Inspection on 03/11/09 for Rushymead

This is the latest available inspection report for this service, carried out on 3rd November 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.

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

Rushymead 01/07/08

Rushymead 10/07/07

Rushymead 19/07/06

Rushymead 28/11/05

Rushymead 16/05/05

Rushymead 05/01/05

Rushymead 20/09/04

Rushymead 12/02/04

Rushymead 15/09/03

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 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Rushymead Tower Road Coleshill Amersham Buckinghamshire HP7 0LA Lead Inspector Joan Browne Key Unannounced Inspection 09:00 3rd November 2009 DS0000023016.V378256.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Rushymead DS0000023016.V378256.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 Rushymead DS0000023016.V378256.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rushymead Address Tower Road Coleshill Amersham Buckinghamshire HP7 0LA 01494 727738 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) rushymead@aol.com The Michael Batt Charitable Trust Mrs Denise Yvonne Macklin Care Home 28 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Rushymead DS0000023016.V378256.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: Old age, not falling within any other category (OP) 2. Dementia (DE). The maximum number of service users to be accommodated is 28. Date of last inspection 4th June 2009 Brief Description of the Service: Rushymead is a care home providing personal care and accommodation for up to twenty-eight older people with physical frailties and dementia. The Michael Batt Charitable Trust owns the home, which is a registered charity. The home is located in the village of Coleshill two miles south of Amersham. Public transport and local amenities are not easily accessible. The building has been adapted for use as a residential care home for over twenty years and was first registered in 1991. The home is situated on three floors and is divided into three units. Each unit has its own sitting and dining areas with kitchenette facilities. There are twenty-six single rooms and one double room. Five bedrooms have en suite facilities and there is a passenger lift. The gardens are extensive and well maintained. Rushymead DS0000023016.V378256.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 1 star. This means that people who use this service experience adequate quality outcomes. This unannounced key inspection was carried out on 3 November 2009 and covered all of the key national Minimum Standards for older people. The inspection lasted for approximately 9 hours commencing at 09:00 am and concluding at 17:00 pm. The last key inspection on this service was completed on 4 June 2009. We did not request the home to complete an annual quality assurance assessment (AQAA) questionnaire for this inspection because the home had completed an AQAA less than one year ago. However, surveys were sent to a selection of people living at the home, staff and visiting professionals. Any replies that were received have helped to form judgements about the service. Information received by the Commission since the last inspection was also taken into account. We did this inspection with an expert by experience who spoke to people using the service and staff. An expert by experience is a person who either has a shared experience of using services or understands how people in this service communicate. They visited the service with us to help us get a picture of what it is like to live in or use the service. This is important because the views and experiences of people who use services are central to helping us make a judgement about the quality of care. Eleven service users, five staff members and two health care professionals completed surveys and their replies have helped to form judgements about the service. The registered manager, deputy manager, service users and staff members were involved in the inspection process and their responses and views of the home have been incorporated into the report. Further information was gained by observing staffs practice, examination of care plan documentation, staffs records, health and safety records and a tour of the premises. The final part of the visit was spent giving feedback to the manager about the findings of the visit. Two requirements were made on this visit. Please see health and personal care and environment outcome areas for full disclosure. We (the commission) would like to thank all the service users, and staff who made the visit so productive and pleasant on the day. Rushymead DS0000023016.V378256.R01.S.doc Version 5.2 Page 6 What the service does well: Service users who responded to the Commissions survey said that the staff were caring and helpful and always have a smile. Service users who responded to the Commissions survey said that the staff were friendly and approachable. Service users who responded to the Commissions survey said that the home provides excellent care in a homely environment. The care needs of prospective service users are assessed prior to admission to ensure that identified needs can be met. The home ensures that service users have regular health checks to promote their well-being. The home ensures that service users live in a safe well maintained environment and have access to safe and comfortable indoor and outdoor communal facilities. Service users said that the laundry facility in the home was reliable and the home was clean pleasant and hygienic. What has improved since the last inspection? What they could do better: Staff practice must be consistent to ensure that handwritten entries on the medication administration record sheets are countersigned by a second staff member to minimise the risk of errors when transcribing. The home must have a robust system for giving medicines safely to service users. This is to minimise the risk of staff accidentally administering the wrong dose. The home must review the activity programme to ensure that arrangements are made for service users to be engaged with an activity of their choice if they wish to when the activity organiser is not available. The manager must seek advice from the infection control adviser regarding the practice in the home to share hoist slings and turning sheets. This is to ensure Rushymead DS0000023016.V378256.R01.S.doc Version 5.2 Page 7 that there is a safe system in place to prevent the spread of infection in the home. 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. Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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 has an admission procedure. This means that no service user is admitted to the home without having their needs assessed and been assured that their diverse needs will be met. EVIDENCE: The manager confirmed that prospective service users needs are assessed prior to admission to the home. We were told that the manager and deputy manager carry out joint assessments. A review of two service users care plans who were recently admitted to the home demonstrated that pre-admission assessments were undertaken. The home ensures that prospective service users are notified in writing, the room number that has been reserved for them and the weekly charges they would be expected to contribute. Eleven Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 10 people who responded to the Commissions survey said that they had received adequate information from the home to help them decide if it was the right place for them. Contracts were seen in the two care plan documentation examined. Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes care planning system has improved but inconsistency in staffs medication recording practice could place service users at risk. EVIDENCE: The home uses a standardised care plan documentation which consists of long term and short term needs. Each person also has supplementary person centred care plan detailing how individuals wished for staff to support them with their diverse needs. At the previous inspection a requirement was made for the home to have a system in place to ensure that identified long term needs of service users are kept under review. It was also required that needs identified in the care plans should have clear guidance for staff to follow to enable them to support service users adequately in all areas of their life. We looked at nine care plan documentation. It was found that the home now has a Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 12 system in place to ensure that service users long term care plan needs are reviewed six monthly or as and when required. The short term care plan needs were being reviewed monthly and contained adequate information on how identified needs should be met to enable staff to provide the appropriate level of support. The daily cleansing sheet (this is a sheet that staff record all personal given to service users) was appropriately maintained. This means that there is an audit trail of daily personal care provided by staff. Individuals dependency profiles were being reviewed and evaluated monthly. Where ever possible, care plans were signed by service users or their representative to confirm their involvement in the process. A requirement was made at the previous key inspection for photographs of service users to be kept in the care plan documentation to confirm proof of identity. It is pleasing to report that all the care plan documentation examined on the day of the inspection contained photographs of individuals. Risk assessments relating to moving and handling and falls were in place. Supporting plans were in place for those service users who were identified at risk of falls. Service users were registered with two local general practitioner (GP) surgeries. We were told that the GP visits as and when required. On the day of the inspection one of the GPs was visiting the home to review service users health care needs. A discussion was held with the GP regarding end of life care plans and the best place for them to be kept to ensure that they were accessible to staff and health care professionals and to promote confidentiality. A chiropodist visits the home every six weeks and regular visits are carried out by the optician. Service users weights were being monitored monthly. Each service user has a multi-disciplinary sheet in their care plan documentation to record visits made by the doctor or other health care professionals. Senior staff are expected to record the outcome of visits and detail any treatment which may have been prescribed. Two health care professionals who responded to the Commissions survey said that the home always ensure that service users social and health care needs were properly monitored. Service users who responded to the Commissions survey said that the home always or usually ensure that they are provided with the medical care required. A service user spoken to during the inspection said that she was well cared for. This was substantiated by her visitor. The following additional comments were noted: Staff are quite proactive when dealing with my Nan and seem to know what she wants and how to look after her. On the day of the inspection there were no service users assessed as capable to self-administer their medication. The medication administration record (MAR) sheets were checked and there were no gaps noted. There was an audit trail of all medicines entering and leaving the home. There were no service users in receipt of controlled medication on the day of the inspection. There was a sample signature in the medication record folder for those staff identified as capable to administer medication. It was noted that staffs practice was not always consistent when recording handwritten entries on the MAR sheets. For example, handwritten entries on two particular MAR sheets Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 13 were not countersigned by a second staff member. A particular medicine for a service user did not have a printed label with the name of the medicine and instructions detailing how it should be administered. The manager is advised to ensure that handwritten entries on the MAR sheets are countersigned by a second member of staff to minimise the risk of error when transcribing. There must be system in place for giving medicines safely. This is to avoid accidentally giving medicines in the wrong dose or to the wrong person. We saw evidence of monthly audits of the MAR sheets being undertaken. Senior staff spoken to on the day of the visit confirmed that they had recently undertaken training in the safe handling and administration of medication. We observed staff knocking on service users bedroom doors before entering. This showed an understanding of the importance of promoting and maintaining individuals privacy and dignity. Staff were also observed treating service users in a kind and respectful manner. Those spoken to confirmed that staff respected their privacy and dignity. We were told that medical examination and personal care is provided in individuals bedrooms. Service users were dressed appropriately for the weather and their attire was clean and tidy with attention to detail. Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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 does not have any restrictions on visiting this means that service users are free to receive visitors and maintain contact with their family and friends. There is a balanced and varied selection of food available to meet service users taste and choices. EVIDENCE: There was a list of available activities displayed on each unit but there was no specific timetable. We were told that the activity co-ordinator continues to work three times weekly on a Wednesday, Thursdays and Friday. Due to her personal circumstances she was not able to increase her hours despite some comment from the manager at the last visit that there was a possibility that she would be able to increase her hours. This meant that there was a lack of activity on Mondays and Tuesdays unless the carers on duty had the time to engage service users in an activity. We were told that Monday and Tuesdays were the days that are used to accommodate the district nurse, the chiropodist or the doctor who does a regular 4/6 week health check screening. Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 15 On the day of the inspection there was a “clothes show” being organised for the afternoon which many of the service users were looking forward to. Those service users spoken to said that they continue to be happy with the activity co-ordinator and the work that she does. The following comments were noted from a particular service user: “she does try to encourage and involve you in some activity or another”. A second person said that the school children were coming in to sing at Christmas. A third individual made reference to a Christmas party which is held for service users, relatives and staff. The manager confirmed that a church service is held regularly in the home. This means that service users are supported to promote their spiritual needs if they wish to. The home does not have any restrictions on visiting and service users are able to receive visitors in private and chose whom they see and do not see. Information about local advocacy service was displayed on the notice board at the front entrance. There was a comment box for service users and their relatives to put forward suggestions about the service delivery. Some bedrooms seen were personalised with service users personal furniture. This means that individuals were made aware of their entitlement to bring personal possessions with them to personalise their bedrooms if they wished to. There is a four week food menu. Service users make their choices the day before. We spoke to several service users to obtain their views on the menu and what choices were available. One person said that the food had improved. A second person said that the choices seem to be better. Comments from one individual were not positive: The following comments were noted: they think we are rabbits because we get a lot of carrots. There was also some confusion between service users when offered courgettes. It was suggested that they were warm cucumbers. They did not appear to be a popular choice of vegetable. The chef was spoken to and confirmed that if there was something in particular a service user wanted for lunch the kitchen staff would do their very best to accommodate the request without hesitation. She confirmed that the carers were aware of individuals dietary likes and dislikes. There were no service users on the day of the inspection in receipt of special diets on the grounds of religious or cultural needs. Staff were observed being sensitive to the needs of those service users who find it difficult to eat and gave assistance with feeding. Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. A random sample of care workers training record demonstrated that care workers are being trained to undertake the duties of meeting the service users assessed need, thereby protecting them from abuse. EVIDENCE: The home has a complaints procedure which was displayed in the home to remind service users and relatives how to make a complaint if they wished to. Seven service users who responded to the Commissions survey said that they knew how to make a complaint. Four respondents said that they did not know how to make a complaint. The manager confirmed that since the last key inspection she had written to service users and their relatives to remind them of the homes complaints procedure. The complaints folder was examined. There was one verbal complaint and one concern recorded with details of the action taken by the manager. The home has a safeguarding of vulnerable adult policy. Training records examined verified that the majority of staff had undertaken updated training in the safeguarding of vulnerable adults. The manager was able to evidence that recently appointed staff members had been allocated places to undertake safeguarding of vulnerable adult training with Bucks County Council. Staff spoken to said that they were clear about what action should be taken if they suspected or witnessed an incident of Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 17 abuse. Service users spoken to during the visit said that they felt safe living in the home and were very happy with the care provision. The home has had one safeguarding referral and investigation which the Commission was aware of. The home provided information to external agencies when requested and acted appropriately to protect service users safety. Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate 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 satisfactory which means that service users live in a home that is well-maintained to meet their diverse needs. EVIDENCE: The home is set in secluded grounds and has been adapted for its present use and divided into three small units each with its own sitting room/dining area and small kitchenette. It has large and attractive gardens which are kept tidy. Service users have access to all parts of the home including outside areas. There are ramps provided to enable wheelchair users to access safely. CCTV cameras are installed in the grounds and entrance areas for security purposes only and do not appear to intrude on service users daily life. Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 19 Bedrooms vary in size and was single occupancy with some having en suite facilities. Individuals are made aware that they can bring small items of furniture and personal belongings if they wished to personalise their rooms. Some bedrooms seen were personalised with small pieces of furniture, family photographs and mementos reflecting the characters of individuals. Bathrooms and toilets were fitted with the appropriate aids and adaptations to promote and meet the needs of service users and were satisfactorily maintained. The lounge and dining areas on each floor were pleasantly decorated and furnished. Service users who responded to the Commissions survey said that the home was always or usually fresh and clean. The following additional comments were noted: The home is always clean and tidy. The home seems very clean and smells nice. The atmosphere on all three units was very relaxed. Service users continue to be happy with the laundry service they were receiving. The following comments were noted from a service user: I have not lost any laundry yet and I have been here a few weeks. The laundry area was clean, tidy and fitted with the appropriate washing machines with the specified programming ability to meet disinfection standards. On the day of the inspection the home was clean and tidy with no offensive odours. We observed a domestic staff pulling beds from the walls to ensure that the rooms were being thoroughly cleaned. The training records examined indicated that staff had undertaken updated training in infection control. We were told that those service users who needed assistance from staff with the use of the hoist for moving and handling and transfer from the bed to chair did not have their own individual slings for hoisting. The manager is required to seek advice from the infection control adviser regarding the use of shared hoist slings and turning sheets to ensure that systems are in place to prevent the spread of infection at the care home. Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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 has an ongoing training programme. This means that staff are trained and skilled to fulfil the aims of the home and meet the changing needs of the service users. The homes recruitment procedure has improved to ensure that only staff that are suitable to work with vulnerable people are employed. EVIDENCE: The staffing rota demonstrated that on each unit a member of staff is allocated. On the morning shift there are two additional staff floating on the three units making it a total of five staff to assist with moving and handling and personal care. This number is reduced to four in the afternoon and three at night. It was noted that the team leader on duty was exemplary in the way in which she interacted with both staff and service users. She seemed to instinctively know what help was needed on each floor, how to support staff and found the time to engage with many of the service users as she carried out her duties. The manager said that the staffing numbers provided was adequate to meet the assessed needs of service users. The home ensures that adequate domestic and kitchen staff are employed to maintain high standards Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 21 of hygiene in the home. Comments from staff regarding the week-end rota were fed back to the manager to be actioned. The following comments about staff were noted from service users who responded to the Commissions surveys: The staff are very caring and helpful. The staff respect residents privacy. The staff are always courteous and welcoming. It was noted that some service users on one particular unit found it difficult to interact with a particular carer because of a language barrier. However, the carers body language demonstrated kindness and a caring disposition. Without a confident ability to speak English this fell some what short. The home has introduced a supervision practice framework this means that staff were being supported and given the opportunity to discuss and review their practice with a focus on improving outcomes for service users. 98 of care staff had achieved the national vocational qualification (NVQ) in direct care at level 2 and the remaining 2 were working toward achieving the qualification. The personal files for five staff members were examined. All staff had completed an application form and were in receipt of terms and conditions of employment. Criminal record bureau clearance and PoVA first check. All files contained the information required under care Homes Regulations 2001 Schedule 2. For those staff that had commenced employment with a PoVA first check there was written evidence to demonstrate that they were working under supervision. The manager had reviewed the practice in the home when employing agency workers. Information is now obtained by the home regarding agency workers suitability to work with vulnerable people. Documented evidence indicated that staff receive mandatory training with yearly updates to maintain their competency and fulfil their duties. We were told that all newly appointed staff undertake the Skills for care Common Induction programme. Staff spoken to confirmed that they had received adequate training to support them in carrying out their responsibilities. Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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 run in the best interests of service users which mean that their health and safety would be protected and promoted. EVIDENCE: The registered manager holds the registered managers award (RMA) certificate and the national vocational qualification (NVQ) level 4. The manager is accountable to the board of Trustees. Care staff and ancillary staff are accountable to the manager. The manager said that she updates her knowledge, skills and competence by reading care journals, and undertaking Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 23 mandatory training. A deputy manager, team leaders and care and support staff support the manager in the day to day running of the home. Some staff spoken to during the visit said that communication in the home had improved. They confirmed that a recent staff meeting had taken place and formal supervision had commenced. At the previous inspection a requirement was made for the home to formalise a supervision framework to ensure that staff are appropriately supported and supervised. The manager was able to demonstrate that thirteen staff had received formal one to one supervision and appraisal. Staffs practice was also observed. The manager said that she was in the process of sourcing training for team leaders to enable them to facilitate supervision meetings with staff. At the previous key inspection it was noted that regulation 26 visits were not regular and a requirement was made for regular visits to be carried out. Records made available during this inspection indicated that regular visits had taken place since June 2009. We saw evidence that regular monitoring of the care plans and medication record sheets were being carried out monthly. The manager said that satisfaction questionnaires had been sent out to relatives and stakeholders to obtain their views on how the home was achieving goals for service users. The manager said that procedures for dealing with service users money were well maintained and in line with the organisations policy. A sample of records relating to health and safety were examined and found to be appropriately maintained. Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 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 Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 25 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. 1 Standard OP9 Regulation 13(2) Requirement There must be a consistent system for recording and administering medicines safely in the home. This is to ensure that the right dose of medicine is administered to service users. The registered manager must seek advice from the infection control officer regarding the practice of sharing hoist slings and turning sheets. This is to ensure that suitable arrangements are in place to prevent the spread of infection at the care home. Timescale for action 16/12/09 2 OP26 13(3) 16/12/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 26 No. Refer to Standard Good Practice Recommendations Rushymead DS0000023016.V378256.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission South East Region 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. 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. 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