Inspection on 21/01/08 for Soroptimist House

The medication practices in the home are well managed and we evidenced good liaison between staff and visiting professionals from the health sector and church representatives. Respect, sensitivity and dignity are evident in the interactions between staff and service users. The home has a good staff retention rate, giving service users the benefit of consistent carers. The home listens and responds positively to the views of service users.

What has improved since the last inspection?

The carpets in the hall and corridors on the ground floor have been replaced. The first floor bathroom has been converted into a walk-in/wheelchair shower room, giving service users increased choice.

What the care home could do better:

The home should ensure that formal supervision for care staff takes place at least six times per year. Induction for new staff should be consistent with theSkills for Care common induction standards. The home should ensure that any requirements made by regulatory authorities, such as Environmental Health, are acted on without undue delay.

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Soroptimist House 91 Tettenhall Road Chapel Ash Wolverhampton West Midlands WV3 9PG Lead Inspector Martin George Key Unannounced Inspection 21st January 2008 09:45 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 Soroptimist House DS0000030054.V358262.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. Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Soroptimist House Address 91 Tettenhall Road Chapel Ash Wolverhampton West Midlands WV3 9PG 01902 710581 01902 710581 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) Wolverhampton Soroptimist Housing Association Miss Annette Massey Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Old age, not falling within any other category including females over 60 years of age. 15th May 2006 Date of last inspection Brief Description of the Service: The home is a modern purpose-built building slightly set back from the main road. It is approximately one mile from Wolverhampton city centre, with convenient access to public transport and the local shops. The home accommodates 30 residents, in single bedrooms, on three floors. There is a passenger lift that serves all floors. There is also a communal dining room, which has recently been extended, with direct access to the kitchen. There are well-maintained gardens at the front and rear of the premises. The fees range from £352 - £372 Soroptimist House DS0000030054.V358262.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 carried out by a single inspector between 09:45 and 16:00. As part of the inspection all National Minimum Standards defined by the Commission for Social Care Inspection (CSCI) as ‘key’ were inspected. Information about the performance of the home was sought and collated in a number of ways. Prior to inspection we were provided with written information and data about the home through their annual quality assurance assessment (AQAA). The views of a number of people living and working at the home were acquired through discussions during the inspection. Some service users also completed surveys. Information was analysed prior to inspection and helped to formulate a plan for the visit and helped in determining a judgement about the quality of care the home provides. On the day of the inspection we spoke to the temporary assistant manager, deputy manager, staff and service users and observed practice and this provided evidence in support of the records that were also checked on the day. What the service does well: What has improved since the last inspection? What they could do better: The home should ensure that formal supervision for care staff takes place at least six times per year. Induction for new staff should be consistent with the Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 6 Skills for Care common induction standards. The home should ensure that any requirements made by regulatory authorities, such as Environmental Health, are acted on without undue delay. 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. Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 7 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 Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 8 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): 1, 2 and 3 Quality in this outcome area is good. Pre-placement assessments of need are carried out to ensure that service user needs are identified and these inform service user plans to ensure needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service user records we looked at provided evidence of good quality preplacement assessments of need. The records of the service user on respite also had a good quality pre-placement assessment, but there was no indication of who completed it and it was not dated. The Annual Quality Assurance Assessment (AQAA) submitted by the home explains that opportunities are given for visits by prospective service users and Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 9 their families prior to admission. Two service users we spoke to confirmed they had been given this opportunity and said they appreciated it. The contracts we saw were comprehensive, signed and dated and clearly identified any additional costs for services. We were unable to find a contract on the records for the service user on respite care. The home is intending to update the Statement of Purpose and contract to make them more user friendly and this shows a commitment to meeting service user needs. The home does not provide intermediate care. Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 10 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): 7, 8, 9 and 10 Quality in this outcome area is good. Service user plans identify a range of needs. The frequency of reviews ensure needs continue to be assessed and met. Medication practices safeguard service users from potential harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service user plans we saw had sufficient information to meet care, health and personal needs and these are regularly reviewed to ensure service user needs continue to be met. They include risk assessments to ensure that areas of potential risk to service users are known about by staff. A couple of GP’s visited the home during the period of the inspection and conversations we observed between the GP’s and the senior on duty evidenced the health needs of service users were being well managed. Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 11 Several telephone calls and discussions we observed provided evidence of a very open professional relationship with external agencies and individuals, such as doctors and church representatives, indicating that the home is aware of a range of service user needs, including cultural and religious. Medication practice is efficient and is consistent with best practice guidance. Part of an administration round we observed was sensitive to service user need. The senior on duty explained the ordering, storage, administration, recording and disposal processes used by the home, including that used for controlled drugs, and we are satisfied that service users are properly protected in this area of practice. Relevant staff have completed accredited medication training. The degree of respect and sensitivity shown to service users was good and there was awareness of the need to maintain dignity, and how to do this. Service users we spoke to stated they were happy with how staff treated them. Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14 and 15 Quality in this outcome area is good. The home listens and responds well to service user preferences with regard to meals and activities and tries hard to encourage the involvement of relatives. Community involvement is seen as important. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home makes efforts to involve service users as much as possible to ensure needs and preferences are known and can be responded to where possible. Service users spoken to confirmed they were offered choice regarding food, visitors and activities. Although the home is aware of the importance of keeping links with the local community it identified in the AQAA that this is an area for improvement and that it needs to establish strong community links for those that wish to go out. This will help to address some of the comments regarding activities made in the service user surveys organised by the home in October 2007. Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 13 The home would like to find ways of getting more participation from family members to ensure the important family links for service users are not lost. A vicar who visited the home on the day of the inspection was very complimentary about the level of care and sensitivity provided by staff at the home, especially around issues of bereavement. Menus are varied and nutritious and the home involves service users as much as possible in food choices. Mealtimes are not rushed and staff are attentive to service user need regarding eating, but the level of noise coming from the kitchen gave the impression of a busy canteen rather than a dining room in an older people’s home, detracting somewhat from making it a relaxed mealtime environment. The dining area is nonetheless a very pleasant room with a lovely view of the garden. Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. The home has a good complaints procedure, widely available and clearly understood by service users, their relatives and staff. Safeguarding is given the necessary priority in terms of training and service users feel well cared for. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a comprehensive complaints policy and information about it is made readily available to service users and their families. The last recorded complaint was dated 16/12/04 and the assistant and deputy manager informed us that there have been no complaints since then. Evidence from the way the complaint was dealt with and resolved indicates that the home manages complaints with service user interests in mind. Our observation of practice on the day, examination of training records and discussion with staff satisfied us that knowledge, awareness and competence in this area of practice is sufficient to satisfactorily safeguard service users from the risk of abuse. The home has identified in the AQAA that it wants to provide staff with further training in this area of practice to provide staff with additional knowledge and skills to enhance their ability to safeguard service users. Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 15 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): 19, 20, 22, 23, 24 and 26 Quality in this outcome area is good. Service users benefit from a well maintained and spacious environment and have a delightful garden area in which to relax. Some environmental health issues require more vigilance to fully safeguard service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are obviously encouraged to bring their personal possessions to make their bedrooms feel more homely. Bedrooms are of a decent size and have pleasant views. All the rooms we saw had the same magnolia walls and it would be good to see the home consider varying the colour schemes, if possible to service user preference. Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 16 We were informed that when a carpet in a bedroom needs professional cleaning or replacement the home will only carry this out with the express permission of the service user or their family, because of the cost implication for them. We noted that some of the rooms had a faint odour, suggesting that professional cleaning or replacement was becoming a priority. We would like to see the home consider ways of ensuring service user dignity in this aspect of care is maintained, whilst keeping within obvious financial constraints. During a tour of the home we noted that several bedrooms and bathrooms either did not have alarm call cords at all or the cords were not long enough to allow a service user who fell to the floor to reach it. The assistant manager who showed us around was surprised at the absence of cords and stated she was sure they were usually in place. The absence of these cords creates potential safeguarding issues and needs to be addressed with the necessary urgency. Fire and Environmental Health Officer (EHO) reports were seen. We were pleased to see an action plan, dated 18/09/07, following the EHO report but it was not clear whether some of the actions identified had been completed, such as whether the food policy had been updated, the temperature records template amended or whether the food temperature probe had been calibrated. We noted that some EHO issues were raised over a period of years, examples being concerns over dirty or damaged fly screens and cereal packets being left open in the dry store, leading to risk of cross contamination. The garden is a very pleasant and well maintained area, suitable for service users to use safely. Ramps went into the garden from several exits. We spoke to an assessor from Walsall College who was assessing employees on the infection control units they were completing. He confirmed the level of understanding about infection control was good. Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 17 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): 27, 28, 29 and 30 Quality in this outcome area is good. Recruitment practices and the commitment to qualifying staff shows how the home wants to provide high quality care to service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We checked staff records and found them to be compliant with schedule 2, Care Homes Regulations. Necessary checks were found and the files contained evidence of a good recruitment process. Terms and conditions of employment were on file and signed. We noted that the head cook did not appear to have confirmation of a Criminal Records Bureau (CRB) check and we were later informed that the home had been advised by the CRB that he did not need one as he had no direct contact with service users. We explained that we would prefer to have all staff CRB checked to ensure service users are safeguarded as well as possible. The home readily agreed to address this without delay. The care staffing compliment is of mixed ethnicity and is sufficient in number to meet the needs of the service user group throughout the 24 hour period. The home does not use agency staff. Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 18 The AQAA identifies that the staff team is predominantly within the 35-55 age range and those employed in a care role are exclusively female. The commitment to having a qualified staff team is evident, with the home having all staff qualified or working toward their National Vocational Qualification (NVQ), ensuring service users have carers with evidenced competence. Staff turnover is very low, giving service users the opportunity to establish good relationships with their carers. The level of training provided to staff is good, although a clearer training matrix would be useful to more easily identify which courses staff have completed and when refresher training is due. The home has identified this as an area for improvement in the AQAA. Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 19 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): 31, 33, 35, 36 and 38 Quality in this outcome area is good. The home has a competent team of managers who have the interests of service users as their primary consideration. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has many years experience and holds relevant practitioner and management qualifications. Lines of accountability are well defined and there is also good support from the management committee, who are keen to continually develop the quality of care provided to service users. Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 20 We examined personal allowance records for service users and these appeared to be in good order. The AQAA shows that only 50 of permanent catering staff and 20 of permanent care staff have received training in safe food handling and we would like to see the home rectify this shortfall without undue delay. Staff files we examined contained competence based personal development reviews, which are suitable for use as a formal supervision format, but the frequency of 6 per year is not being met and needs to be addressed to provide evidence that management are consistently monitoring staff performance and providing support to ensure service users continually receive the best possible service provision. The home has identified this as an area for improvement in the AQAA. We found evidence that the home has all necessary equipment and system checks carried out, evidencing good safeguarding practice in this area. As mentioned in the Environment section of this report we saw evidence of Fire and Environmental Health Officer (EHO) reports, but we would like to see issues raised by the EHO fully resolved without undue delay. Although we were informed that staff meetings take place regularly we were unable to find any staff meeting minutes dated later than 25/01/07. We would like to see staff meeting minutes kept easily accessible, and to meet best practice the home may wish to consider having staff initial them when they have read and understood them. Accident records were fully completed and kept according to policy. Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 21 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 Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 22 CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x 2 3 3 x 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 3 x 2 Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP22 Regulation 16(2)(c) Requirement Timescale for action 01/03/08 2 OP38 16(2)(j) Bedrooms and bathrooms must have alarm call cords that can be reached should a service user fall to the floor The home must meet 01/03/08 requirements made by the Environmental Health Officer in accordance with their action plan, completed following receipt of the EHO report RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP30 OP36 Good Practice Recommendations The home should develop the current induction programme to make it consistent with the Skills for Care common induction standards The registered person must ensure that all care staff receive formal supervision at least six times a year (previous timescale for action 01/08/06) Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. Extracts may not be used or reproduced without the express permission of CSCI Soroptimist House DS0000030054.V358262.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!