NURSES AGENCY The Extra Care Charitable Trust - NA The Extra Care Charitable Trust Ryfields Village Arena Gardens Warrington Cheshire WA2 7GB Lead Inspector Joan Adam Key Unannounced Inspection 4th September 2006 09:30 The Extra Care Charitable Trust - NA DS0000052721.V305092.R01.S.doc Version 5.2 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 Inspection Report Author CSCI Audience General Public Further copies from 0870 240 7535 (telephone order line) Copyright 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 Internet address www.csci.org.uk The Extra Care Charitable Trust - NA DS0000052721.V305092.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 agency are those for Nurses Agencies. 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. The Extra Care Charitable Trust - NA DS0000052721.V305092.R01.S.doc Version 5.2 Page 3
SERVICE INFORMATION Name of service The Extra Care Charitable Trust - NA Address The Extra Care Charitable Trust Ryfields Village Arena Gardens Warrington Cheshire WA2 7GB Telephone number 01925 582000 Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration The Extra Care Charitable Trust Hayley Haughton Nurses Agencies The Extra Care Charitable Trust - NA DS0000052721.V305092.R01.S.doc Version 5.2 Page 4
SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 Brief Description of the Service: Extracare nursing agency is based in Ryfields Village in Orford, Warrington Cheshire. Ryfields Village is a large complex consisting of private accommodation and shops, gym etc. The office for the nurse s agency is contained within this complex. The agency provides Registered General Nurses to service users who require nursing care within the confines of the village. A domiciliary care agency operates alongside the nursing agency. A Registered General Nurse is employed to undertake interviews and supervise the placement of all grades of nurses to be supplied by the agency. The fees are based on an individual basis according to the level of care required. The Extra Care Charitable Trust - NA DS0000052721.V305092.R01.S.doc Version 5.2 Page 5
SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the agency premises was part of the Commission for Social Care Inspection annual inspection programme. The visit took place over three hours on 4 th September 2006. The inspection consisted of a tour of the premises, examination of records and discussion with the manager. Prior to the visit the service history for the agency was reviewed. The manager had provided a completed pre-inspection questionnaire. Feedback following the inspection was given to the registered manager on the day of the site visit. What the service does well: The offices are well equipped and provide a safe and pleasant environment for staff and visitors. An appropriate management structure and clear lines of accountability are in place. The manager is a qualified nurse who keeps up to date in her knowledge and clinical practice so the agency is run in an efficient and effective manner. Staff are provided with a written contract and information about the standards of conduct expected from them. There is a quality assurance system in place to ensure that the agency operates in the best interests of its service users and staff. The agency provides a consistent and reliable service that meets the needs of the service users. Staff surveys indicated that the management team are approachable and helpful at all times. The Extra Care Charitable Trust - NA DS0000052721.V305092.R01.S.doc Version 5.2 Page 6
What has improved since the last inspection? The statement of purpose has been up dated to enable service users to have adequate information regarding the agency. What they could do better: The agencies policy on the administration of medication go beyond the expectations and requirements necessary for a Nurses Agency. It is recommended that the medication policy is reviewed to meet with the National Minimum Standard. 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 Extra Care Charitable Trust - NA DS0000052721.V305092.R01.S.doc Version 5.2 Page 7
DETAILS OF INSPECTOR FINDINGS CONTENTS Information (Standard 1) Registered Persons (Standard 2) Recruitment and Supply of Nurses (Standards 3-6) Complaints and Protection (Standards 7-11) Management and Administration (Standards 12-18) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Extra Care Charitable Trust - NA DS0000052721.V305092.R01.S.doc Version 5.2 Page 8
Information The intended outcome for Standard 1 is: 1. Prospective service users have the information they need about the agency in order to make an informed decision on whether to engage its services. JUDGEMENT we looked at the outcome for standard: 1 The quality rating for this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are provided with the information they need to make an informed choice about whether to use the agency. EVIDENCE: The certificate of registration was displayed. A copy of the statement of purpose was supplied at the inspection. It has been updated to contain all relevant information required. Information provided to service users included how to contact the agency at all times, including out of office hours. The Extra Care Charitable Trust - NA DS0000052721.V305092.R01.S.doc Version 5.2 Page 9
Registered Persons The intended outcome for Standard 2 is: 2. Service users are assured of the integrity of the agency and have confidence that it is run by a fit person or organisation. JUDGEMENT we looked at the outcome for standard: 2 The quality rating for this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users can have confidence that the agency is run by a fit person. EVIDENCE: The manager is a qualified nurse and has been registered with CSCI. She can demonstrate that she is competent to run the agency and has the relevant training and experience to manage the service. She has obtained NVQ level four registered managers award. The Extra Care Charitable Trust - NA DS0000052721.V305092.R01.S.doc Version 5.2 Page 10
Recruitment and Supply of Nurses The intended outcomes for Standards 3-6 are: 3. The process for recruitment and selection of nurses meets all the requirements of legislation and employment law including that related to equal opportunities and anti-discriminatory practice. 4. Service users are confident that nurses supplied by the agency will provide good quality care and will not jeopardise the safety of patients. 5. The agency has documentary evidence demonstrating the personal identification, registration, ongoing eligibility to be employed as a nurse, and relevant qualifications of each nurse to be supplied. 6. Nurses supplied by the agency are competent and trained to undertake the activities for which they are employed and responsible. The Commission considers Standards 3, 4 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT we looked at outcomes for the following standard(s): 3,4,6 The quality rating for this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users can be satisfied that the agency has robust recruitment procedures and carries out the appropriate checks to ensure that staff supplied are qualified and competent to undertake the duties for which they are employed. EVIDENCE: The registered manager is a qualified nurse. She is responsible for interviewing prospective trained nurses, reviewing the applications, references and medical declarations of all staff employed by the agency. Recruitment policies and procedures are in place to assist the manager in this role. The personnel records of three nurses were examined at this inspection. All contained two satisfactory references, completed self-medical questionnaires, records of hours worked, and satisfactory Criminal Record Bureau disclosures. Copies of the staffs immunisation records were seen. The Extra Care Charitable Trust - NA DS0000052721.V305092.R01.S.doc Version 5.2 Page 11
All agency staff undertook a formal induction process, which covered the responsibilities that the nurse supplied would have. This was undertaken prior to the nurse attending to service users. There were satisfactory written policies for the administration of medicines to service users who required assistance with this. The agencies policy on the administration of medication go beyond the expectations and requirements necessary for a Nurses Agency. Current working practices as agreed at the point of registration with CSCI do not conform to this policy, however,the agency is conforming to the NMS. The agency is advised to review this policy to conform to the NMS. The Extra Care Charitable Trust - NA DS0000052721.V305092.R01.S.doc Version 5.2 Page 12
Complaints and Protection The intended outcomes for Standards 7-11 are: 7. Service users are confident that their complaints will be listened to, taken seriously and acted upon. 8. Service users who are also patients are protected from abuse, where the agency is an employment business. 9. Service users who are patients are protected by the agency s procedures for assistance with medication, where the agency is an employment business. 10. Action is taken to protect confidentiality of information relating to service users who are also patients, their carers and advocates. 11. The health, safety and welfare of service users who are also patients, and of nurses, are promoted and protected, where the agency is an employment business. The Commission considers Standards 7, 8, 9 and 11 the key standards to be inspected at least once during a 12 month period. JUDGEMENT we looked at outcomes for the following standard(s): 7,8,9,11 The quality rating for this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are protected by robust complaints and protection policies and procedures, which ensure that any concerns are taken seriously and acted upon appropriately. EVIDENCE: A clear written complaints procedure was maintained, which was included in the statement of purpose and advised that complaints could be taken up with CSCI if the complainant was dissatisfied with the agency s response. Full written records of all complaints were kept, including details of any action taken as a result. Nurses supplied by the agency were promptly informed of complaints relating to themselves. There is a procedure in place for reporting nurses to the NMC where there is evidence of misconduct. The Extra Care Charitable Trust - NA DS0000052721.V305092.R01.S.doc Version 5.2 Page 13
There were satisfactory procedures in place for responding to suspicion or evidence of abuse, including a whistle blowing policy. There were also clear policies and procedures on the safe handling of money and property, which precluded nurses supplied by the agency assisting in the making of or benefiting from service users wills. The agency had a policy that incorporated the Nursing and Midwifery Council s guidelines on the administration of medication. All staff were requested to sign this and a copy was placed in their personnel file. Staff working at Ryfields receive basic health and safety training prior to working with a service user. Fire alarm tests at the village were conducted weekly. A fire risk assessment was carried out on the building. The manager of the agency confirmed that all equipment is checked prior to use in a patient s own home. The Extra Care Charitable Trust - NA DS0000052721.V305092.R01.S.doc Version 5.2 Page 14
Management and Administration The intended outcomes for Standards 12 18 are: 12. Approved accounting and financial procedures are adopted to ensure the effective and efficient running of the business and its continued financial viability. 13. There are designated premises suitably equipped for the purpose of the day to day operation and management of the service. 14. An appropriate management structure and clear lines of accountability are in place. 15. Nurses supplied by the agency know the standards of conduct expected of them and are aware of the agency s organisational policies, where the agency is an employment business. 16. There is a written agreement between the Agency and nurses. 17. Service users and nurses interests are safeguarded by the agency s record keeping policies and procedures. 18. The agency operates in the best interests of service users and of nurses supplied by it. The Commission considers Standards 15 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT we looked at outcomes for the following standard(s): 15,18 The quality rating for this outcome area is good. This judgement has been made using available evidence including a visit to the service. The agency operates in the best interests of service users and of nurses supplied by it. EVIDENCE: The premises provided clean, comfortable, office accommodation and staff rooms that were suitably equipped. There was suitable and sufficient office equipment and resources for managing the business. The management structure reflected the size of the agency and the volume and complexity of the care provided. Job descriptions were provided for the operations manager and the agency manager. The Extra Care Charitable Trust - NA DS0000052721.V305092.R01.S.doc Version 5.2 Page 15
Staff were provided with a handbook upon commencement of employment. This contained a written set of organisational policies. The staff files checked contained copies of a written contract of service outlining the terms and conditions of engagement. The agency maintained up to date records of service users and nurses supplied by the agency. A Quality assurance system is in place and internal audits are carried out on a regular basis. The service user questionnaires received by the agency were positive with no issues raised. The Extra Care Charitable Trust - NA DS0000052721.V305092.R01.S.doc Version 5.2 Page 16
SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Nurses Agencies have been met and uses the following scale. 4 Standard Exceeded (Commendable) 3 Standard Met (No Shortfalls) 2 Standard Almost Met (Minor Shortfalls) 1 Standard Not Met (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 INFORMATION COMPLAINTS AND PROTECTION Standard No Score Standard No Score 1 3 7 3 8 3 REGISTERED PERSON 9 2 Standard No Score 10 X 2 3 11 3 RECRUITMENT AND SUPPLY MANAGEMENT AND OF NURSES ADMINISTRATION Standard No Score 12 X 3 3 13 X 4 3 14 X 5 X 15 3 6 3 16 X 17 X 18 3 The Extra Care Charitable Trust - NA DS0000052721.V305092.R01.S.doc Version 5.2 Page 17
Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations Standard 1. NU9 It is recommended that the medication policy is reviewed to meet with the NMS The Extra Care Charitable Trust - NA DS0000052721.V305092.R01.S.doc Version 5.2 Page 18
Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: 0845 015 0120 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 The Extra Care Charitable Trust - NA DS0000052721.V305092.R01.S.doc Version 5.2 Page 19