(6)(b) as the acting manager has now attained the required QCF at level 5and is registered with the CCW. We await his Page 2

3 completed application to register as manager following which we will remove the noncompliance notice. What needs to be done to improve the service? We did not issue any non-compliance notices as a result of this inspection. This is because we are confident that the registered persons and acting manager will address the recommendations we have made to the benefit of people using the service. Recommendations for improvement: We recommend that the registered persons and acting manager consider the use of a nutritional risk assessment tool such as The Malnutrition Universal Screening Tool (MUST) to assess and review the nutritional status of any resident about whom they may have concerns regarding their diet in line with Regulation 12(1)(a). The registered persons should ensure that they keep copies of staff s birth certificates and passports (where available) as part of proof of identity and in line with Regulation 17(2) Schedule 4 paragraph 6 of The Care Homes (Wales) Regulations We have previously discussed the need for the registered persons to consider applying for a variation to care for people with dementia. Because there was no person with a definitive diagnosis of dementia and there was, at the time no manager registered at the home, this was deferred. However, due to the above circumstances having changed, we now recommend that the registered persons apply for a variation to ensure they are operating within their category of registration and therefore satisfy the requirements of the Care Standards Act Part II, Section 15. Page 3

4 Quality Of Life People can be confident that they will be treated in a respectful manner and that their wishes and needs will be taken into consideration. This is because we observed people being given choices with regards to when they wish to rise in the mornings, what clothes they wish to wear, where they spend their day and what they wish to have for their meals. We looked in detail at the care records of four people using the service. We saw that reviews take place monthly and include any changes to people s condition or personal wishes. The reviews we saw were very thorough but included considerable duplication. We discussed, with the acting manager, ways in which the work associated with this could be reduced without loss of quality of the information. We also discussed the need for him to delegate responsibility for reviewing care to designated senior carers as, at present, he is completing reviews and the administrator is currently typing up new care plans each month. This will be further explored within the staff team. People can be confident that the home uses risk assessments which are pertinent and properly implemented. During our inspection there was no person being cared for who had significant issues with eating and drinking. However a number of people required specialist diets. We saw that staff were vigilant in weighing residents but were not using a nutritional risk assessment. We spoke to the acting manager about this and suggested he consider the use of the Malnutrition Universal Screening Tool (MUST) where there are concerns about a person s dietary intake or nutritional status. This will assist staff to monitor their condition and take appropriate action if the tool suggests this is required. Regulation 12(1)(a). We asked people what they thought of the food and those we spoke to informed us that they enjoyed their meals and that these are varied and tasty. We saw menus are in place for a three week period and spoke to the cook on duty. We noted that there is only one main course listed in the menu for the main meal. However people told us that other meals are made to order and the cook stated that they are able to provide a different hot meal if required and keep meals for any person who may not be present when the main (lunchtime) meal is served. People can be confident that their health needs will be met. This is because we saw evidence of good communications with primary health care team members (GPs and district nurses) and also other professionals such as the speech and language therapist (SALT). Information regarding contact was well recorded and easy to understand. We did not look in detail at issues around medication. However we noted no issues with storage, administration or record keeping in relation to this. People benefit from a varied programme of activities and we saw evidence of a number of activities within the home, including visiting entertainers which people told us they thoroughly enjoy. Many people have family living close by and are often taken out by them. There are also a number of residents who are members of local clubs and groups and the home staff facilitate their continued participation in these. During our visit we saw Page 4

5 people popping into the home to chat to residents who they had known before they became resident and the home staff welcomed and encouraged this. Currently there are no people using the service who s first language is Welsh. However at least one resident is fluent in the Welsh language. The home has one member of staff who speaks Welsh fluently and a number who are able to understand and converse in the language to a reasonable extent. Most staff have some knowledge of the language having learnt it at school and have picked up some conversational phrases. Our observations through the use of SOFI suggest that staff are attentive to people s needs, wishes and preferences. We observed a staff member sitting and quietly speaking to a resident who had become agitated. She seemed to understand the resident intimately and calmed her down, not leaving until she was happy and settled. People we spoke to said they do not have to wait for long periods if they ring the bell and staff are pleasant and patient with them. We saw that visitors were made welcome at any time and offered hot drinks when they arrived. Page 5

6 Quality Of Staffing We did not focus of issues related to staff on this occasion. This theme will be more fully considered at a future baseline inspection. However we note that there appears to be suitable numbers of staff on duty and care staff told us that, although they are busy during periods of the day, they are able to respond to the personal care needs of residents in a timely fashion. People using the service told us that staff also are able to spend time speaking to them and involving themselves in activities during the afternoons. We looked at the personnel records of three members of staff who have been recruited within the past twelve months and found these to be generally in order. We reminded the acting manager that he should keep a copy of each persons birth certificate and passport, if available, as proof of identity in line with Regulation 17 (2) Schedule 4 para 6 of the Care Homes (Wales) Regulations We also noted that, should a person have a conviction which is present on the enhanced police check, records of discussion between the registered persons and prospective member of staff at interview and reasons for subsequent decision to employ, should be kept. Page 6

7 Quality Of Leadership and Management While we did not focus on all aspects of leadership and management during this inspection (this theme will be more fully explored at future baseline inspections) we did discuss a number of issues with the acting manager and the registered persons. The home has not had a manager registered with the CSSIW since March However since this time a manager has been appointed and has been working towards the necessary qualifications to register with the Care Council for Wales and the CSSIW. At this inspection the acting manager has recently completed his QCF level 5and had just received his certificate of registration with the Care Council for Wales. He was in the process of completing his application for registration with the CSSIW. This means that the home will shortly be compliant with Regulation 9(6)(b) in relation to this. We note that people can be assured that throughout this time the home has been safely and robustly managed. This is because the acting manager has grown in experience and has been fully supported by the registered persons who are present at the home on a daily basis. At the last inspection we discussed the rising number of people living at the home with at least an element of memory impairment. Recently a number of people have been diagnosed with dementia or significant mental infirmity. The registered persons agreed that a variation should now be applied for to acknowledge the number of people for whom they currently provide care who suffer from dementia and for those that they may be asked to admit in the future. This will ensure they satisfy the requirements of the Care Standards Act Part II Section 15. We understand that the variation application will be completed at the same time as the acting manager applies for his own registration. We discussed a recent issue relating to a member of staff where an internal investigation was agreed to with the social services adult protection team. The acting manager was aware of his responsibilities and understood and had taken the required action. Page 7

8 Quality Of The Environment We did not focus on the quality of the environment on this occasion. This theme will be considered at a future baseline inspection. However, we can assure people that they will receive care and accommodation in a clean and pleasant environment that is free from any unpleasant odours. On our visual inspection we noted that all toilet and bathrooms were clean, well maintained and free from clutter. The premises combine a traditional large town house with two purpose built extensions. There are pleasant large communal sitting rooms and dining areas and the entrance area is currently through the conservatory and is welcoming light and airy. There are plans to extend to the side of the conservatory which will mean that there is a separate entrance foyer away from this providing more privacy for residents who chose to sit here. Page 8

9 How we inspect and report on services We conduct two types of inspection; baseline and focused. Both consider the experience of people using services. Baseline inspections assess whether the registration of a service is justified and whether the conditions of registration are appropriate. For most services, we carry out these inspections every three years. Exceptions are registered child minders, out of school care, sessional care, crèches and open access provision, which are every four years. At these inspections we check whether the service has a clear, effective Statement of Purpose and whether the service delivers on the commitments set out in its Statement of Purpose. In assessing whether registration is justified inspectors check that the service can demonstrate a history of compliance with regulations. Focused inspections consider the experience of people using services and we will look at compliance with regulations when poor outcomes for people using services are identified. We carry out these inspections in between baseline inspections. Focused inspections will always consider the quality of life of people using services and may look at other areas. Baseline and focused inspections may be scheduled or carried out in response to concerns. Inspectors use a variety of methods to gather information during inspections. These may include; Talking with people who use services and their representatives Talking to staff and the manager Looking at documentation Observation of staff interactions with people and of the environment Comments made within questionnaires returned from people who use services, staff and health and social care professionals We inspect and report our findings under Quality Themes. Those relevant to each type of service are referred to within our inspection reports. Further information about what we do can be found in our leaflet Improving Care and Social Services in Wales. You can download this from our website, Improving Care and Social Services in Wales or ask us to send you a copy by telephoning your local CSSIW regional office. Page 9