Inspection on 01/05/08 for Isis Care and Retirement Centre

This is the latest available inspection report for this service, carried out on 1st May 2008.

CSCI found this care home to be providing an Excellent 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

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Isis Care and Retirement Centre Cornwallis Road Oxford OX4 3NH Lead Inspector Marie Carvell Unannounced Inspection 10:15 1 & 2nd May 2008 st X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000068950.V363779.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000068950.V363779.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Isis Care and Retirement Centre Address Cornwallis Road Oxford OX4 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) 01865 397980 01865 399920 manager.isis@osjctoxon.co.uk The Orders of St John Care Trust Mr Nicholas Michael William Hill Care Home 80 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places DS0000068950.V363779.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with Nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - OP Dementia - DE The maximum number of service users who can be accommodated is 80 (eighty) 14th May 2007 2. Date of last inspection Brief Description of the Service: Isis Care and Retirement Centre opened in December 2006 and is operated by the Orders of St John Care Trust. It is a care home providing personal care and accommodation for eighty older people, fourteen places can be provided for service users who require rehabilitation (intermediate care). The care home is managed by The Orders of St John Care Trust, which is responsible for many care homes in Oxfordshire that were formerly provided by the County Council. Isis Care and Retirement Centre is located near to the centre of Oxford, close to local amenities. The property is divided internally into four wings, all of which have their own lounges and dining areas with quiet areas on each floor. There is a bar/bistro, library, internet café, a shop and a hairdressing salon for residents’ use. All bedrooms are single with en suite facilities and the home has well maintained grounds that are easily accessible. Fees for the service range from £ 505.00 - £975.00 per week. There are additional charges for hairdressing, chiropody (none diabetic service users), newspapers, toiletries and some outings. DS0000068950.V363779.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 3 stars. This means the people who use this service experience excellent quality outcomes. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’ carried out over two days. The inspector arrived at the service at 10.15 and was in the service until 17.20 on the first day and from 10.00 until 16.40 on the second day. It was a thorough look at how well the service is doing. It took into account detailed information provided by the registered manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the service and other people seen during the inspection or who responded to surveys that the Commission had sent out. Three service users and five members of staff responded to surveys sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standards of the service. The inspector toured the building, examined records, including the case tracking of eight service user’s files and met with service users individually and as a group in each of the lounges. The inspector also spent time with the manager, head of care, nursing, care, ancillary staff and visitors to the home. In addition the inspector spent time observing how care was being delivered to service users and joined service users for lunch on both days of the inspection. At the last inspection carried out May 2007, two statutory requirements and two good practice recommendations were made; these are referred to in the body of the report. Feedback was given to the manager and head of care, who were present throughout the two days and at the end of the inspection. DS0000068950.V363779.R01.S.doc Version 5.2 Page 6 What the service does well: All prospective service users and their representatives are provided with a copy of the home’s Statement of Purpose, Service Users Guide, home’s brochure and a copy of the last inspection report. Oxfordshire Social Services have a block contract with the home for sixty six of the eighty beds. Copies of the Care Management needs assessment is provided to the home with supporting information from health and social care professionals for service users being admitted for intermediate care. The manager or head of care then undertakes a pre- admission assessment to ensure that the home is able to meet the prospective service user’s needs. Healthcare professionals who work within the intermediate care unit carry out a separate pre-admission assessment. All prospective service users and their representatives are encouraged to visit the home, stay for a while to meet the staff team and other service users, before making a decision to move in on a trial period. All service users are admitted for a trial period of four to six weeks, a formal review meeting is carried out before a decision is made to stay permanently. One of the many strengths of the home is that it is able to provide a variety of care packages to meet the assessed needs of individuals from a short stay placement, recuperation, intermediate care following an hospital admission or permanent care. Surveys completed by three service users confirmed that they had received enough information about the home before they moved in to be able to decide if it was the right place for them and had received a contract/ terms and conditions. All service users have a comprehensive care plan, drawn up from a preadmission assessment of need, to ensure that service users needs are fully met. Service users and their representatives, as appropriate, are involved in the care planning process and care plans are signed and dated by the service user and their representatives. Care plans are reviewed each month by senior staff. It was evident from information recorded in service user files that the home works closely with other healthcare professionals, such as the tissue viability nurse, fall specialist service, community matron for palliative care, continence advisory service, occupational therapists, physiotherapists and speech and language therapists. Training has been provided to staff to identify service users at risk of falls. Entries made in daily contact sheet validated information recorded in care plans. All service users have a formal review of their care every six months, which include health and social care professionals as appropriate. DS0000068950.V363779.R01.S.doc Version 5.2 Page 7 Service users in the home receiving intermediate care a weekly professional meeting takes place consisting of the head of care, physiotherapist, occupational therapist, care manager and the service users named nurse/key worker to discuss progress and review care plans and treatments. Healthcare documentation for service users receiving intermediate care is maintained to a high standard. Results from a survey completed in October 2007, demonstrated that service users admitted to the home for intermediate care showed a higher than county average success rate of successful return home for service users using this facility. Service users confirmed that the routines in the home are flexible, such as being able to choose how to spend their day, when to go to bed and when to get up in the morning. There is a comprehensive complaints procedure in place. In the last twelve months the home has received nine complaints, five complaints were upheld and all resolved within twenty eight days. The home records all complaints whether received verbally or in writing. Complaints were seen to be clearly recorded and detailed with action taken and outcomes recorded. Service users and relatives spoken to were aware of the complaints procedure and said that they felt that their concerns/complaints were listened to, taken seriously and addressed. The home is purpose built and is maintained to a high standard. The location and layout of the building is suitable for its stated purpose. Service users expressed their satisfaction of the premises, facilities and grounds. Communal areas of the home are comfortable and well furnished. Staff spoken to during the inspection expressed their satisfaction of working in the hour, felt that working conditions were good, felt well supported and that they were able to make a difference to the daily lives of service users. Communication systems in the home appear to be well organised, with staff handovers taking place at the beginning of each shift. Staff meetings take place and staff feel that morale is good in the home. All grades of staff were observed to be professional in their approach to service users, throughout the two day inspection. The manager obtains feedback from service users, relatives and visitors to the home when talking to them in the home. Because the home has an open door policy, people are encouraged to see the manager without having to make an appointment. Policies and procedures are in place and are reviewed on a regular basis. Quality assurance systems are in place and the manager/ senior member of staff undertake regular audits. Evidence was available to demonstrate how the DS0000068950.V363779.R01.S.doc Version 5.2 Page 8 views of service users are obtained to measure the home’s success in meeting the aims, objectives and home’s statement of purpose. What has improved since the last inspection? What they could do better: The manager and his staff team strive to improve the care provided to service users and develop procedures and practices. The manager has confirmed with the Commission that care planning documentation will be developed to include the emotional and social care needs of service users and end of life care. Following a discussion with the community pharmacist, manager and head of care a decision was made for the collection of medication no longer needed, to be collected, in the future by the home’s existing clinical waste contractors to meet current legislation. DS0000068950.V363779.R01.S.doc Version 5.2 Page 9 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000068950.V363779.R01.S.doc Version 5.2 Page 10 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 DS0000068950.V363779.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,3,4, 5 and 6. Quality in this outcome area is excellent. Service users and their representatives are given information about the home and encouraged to visit in order to make an informed choice about moving into the home. Service users are fully assessed prior to admission to ensure that their needs can be effectively met by the home. All service users are able to move into the home for a trial period, before making a decision to stay permanently. All service users are provided with a contract or terms and conditions. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All prospective service users and their representatives are provided with a copy of the home’s Statement of Purpose, Service Users Guide, home’s brochure DS0000068950.V363779.R01.S.doc Version 5.2 Page 12 and a copy of the last inspection report. Oxfordshire Social Services have a block contract with the home for sixty six of the eighty beds. Copies of the Care Management needs assessment is provided to the home with supporting information from health and social care professionals for service users being admitted for intermediate care. The manager or head of care then undertakes a pre- admission assessment to ensure that the home is able to meet the prospective service user’s needs. Healthcare professionals who work within the intermediate care unit carry out a separate pre-admission assessment. All prospective service users and their representatives are encouraged to visit the home, stay for a while to meet the staff team and other service users, before making a decision to move in on a trial period. All service users are admitted for a trial period of four to six weeks, a formal review meeting is carried out before a decision is made to stay permanently. One of the many strengths of the home is that it is able to provide a variety of care packages to meet the assessed needs of individuals from a short stay placement, recuperation, intermediate care following an hospital admission or permanent care. Surveys completed by three service users confirmed that they had received enough information about the home before they moved in to be able to decide if it was the right place for them and had received a contract/ terms and conditions. Many service users moved into the home following the closure of two Oxfordshire care homes. Several service users said that they were anxious about leaving Iffley Court as they had lives there for many years, and despite having to share a bedroom, it was home. Service users explained the transfer from the previous home to ‘ the Isis’ and said that they were given the opportunity to visit several times to see the premises, facilities and their allocated bedroom with en-suite facilities. A great deal of thought had been put into involving the service user and their representatives with colour schemes and personalising bedrooms. Several service users invited the inspector to view their bedroom. The inspector observed a member of staff attending to a service user being admitted to the home during the inspection and it was noted that this was being done in a calm, patient and relaxed manner. The service user was being shown how to use the call bell system in the bedroom and reassured to ask for assistance at any time. The service user was provided with refreshments and was clearly being given time to settle into the home. DS0000068950.V363779.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10 and 11. Standard 9 was subject to requirement at the last inspection and standard 8 was subject to a good practice recommendation. Quality in this outcome area is good. Care plans need to be further developed to include emotional and social care needs. Medication storage, administration and recording were seen to be well maintained. Service users feel that they are treated with dignity and respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service users have a comprehensive care plan, drawn up from a preadmission assessment of need, to ensure that service users needs are fully DS0000068950.V363779.R01.S.doc Version 5.2 Page 14 met. Service users and their representatives, as appropriate, are involved in the care planning process and care plans are signed and dated by the service user and their representatives. Care plans are reviewed each month by senior staff. It was evident from information recorded in service user files that the home works closely with other healthcare professionals, such as the tissue viability nurse, fall specialist service, community matron for palliative care, continence advisory service, occupational therapists, physiotherapists and speech and language therapists. Training has been provided to staff to identify service users at risk of falls. Entries made in daily contact sheet validated information recorded in care plans. All service users have a formal review of their care every six months, which include health and social care professionals as appropriate. Although the information regarding health and personal care is detailed, no information is recorded about the emotional and social care needs of the service user and how these are to be met, following the inspection the Commission received an action plan from the manager detailing action to be taken to include these areas within the care planning process. Entries made in daily comments sheets were detailed and validated care plans. Comments made on service user surveys were varied. To the question “ do you receive the care and support you need”. Two surveys stated ‘ usually’ and one survey stated ‘always’. Comments included ‘ I am well cared for and the staff and carers are very kind and helpful. The food is good and the home is superb. No complaints’, ‘ I think my X is well looked after in this home, I don’t know what happens on a daily basis’, ‘There needs to be more staff, as there are times when one member of staff is left on their own to look after the resident’. Appropriate risk assessments are in place, and form part of the care plan. At the last inspection a good practice recommendation was made that a nationally validated nutritional screening tool that is completed shortly after admission and reviewed at appropriate interviews is implemented. This has been actioned. Evidence was seen that all service users are weighed on admission and then at monthly intervals and that evidence based nutritional assessment is undertaken. The medical care needs of service users are met by local GP practices, who visit the home as necessary. A range of healthcare professionals visits the home on a regular basis. From evidence seen and from discussion with service users and nursing staff, the health and medical needs of service users are well met. The healthcare needs of service users admitted to the home for social care are met by the District Nursing service. DS0000068950.V363779.R01.S.doc Version 5.2 Page 15 Comments made on service user surveys to the question “ do you receive the medical support you need”. Two surveys stated ‘usually’ and one stated ‘always’. Service users in the home receiving intermediate care a weekly professional meeting takes place consisting of the head of care, physiotherapist, occupational therapist, care manager and the service users named nurse/key worker to discuss progress and review care plans and treatments. Healthcare documentation for service users receiving intermediate care is maintained to a high standard. Results from a survey completed in October 2007, demonstrated that service users admitted to the home for intermediate care showed a higher than county average success rate of successful return home for service users using this facility. At the last inspection a requirement was made that medication administration records should use the appropriate coding system when medication is not given, short lived medication should be dated on opening and regular audits undertaken to ensure procedures are being adhered to. This has been addressed. Medication storage, administration, recording and procedures for disposal of medication were examined on each of the units. Storage of medication including medication to be kept at a lower temperature, were stored appropriately and securely, medication administration records were well maintained with no obvious gaps in recordings, with the correct medication codes being used for medication not given. The head of care undertakes regular medication audits. Following a discussion with the community pharmacist, manager and head of care a decision was made for the collection of medication no longer needed, to be collected, in the future by the home’s existing clinical waste contractors to meet current legislation. The inspector spent time with service users in each of the units. Staff were observed to interact with service users in a respectful and appropriate manner. Staff were observed to interact with service users in a respectful and professional manner. Time was spent with relatives during the two days. Relatives expressed their satisfaction of the facilities available, the care provided, the staff team and the management of the home. Service users were observed to be dressed appropriately and well groomed. Attention had been given to ensuring service users had dentures, spectacles and hearing aids in place. None of the service user files seen during the inspection, contained information regarding the service user’s wishes regarding arrangements to be made at the time of their death. This was discussed with the manager and head of care, who are currently developing an ‘ end of life’ care plan for each service user, involving the service users, representatives as appropriate and the medical team. DS0000068950.V363779.R01.S.doc Version 5.2 Page 16 As in many other care homes, there is a wide range of racial, ethnic and faith backgrounds represented within the staff group compared with the current service users. From discussion with the manager, the inspector considers that the home is able to provide a service to meet the needs of individual service users of various religious, racial or cultural needs. DS0000068950.V363779.R01.S.doc Version 5.2 Page 17 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15. Quality in this outcome area is good. Service users are encouraged to make choices and to remain independent for as long as possible. There is a wide range of activities in place to meet the social needs of service users. Service users are provided with a varied, wholesome and nutritious diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information about weekly activities in displayed on notice boards throughout the home and there is a monthly activities schedule also displayed. All activities undertaken are recorded on a daily basis. Comments made on service user surveys to the question “ are there activities arranged by the home that you can take part in”. Two surveys stated ‘sometimes’ and one stated ‘usually’. DS0000068950.V363779.R01.S.doc Version 5.2 Page 18 Many of the service users have friends and family who are able to visit on a regular basis. Service users are encouraged to maintain contact, as far as possible, with the local community. Service users said that their friends and relatives were always made welcome. Resident meetings are held every four months and are well attended. Religious ministers visit the home on a regular basis and arrangements can be made for service users to attend a local place of worship, if requested. Service users confirmed that the routines in the home are flexible, such as being able to choose how to spend their day, when to go to bed and when to get up in the morning. The inspector joined service users in one unit for the mid day meal. Tables were laid with napkins and condiments. The day’s menu was displayed and service users confirmed that they are offered a choice of meals and this is recorded. Menus seen evidenced that service users are offered a varied, wholesome and nutritious diet. The meal served was hot, tasty and served attractively. Staff were observed to be assisting service users in a discreet and dignified manner. The inspector joined service users for the mid day meal on both days of the inspection. Tables were laid with napkins and condiments. The day’s menu was displayed. Service users are offered a choice of meals and this was recorded. Most service users said that the food was “very good”, “tasty” and “ always a choice”. Menus seen evidenced that service users are offered a varied, well balanced and nutritious diet. The meals served were hot, tasty and served attractively. Staff were observed to be assisting service users in an attentive, discreet and dignified manner. Protected mealtimes have been introduced in the home, which means that all nursing staff are available in the dining rooms to assist with feeding service users and monitoring food intake. Surveys completed by two service users stated that ‘usually’ liked the meals at the home and one service user stated that they ‘ sometimes’ liked the meals at the home. Comments made on service user surveys included ‘staff come round and ask our preferences, but this is not what we always receive. Always plenty of potatoes, but not enough meat and usually the chicken, fish etc. is overcooked and dry. DS0000068950.V363779.R01.S.doc Version 5.2 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is excellent. The home has a comprehensive complaints process in place. Policies and procedures are in place to protect service users from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a comprehensive complaints procedure in place. In the last twelve months the home has received nine complaints, five complaints were upheld and all resolved within twenty eight days. The home records all complaints whether received verbally or in writing. Complaints were seen to be clearly recorded and detailed with action taken and outcomes recorded. Service users and relatives spoken to were aware of the complaints procedure and said that they felt that their concerns/complaints were listened to, taken seriously and addressed. Surveys completed by one service user stated that they ‘always’ knew who to speak to if they were unhappy, one service user ‘sometimes’ knew who to speak to and one service user ‘usually’ knew who to speak to if they were not happy. Comments received from one service user included ‘ some things are told to staff, but not dealt with unless a relative complains’. The home has DS0000068950.V363779.R01.S.doc Version 5.2 Page 20 an open door policy and look at complaints as a useful tool in getting to know service users and relatives and their wants and needs. The manager feels that complaints are an excellent tool for monitoring and defining the service, and to enable the home to both learn and develop as a service. Since the last inspection, the Commission has not received any information regarding complaints about this service. All staff receive training in the home’s policies and procedures for protecting service users from abuse and the home’s whistle blowing policy, this was confirmed by staff on duty and training records. Training is provided during staff induction and then updated on a regular basis. The home has a copy of the Oxfordshire safeguarding Adults procedures. No safeguarding adult referrals or safeguarding adult investigations have taken place since the last inspection. No referrals have been made for inclusion on the POVA (Protection of Vulnerable Adults) list. DS0000068950.V363779.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,20,21,22,23,24,25 and 26. Quality in this outcome area is excellent. The home provides safe, well maintained and spacious accommodation for service users. The home was found to be clean, hygienic and free from unpleasant odours. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is purpose built and is maintained to a high standard. The location and layout of the building is suitable for its stated purpose. Service users expressed their satisfaction of the premises, facilities and grounds. Communal areas of the home are comfortable and well furnished. Throughout the home there are areas for service users to use, including a designated smoking area, DS0000068950.V363779.R01.S.doc Version 5.2 Page 22 visitor’s rooms, quiet areas and the ‘ The ballroom’, a large room used for a range of activities and functions. Service users have access to a well maintained, safe and secure garden. Hot water outlets in bedrooms and bathrooms are maintained at the recommended temperature. All windows are fitted with window restrictors and radiators are covered. A nurse call alarm system is installed in all communal areas, bedrooms and bathrooms. All bedrooms are for single occupancy and have an en-suite shower, washbasin and toilet. Bedrooms are of a reasonable size and are able to accommodate wheelchairs and aids to assist with daily living with ease. Service users are encouraged to personalise their bedrooms. Most service users have a television set and some have a private telephone. Communal bathrooms and toilets are fitted with appropriate aids and adaptations to help maintain independence. All areas of the home were seen to be clean, well maintained and free from unpleasant odours. From discussion with members of the housekeeping staff on duty, it is evident that they take pride in maintaining high standards of cleanliness throughout the home. The laundry is well equipped. All housekeeping and laundry staff have received training in COSHH, infection control and health and safety. Policies and procedures are in place. Staff are provided with protective clothing, such as disposable aprons and gloves for use when carrying out personal care to service users. DS0000068950.V363779.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30. Standard 28 was subject to a good practice recommendation at the last inspection. Quality in this outcome area is good. Staff recruitment procedures are robust and protect service users from harm. Staffing levels appear to be adequate to meet the needs of the service users. Staff are well trained and supervised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From discussion with the manager, nursing, care and ancillary staff, staffing levels are adequate to meet the needs of the service users. From examination of a sample of eight staff files, discussion with staff on duty and comments made on the five surveys completed by staff, the home has robust recruitment procedures in place. Staff files contained all documentation required by regulation and evidence was seen of formal interviews, undertaken by two senior members of staff, having taken place. At the last inspection a good practice recommendation was made that when references are received without a company stamp or a compliments slip, then the reference is verbally DS0000068950.V363779.R01.S.doc Version 5.2 Page 24 verified and documented and that where there are gaps in employment history, then the reasons, should be documented. This has been addressed Seven members of staff have resigned since the last inspection. Exit interviews take place, when possible. The home is currently fully staffed. All new members of staff undertake induction training, appropriate to their post once in post, complete mandatory training and specialist training. OSJCT has its own training centre that provides a high standard of training both in and external to the home. The home has a staff training and development plan in place and the head of care has undertaken a course ‘training the trainer’. Regular updating of skills is provided to all staff. All surveys completed by members of staff stated that they received relevant training to their role. Members of staff are encouraged to undertake NVQ (national vocational qualification) training. The home has 78 of the staff team having completed NVQ level II or III. It is anticipated that the home will shortly have 100 of care staff with this qualification. Time was spent with an external NVQ assessor, who confirmed the commitment made by the home and staff team to complete this training. Comments made on surveys completed by members of staff included ‘before my CRB (Criminal records bureau checks) came back I could not carry out care with service users. I had to work under supervision. I.e. had to be two of us all of the time, despite the fact I am a qualified nurse’, ‘ induction included every aspect of my work, I worked with my supervisor’, ‘the service provides continuous training for all employees’, ‘staffing levels can be a problem’, ‘ staff levels can be a problem if a shift cannot be covered due to sickness etc.’, ‘ more staff is needed to enable more quality one to one time with service users’,’ there is not enough one to one time to spend with the service users. The whole shift often goes by in a blur’. Staff spoken to during the inspection expressed their satisfaction of working in the hour, felt that working conditions were good, felt well supported and that they were able to make a difference to the daily lives of service users. Communication systems in the home appear to be well organised, with staff handovers taking place at the beginning of each shift. Staff meetings take place and staff feel that morale is good in the home. All grades of staff were observed to be professional in their approach to service users, throughout the two day inspection. DS0000068950.V363779.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,36 and 38. Standard 36 was subject to a good practice recommendation at the last inspection. Quality in this outcome area is good. Service users benefit from a well managed home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is well qualified, experienced nurse with extensive management experience. Both the manager and head of care are supernumery to the home’s staffing levels and are supported by a team of administrative staff and heads of departments. DS0000068950.V363779.R01.S.doc Version 5.2 Page 26 In discussion with service users, visitors to the home and staff on duty, all expressed the view that the home was well managed and run in the best interests of the service users. Comments received about the manager and his management style of the home, included the manager is ‘ very fair’, ‘very good, he knows his job’, ‘very good with residents’, ‘ flexible’, ‘ responsive’, excellent employer’. Procedures are in place for dealing with service users monies and valuables held in safekeeping. From discussion with the administrator and examination of a sample of financial records, it was evident that records are well maintained. Regular auditing of accounts take place. At the last inspection a good practice recommendation was made that staff receive formal supervision at least six times per year. This has been addressed and all staff receive formal 1-1 supervision every two months from either a senior member of staff or the manager. Records of supervision undertaken were seen to be well maintained, actions agreed, recorded and signed by both the supervisor and supervisee. The manager obtains feedback from service users, relatives and visitors to the home when talking to them in the home. Because the home has an open door policy, people are encouraged to see the manager without having to make an appointment. Policies and procedures are in place and are reviewed on a regular basis. Quality assurance systems are in place and the manager/ senior member of staff undertake regular audits. Evidence was available to demonstrate how the views of service users are obtained to measure the home’s success in meeting the aims, objectives and home’s statement of purpose. Reports written by a Cluster Manager, who is also a registered manager of a OSJCT home, completes a written report on behalf of the provider, following a monthly unannounced visit to the home, these were available for examination by the inspector. Communication systems in the home are Communication systems in the home are well organised, with regular meetings held with nursing and care staff, catering, laundry and maintenance/health and safety staff. Meetings are well attended and are minuted. A sample of records relating to health, safety and welfare were examined and found to be up to date and well maintained. DS0000068950.V363779.R01.S.doc Version 5.2 Page 27 DS0000068950.V363779.R01.S.doc Version 5.2 Page 28 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 4 3 4 4 4 4 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 4 4 4 4 4 4 4 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 3 X 3 DS0000068950.V363779.R01.S.doc Version 5.2 Page 29 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 DS0000068950.V363779.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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