Inspection on 06/08/09 for Culwood House

This is the latest available inspection report for this service, carried out on 6th August 2009.

CQC found this care home to be providing an Good service.

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

Culwood House 09/04/08

Culwood House 20/04/07

Culwood House 28/07/06

Culwood House 07/02/06

Culwood House 24/05/05

Culwood House 10/01/05

Culwood House 17/08/04

Culwood House 28/03/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 12/10/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Culwood House 130 Lye Green Road Chesham Buckinghamshire HP5 3NH Lead Inspector Barbara Mulligan Key Unannounced Inspection 6th August 2009 09:40 DS0000022968.V377003.R01.S.do c Version 5.2 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. Culwood House DS0000022968.V377003.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 Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Culwood House Address 130 Lye Green Road Chesham Buckinghamshire HP5 3NH 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) 01494 771012 01494 783051 webbecj4572@aol.com www.culwoodhouse.co.uk Mrs Anita Larkin Mr Larkin Mr Chris Webb Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 14. Date of last inspection 26th September 2008 Brief Description of the Service: Culwood House is a privately run care home providing personal care and accommodation for fourteen older people. The home is in an Edwardian building, located on the outskirts of Chesham about one mile from the town centre. There is dropping off space and parking at the front of the building. There is a mature garden with a summer house and shady seating areas for residents. A part of the home is the private residence of the manager. The home is not purpose built and does not have a lift. All bedrooms are single and have en-suite facilities (WC and sink). The fees range from £460 to £625 pounds per week. Additional costs include hairdressing, chiropody, papers and personal effects. Information about the home can be obtained directly from the home. Culwood House DS0000022968.V377003.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 this service experience good quality outcomes. This unannounced key inspection was conducted over the course of a day and covered all the key National Minimum Standards for older people. Inspecting for Better Lives (IBL) involves an Annual Quality Assurance Assessment (AQAA) which is completed by the service. This document, which includes information from a variety of sources, was received in good time, was fully completed and contained the information we needed. This initially helps us to prioritise the order of the inspection and identify areas that require more attention during the inspection process. This document is referred to throughout the report. The manager of the home was unable to be in attendance for the inspection, however the deputy manager assisted with the inspection throughout the day. The information contained in this report was gathered mainly from observation by the inspector, speaking with a number of service users, visiting relatives and care staff. Further information was gathered from records kept at the home. A key theme of the visit was how effectively the service meets needs arising from equality and diversity. Feedback on the inspection findings and areas needing improvement was given to the management of the home at the end of the inspection. The management of the home, the staff and service users are thanked for their cooperation and hospitality during this unannounced visit. What the service does well: Potential service users receive a thorough needs assessment to ensure the home can meet the care needs of the service users. One visiting relative informed us that they had been able to bring their relative to visit the home and the staff had been very welcoming and answered all their questions. Care plans have been produced for all people who use the service, and these inform the care staff what they must do to meet the needs of the individual. One person spoken to on the day of the visit said “I think I am lucky to be in a home like this. It has everything and I’m looked after very well”. Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 6 One visiting relative spoken to on the day of the visit said “It’s lovely here. I know my relative is in the best place and gets the best care. They are looked after very well and I know the staff always do what ever they can to help.” There is a motivated and established staff team that consists of care staff who respond to service users in a respectful and appropriate manner. The home provides a range of activities to suit people using the service expectations and preferences. The health needs of people using the service are well met with input from different healthcare professionals. One person spoken to on the day of the visit said “I am well looked after. If I feel poorly I can see my Dr in my room.” One visiting relative said, “I know my relative is in good hands and the home acts quickly if there are any reasons to be concerned.” The home has facilities in place to enable people to promote their spiritual interests. The home ensures that relatives and friends are able to visit at anytime, within reason. The home provides a pleasant and comfortable environment in which people can live. Communication between people who use the service and staff was observed to be positive and open. The home ensures that people using the service are provided with a choice of wholesome and appealing meals in pleasing surroundings. Comments made about the food include, the food is lovely, very nice” and “the food is always good. You never go hungry here”. There is a range of policies and procedures, and a staff information pack, providing staff with relevant information about all aspects of care and the home/organisation. Health and Safety procedures are in place and records are well maintained. The evidence seen and comments received indicate that this service meets the diverse needs e.g. religious, racial, cultural, disability of individuals within the limits of its Statement of Purpose. What has improved since the last inspection? There has been an improvement in the development of care plans to ensure that care is provided in a person centred manner. Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 7 Some areas of the home have been redecorated and refurbished to ensure that people live in a home that is safe and well maintained. The staffs practice in the safe handling, recording and administration of medication has improved and is consistently implemented to ensure that people who use the service receive their medication as prescribed. The home has undertaken an audit of all staff personnel files to make sure they all contain the necessary recruitment checks. Appropriate risk assessments have been completed for people who wish to self medicate and appropriate storage facilities have been provided. What they could do better: If you want to know what action the person responsible for this care home is 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. Culwood House DS0000022968.V377003.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 Culwood House DS0000022968.V377003.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. 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. Service user’s needs are assessed prior to admission ensuring that staff are prepared for admission and have a clear understanding of the service user’s requirements. EVIDENCE: Staff who have undertaken training complete the initial needs assessment for any potential service users. Three completed needs assessments were examined, including two people newly admitted to the home. Each file had a completed needs assessment and shows that all areas and conditions of people using the service were assessed prior to offering them a place in the home. Each assessment contained further information about the Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 10 person’s family and friends, likes, dislikes and preferences. Each assessment was dated and signed by the person completing the assessment. The assessment demonstrates that prospective service users, family members or representatives are included in the assessment process if this is appropriate. One visiting relative informed us that they had been able to bring their relative to visit the home and the staff had been very welcoming and answered all their questions. The home does not provide intermediate care, so this standard is not applicable. Culwood House DS0000022968.V377003.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. 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 health, personal and social care needs of people who use the service are adequately identified in the care plans, ensuring the home can meet the needs of the individual. EVIDENCE: The care of three residents; including those new to the service; were looked at and their care plans were examined. Care plans were up to date and contained sufficient detail for staff to learn about residents they support. Specific needs have been identified within the care plans and there is an action plan in place to provide staff with details of how these needs are to be managed and fully met. Some entries in the care plans lack specific details, for example one entry reads, “assist to get out of bed” and another reads, “assist with washing and bathing.” These are vague statements and should be more detailed to provide specific guidance for staff to follow. The home should address this. Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 12 Individual preferences, likes and dislikes and reference to end of life care are recorded in care plans and describes how these will be met. Staff complete daily record notes and these were examined. It was noted that these are not always completed on a daily basis. Some entries lack detail, for example, “ate well, washed and dressed” and “went out this afternoon and enjoyed themselves.” This does not provide the care staff with details of how the individual has been through the day or what they have been doing and does not demonstrate that the care given by staff is the same as noted in care plans. The home should address this to ensure records are maintained daily and contain full details of how people spend their day. One person spoken to on the day of the visit said “I think I am lucky to be in a home like this. It has everything and I’m looked after very well”. One visiting relative spoken to on the day of the visit said “It’s lovely here. I know my relative is in the best place and gets the best care. They are looked after very well and I know the staff always do what ever they can to help.” The staff spoken to are knowledgeable about service users care needs and preferences. There is evidence that care plans are reviewed monthly and updated when appropriate. Visual observations of people using this service showed that people were smartly dressed including jewelry, make up and nail varnish, people were seen to be wearing the aids needed, for example hearing aids and clean glasses. The home receives district nurse support and they are available for advice regarding pressure area care and assist in the provision of pressure relieving equipment. There were no individuals with pressure sores at the time of the visit. Tissue viability assessments are in place for service users and these were seen to be reviewed on a monthly basis and pressure relieving equipment was in place for individuals who need it. Staff provide support to individuals needing to attend outpatient and other appointments. Most service users are registered with three local GP practice. However, one individual has kept their own GP since they were admitted to the home. Risk assessments are in place covering areas such as falls, moving and handling, nutritional assessments, wound assessment and pressure area care. These are up to date, signed and dated by the person completing the assessment. The inspector was told a domiciliary optical service visits the home and service users receive an annual eye test. Residents can visit their own opticians if they wish. Chiropody services visit the home every six week and dental services visit the home annually or as needs arise. Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 13 Records of health screening were noted in multi disciplinary notes which have recently been implemented into the care plans. One person spoken to on the day of the visit said “I am well looked after. If I feel poorly I can see my Dr in my room.” One visiting relative said, “I know my relative is in good hands and the home acts quickly if there are any reasons to be concerned.” The procedures for the administration of medicines were examined during this inspection. At this visit we looked at the medication administration record (MAR) charts, medication supplies and care plans for the three people whose care was being looked at as part of this inspection. At the previous inspection a requirement was issued for arrangements to be in place, and procedures adhered to at all times for the safe storage, administration and recording of medications, at all times. The home has moved to using a blister pack system which ensures safer storage and disposal of medicines. At a previous inspection undertaken in June 2008 it was identified that some packs of medication that had been supplied from the pharmacy were not fully labelled, and the provider was informed that this needed to be discussed with the supplying pharmacy. A requirement was made for the home to make sure that all medicines are given from fully labelled packs, to ensure that residents are receiving the correct medication at the correct dose. It was pleasing to see that this has been complied with and all medicines were clearly labelled. At the previous inspection it was noted that the home had started recording administration of Temazepam in a notebook, but without a running total balance. The home has implemented individual registers to record running totals for those residents on controlled drugs. This was examined and found to be up to date with two signatures and the running balance in place for each person. The home has put together a separate medication policy file for all staff to refer to. Within this file, there are forms for the recording of homely remedies and medication received in to the home which is not in the blister pack. The home now carries out documented weekly checks on medication as well as keeping a record of medication storage temperatures. The MAR charts show one hand written entry on them which was not signed or dated by care staff. When it is necessary to handwrite on a medication administration record chart in the home, the member of staff writing the chart should sign and date the chart and a second carer should check the entry for accuracy and then initial the chart. In addition the entry should include a reference to where this information was sourced, such as the prescribers name. Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 14 At the previous inspection a requirement was issued for appropriate risk assessments to be completed for people who wish to self medicate and appropriate storage facilities be provided. It is pleasing to see that this has been complied with and risk assessments were observed in service user files. At the time of the visit the deputy manager was working to provide written guidelines for as required (PRN) homely remedies medicines. These had not been completed for all people using the service at the time of the visit. However these were received by the Commission before the report was completed. These provide guidelines for the administration of all when required/when needed medicines. The guidelines include when the medicine is to be given and when it is not. Training records show that staff have recently completed medication training and further training is planned. The inspector observed staff assisting people who use the service in a kindly and respectful manner. Staff are obviously aware of the importance of privacy and dignity and were seen to always knock on doors before entering and always addressing the individual by their preferred term of address. The homes induction programme includes training regarding privacy and dignity. One person spoken to said, “staff are kind, caring, and always ask me what they can do and give me a choice”. Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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 is a range of activities available to residents who are encouraged and supported to remain in contact with their families and friends and to use local community facilities ensuring people do not become socially isolated. The presentation and standard of food is good and meets the nutritional needs of people who use the service. EVIDENCE: Care plans show individual routines of daily living and include bathing, rising and retiring times, personal likes, dislikes and preferences. Service users have the opportunity to exercise their choice in relation to leisure, social activities and cultural interests. There is a varied programme of activities provided for those who wish to partake which includes musical events, flower arranging, sewing club, board and card games, art and crafts, cake decorating, hand massages and manicures and a weekly film club. The film club was taking place on the day of the visit. Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 16 The Annual Quality Assurance Assessment (AQAA) tells us that people using the service are often invited to local events and these have included, church tea, the local school Christmas party as well as being offered the church car service if required. The home has access to the local library on wheels service, which provides audio and large print books and approximately every six weeks the home holds a Communion within the home. Activities are posted on a residents notice board. Seasonal activities are provided and these have included Christmas parties and carol singers, Easter Egg Hunts, Halloween and summer BBQ’s. There is an album of photographs showing these events taking place. The home has recently purchased a summerhouse which has been equipped with comfortable, soft furnishing as well as lighting and a cd/radio player so that residents can enjoy the garden. A wireless broadband connection in the home has been provided so that residents with a laptop can access the internet. The organisation has purchased a seven seater vehicle, to use in conjunction with the sister home, so that they can take large groups of residents on outings such as pub lunches. One comment received about the activities in the home was, the activities are very good. The home does their best to make sure everyone is occupied and busy.” Service users are able to receive visitors in the privacy of their own rooms and are able to choose whom they see and do not see. One visiting relative said, I visit once a week and have lunch with my relative. The staff always make me feel welcome when I visit. Sometimes I bring my children and they are invited to lunch with everyone else and the staff make us feel welcome.” The AQAA tells us that the home encourage family and friends to visit at any time, including children and well behaved pets, and invite visitors to join residents for a meal in the privacy of their own room or in a communal area of the home. On the day of the visit several relatives were visiting and having lunch with their families. Service users are offered three meals a day. The menu is decided upon on a weekly basis and the deputy manager said she would usually complete this. It was difficult to ascertain if the service users have input into the weekly menu. Special diets are available to meet residents’ health and cultural needs. The chef endeavours to take individual tastes into account and one visiting relative said that if my relative didn’t want the meal the staff would always ask what they would like instead. The inspector had the opportunity to join people using the service for lunch. Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 17 The meal was relaxed, unrushed and well organised. The food was attractively presented and staff provided support if it was needed. Some people chose to take their meals in their rooms on the day of the visit. Comments made about the food include, the food is lovely, very nice” and “the food is always good. You never go hungry here”. Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 18 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 home is able to effectively manage complaints and safeguard service users ensuring service users are listened to and kept safe from harm and abuse. EVIDENCE: There is a complaints policy and procedure, which clearly describes the way in which complaints should be handled and the deadlines that are set for response. The complaints procedure is accessible to service users and their representatives. The home has produced a staff information pack and the complaints procedure is included in this, the Statement of Purpose and the Service Users Guide. A record of all complaints is maintained, and the complaints log was viewed during this inspection. The home has received two complaints in the last year and this information is recorded in the Annual Quality Assurance Assessment (AQAA). Both complaints are well recorded and responded to within stated timescales. Policies and procedures are in place for safeguarding vulnerable adults (SOVA) and staff have access to a whistle blowing policy. The home should obtain an up to date copy of the local authority safeguarding policy. Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 19 Training records demonstrate that staff have completed safeguarding training and this is regularly updated. The Annual Quality Assurance Assessment tells us that there have not been any safeguarding referrals in the previous twelve months. Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 20 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, 20, 21, 22, 25 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 standard of the environment within the home is good, and on-going improvements to the home provides people who use the service with a safe and homely place to live. EVIDENCE: The home is an Edwardian house and is located on the outskirts of Chesham about one mile from the town centre. The home is on two levels and is suitable for its stated purpose and on-going improvements have been made to the home over the last twelve months. The ground floor is comprised of the entrance hall, a number of seating and dining areas, a conservatory, kitchen, laundry, bathrooms, toilets and some sleeping accommodation. The main lounge is comfortably furnished and in Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 21 good decorative order. Efforts have been made to make these areas look homely, with many personal touches such as pictures, side lamps, books, plants and ornaments. There is a spacious dining room which is nicely decorated and has French windows which open out onto the garden. A small conservatory offers a quiet area for residents to meet with relatives and on the day of the visit one resident was having lunch with several relatives in this area. The hallways on the upper floor would benefit from redecoration and new carpets. The deputy manager said this was part of the refurbishment plan for the coming year. There are accessible toilets available for service users throughout the home and several are close to the lounges and dining area. Bathrooms and toilet areas have the appropriate aids and adaptations to meet the needs of individuals and to promote independence. Laundry facilities are sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared, cooked or eaten and do not intrude on service users. The laundry floor finishes are impermeable and these and the wall finishes are readily cleanable. The home has an infection control policy and the inspector observed this. The Annual Quality Assurance Assessment (AQAA) tells us that eleven staff have completed in Infection Control. Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 22 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. The staffing numbers and skill mix is satisfactory and staff training is sufficient and up to date to ensure that people who use the service benefit from staff who are who are competent to do their job. Improvements to the recruitment process means that people using this service are protected by the recruitment procedures. EVIDENCE: The homes staff rota demonstrates that there are adequate numbers and skill mix of staff on duty at all times. The home presently employs twelve care staff on both part time and full time basis. The registered manager is supernumerary on the roster, allowing for flexibility during peak and holiday periods. Comments received from people on the day of the visit were “the staff are lovely and I think I’m going to be happy here” and “oh yes the staff help me all the time and go out of their way to help me”. The home continues to support care staff on NVQ training and at the time of this inspection there were seven staff who have achieved a national vocational qualification in care. Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 23 At the previous inspection it was identified that there were serious failings in the recruitment procedure and a requirement was issued for an audit to be undertaken of all staff personnel files, to ensure all information and necessary documentation be contained within staff personnel files, and provide confirmation to the Commission of any deficits found and what actions have been taken. The home has since provided us with relevant evidence that they had sought, to ensure staff personnel files contain everything that is required under the Care Homes Regulations 2001. The service also provided us with an improvement plan detailing how improvements were to be made to ensure that a robust recruitment procedure be in place by the end of September 2008. During this visit four staff files were examined, including those staff new to the service. All files have been reorganised since the last inspection and those examined were very organised and all files contain the necessary documentation as needed. All staff complete an induction programme that covers the common induction standards and certificates of completion were observed in the files examined. During the initial induction to the home staff are extra to the numbers on the staff rota and work alongside more experienced staff. Training records show that staff are up to date with their mandatory training which includes moving and handling, fire training, basic food hygiene, infection control, safeguarding vulnerable adults and first aid training. There is specialist training available for staff, and an example of this is seen in files. These include understanding and managing challenging behavior, bereavement and loss, the mental capacity act and emergency life support training. Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 24 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. There have been some weaknesses in the management of the home but consistent and on going improvements ensure the home will be able to satisfactorily meet service users needs. EVIDENCE: The service has recognised that there has been a history of non-compliance within the service and have worked hard to address these shortcomings to improve outcomes for those using the service. Since the inspection undertaken in April 2008 the registered manager has undertaken some training to update his skills and knowledge to ensure that he is equipped with the appropriate skills to provide people with a fully Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 25 comprehensive assessment of needs. The registered manager has not yet commenced the Registered Managers Award, which the deputy manager said was due to difficulties with the company providing this training. The home has now attained some funding for the registered manager and the deputy manager to complete this training. The organisation’s management system includes a quality assurance module which includes a satisfaction survey. These were last sent out in May 2009 and some were still being returned to the home. The deputy manager said an action plan will be drawn up to address any issues arising from the surveys. The deputy manager said the registered manager hopes to hold an annual review of care with service users and families. Staff spoken to confirmed there were staff team meetings held once a month and management meetings take place every morning with management staff from the sister home. There is evidence that staff supervision is now completed on a regular basis. The home does not handle the financial affairs of those using the service; it is an expectation that family members, solicitors or other representative will undertake this role. There are secure facilities available for the safe-keeping of money and valuables. There is a health and safety policy in place and health and safety training is completed and up to date for all staff. Records were seen for fire safety. These cover the homes fire procedures, practice fire drills, fire prevention, fire alarm testing and emergency lighting testing. Testing of the homes fire alarm system is undertaken on a weekly basis and evidence was seen of this. There is a fire based risk assessment that is reviewed annually. COSHH documents have been put into place and service reports are in place for PAT testing, gas appliances and electrical installation. A new nurse call system was installed in the home on 18/06/2008. Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 3 3 X x 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 X 3 X X 3 Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 27 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. 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 Standard Good Practice Recommendations Culwood House DS0000022968.V377003.R01.S.doc Version 5.2 Page 28 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@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. 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