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Inspection on 05/10/07 for South Hayes Care Home

Also see our care home review for South Hayes Care Home for more information

This is the latest available inspection report for this service, carried out on 5th October 2007.

CSCI 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 CSCI 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

The Manager and Staff have worked determinedly since April and have addressed all 14 Requirements identified at the previous Inspection, a number of which were outstanding from earlier Inspections. These efforts have resulted in improvement under several areas of care provision, including Information to Residents/supporters Care planning documentation Improved support for Resident`s leisure activities Medicines administration Staff numbers Staff training Communication with Residents/supporters Health and safetyIn addition the Home has introduced a wider choice in the tea-time/evening meal menu for Residents, and employed and evening kitchen assistant working 7 days per week.

What the care home could do better:

A number of areas, where the Home has begun to address shortfalls, require further and continued development, i.e. Establishment of an on-going written redecoration/refurbishment programme Increased frequency in the use of formal Questionnaires seeking Resident/Visitors views on service quality Review of current levels of care staff numbers/skill-mix set against Resident numbers and levels of dependency

CARE HOMES FOR OLDER PEOPLE South Hayes Care Home 101 London Road Worcester Worcestershire WR5 2DZ Lead Inspector Keith Salmon Unannounced Inspection 5 October 2007 09:30 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 South Hayes Care Home DS0000004144.V348508.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. South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South Hayes Care Home Address 101 London Road Worcester Worcestershire WR5 2DZ 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) 01905 357429 F/P 01905 357429 Regal Care (Worcester) Limited Lynette Rose Thomas Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Reduction in the maximum number of residents who may be accommodated from 48 to 30 until there is agreement with CSCI that an increased maximum number may be reinstated. 4 April 2007 Date of last inspection Brief Description of the Service: South Hayes care home is currently registered to provide personal care for up to 30 older people, who may also have a physical disability. Situated a half mile from Worcester City Centre, close to all local amenities, the home is a large, detached, three-storey building, which has listed status, and occupies an elevated position set back from the road. Accommodation is provided on the ground, first and second floors with a passenger lift affording access to all areas of the home. Fee levels range from £353.00 to £500.00 per week and do not include items such as hairdressing, newspapers, and chiropody. South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced ‘Key’ Inspection commenced at 9.30am, concluded at 5.00pm, and was conducted by Mr Keith Salmon. Present on behalf of the Home was Mrs. Lynette Thomas (Registered Manager). In addition to the inspection of ‘Key’ Standards, this Inspection also sought to review progress in meeting ‘Requirements’ arising from the previous Unannounced Key Inspection held in April 2007. This Report is based on observations made during a tour of the Home, a review of care related documentation, staff duty rotas and staff files, plus a range of other documents/records reflecting the general operation of the home. The Inspector also held individual discussions with 6 Residents, 3 Visitors, the Registered Manager, and several other members of staff. What the service does well: What has improved since the last inspection? The Manager and Staff have worked determinedly since April and have addressed all 14 Requirements identified at the previous Inspection, a number of which were outstanding from earlier Inspections. These efforts have resulted in improvement under several areas of care provision, including Information to Residents/supporters Care planning documentation Improved support for Resident’s leisure activities Medicines administration Staff numbers Staff training Communication with Residents/supporters Health and safety South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 6 In addition the Home has introduced a wider choice in the tea-time/evening meal menu for Residents, and employed and evening kitchen assistant working 7 days per week. What they could do better: 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. South Hayes Care Home DS0000004144.V348508.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 South Hayes Care Home DS0000004144.V348508.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 & 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective Residents, and/or their ‘supporters’, are provided with information which enables them to make a decision as to the home’s suitability to meet care needs Processes to ensure appropriate and thorough care needs assessment, prior to admission, are effectively applied. The findings are utilised to ensure appropriate placement and care provision. EVIDENCE: A Requirement arising from the previous ‘Key’ Inspection, held in April 2007 was “The service users guide must provide potential residents with the information enabling them to make a choice about the homes suitability to meet care needs.” South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 9 Following the April ‘Key’ inspection both the Service User Guide and Statement of Purpose have been revised (in May and July 2007 respectively). These are now in accordance with the relevant National Minimum Standard (NMS) and the Requirement is considered met. In addition to a review of care plans, and related documentation, four Residents were ‘case tracked’ - which involved discussion with each Resident, and in two instances, with their visiting Relatives. This tracking evidenced appropriate and thorough care needs assessment is undertaken by the Manager, prior to admission. Information gathered is utilised in enabling an informed decision regarding the Home’s capability in meeting the individual care needs of each prospective Resident. South Hayes Care Home DS0000004144.V348508.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, & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements in the quality of entries indicate Residents’ individual assessed care needs are now being more reliably met. With medication records now being satisfactorily completed the storage, reception, disposal, and record keeping, relating to medicines administration are all in accordance with accepted ‘good practice.’ The care provided is delivered considerately and effectively with Residents’ privacy and dignity being respected. EVIDENCE: A number of Requirements, cited in the Report of the previous ‘Key’ Inspection, related to Standards within this Outcome Group, some of which remained outstanding from previous Inspections. South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 11 Two requirements related to the quality/quantity of information in Residents’ Care Plans and the on-going management of same, i.e. “Care plans must contain sufficient information to enable care staff to carry out all aspects of care.” “Care plans must be reviewed and up dated at least monthly or more frequently as necessary to ensure changing needs are reflected.” At the previous Inspection it was noted the Manager had begun involving Senior Care Staff more actively in care planning, and in making entries into Care Plans. A criticism at that time was - “Care Plans did not cover all potential areas of need as listed under standard 3.3 of the National Minimum Standards”. A review of care related documentation demonstrated involvement of Senior Care Staff has been further developed, which, in turn, appears to have had a positive effect on the quality of care planning and related documentation. Care Plans comprehensively address the range of individual Resident’s care needs and there was evidence of frequent review (at least monthly). These two Requirements are considered met. A third Requirement centred on the need to promote and ensure the safety and comfort of Residents, i.e. “Risk assessments and suitable care plans must be in place regarding moving and handling, falls, use of bedrails, and pressure care.” Review of care plans reflected attention to issues identified in the above Requirement. In addition, during the tour of the Home it was observed that relevant equipment (e.g. hoists of various types) was available, as were protective buffers for use with bedrails. Staff appeared competent in the use of such equipment and informed the Inspector they had been trained in the use of such equipment. Staff training records supported these claims. This Requirement is met. A further Requirement in this area of care concerned the administration of medicines, i.e. “Medication Administration Record (MAR) sheets must be signed after medication (including creams and ointments) are administered / applied. The reason for non - administration of prescribed medication to residents must be clearly entered onto the MAR sheets.” This Requirement contains two elements, both of which have now been satisfactorily addressed by the Home. South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 12 Review of Residents’ medicine administration records evidenced all medicines administered had been recorded as required by the Standard. In addition, during the tour of the Home, the Inspector observed that for Resident’s who have been prescribed creams or ointments a record (referred to by Staff and Residents involved as ‘cream sheets’) is maintained in each particular Resident’s bedroom. The Manager informed the Inspector that she now, undertakes a weekly audit of MAR sheets, which are selected at random, and Staff substantiated this. A review was undertaken of the policies/procedures relating to the management/administration of medicines, i.e. records relating to the supply, storage, and disposal of medicines, including records of ambient room temperatures, and medicine refrigerator temperatures. All aspects were found to be satisfactory and in accordance with the Standard. The Requirement relating to medicine administration is considered met. A recommendation made at the previous ‘Key’ Inspection suggested that consideration be given to a reduction in the number of double rooms to ensure privacy and dignity is maintained. Since that time the Home’s Owners have applied to the Commission for a change in the maximum number of Service Users the Home may accommodate – a proposal which involves the conversion of double rooms into single rooms with en-suite toilet/shower facilities. This will remain a recommendation pending a decision and resolution of this application. South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 13 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 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is making good progress in involving Residents in promoting, wherever possible, choice and control over their lives, including their day-today life pattern. Opportunities for contact with family/friends/community are established and encouraged. Staff have good understanding of Service Users support and leisure needs, utilising this to assist them in exercising choice and control in their daily lives. The Home provides a daily choice of attractive and nutritious meals based on Residents’ preferences. EVIDENCE: Since the previous Inspection attendance by the ‘Activities Coordinator’ has increased from 3 to 4 days per week totalling approximately 16 hours. This time is deployed in planning activities, conducting activities, and escorting individuals, or small groups, to activities beyond the Home according to their choice. South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 14 Individual Resident’s records, and discussion with Residents/visitors demonstrated activities include musical movement, arts and crafts sessions, gardening - including work in the Home’s greenhouse – visiting entertainers, trips to garden centres, cinema and the theatre. The Home also arranges seasonal celebrations, the most recent being a ‘harvest lunch’, with the menu focussing on a ‘pork and cider’ theme, and some Residents making a direct input by preparing blackberry and apple tart. Strategically, the Home is in the process of altering and refurbishing the basement to provide an activities and leisure area, with work well advanced and expected to be completed by the end of November. The area is planned to be ‘television free’ specifically to facilitate activities such as cards, dominoes, darts, scrabble and quizzes. There is also a ‘snoozelum’ room, containing bean bags, soft moving lighting and music, which is underused and it is intended this room will be brought back into regular use. In addition, an unused bathroom in the basement is to be converted into a hairdressing salon. During the Inspection the Inspector held discussions with 3 visiting relatives, who all confirmed they felt welcome whenever they visit the Home, they had a positive and productive relationship with the staff, and were very happy with the quality of care provided to their relatives. The Manager informed the Inspector the Home holds Residents’ meetings every two months with plans to facilitate more active involvement in the meetings by Residents, e.g. through development of care staff in a ‘key worker’ role. Minutes from the most recent meetings were observed being displayed on the notice board. Alongside this, the Manager is endeavouring to establish Residents’ meetings at which no staff would be present – with an elected representative communicating the group’s thoughts to the Manager. All Residents have availability of a key to their bedroom, and evidence was observed confirming a number have availed themselves of this option, e.g. documentation, some bedrooms seen to be locked during the tour of the Home, and through discussions with Residents. Menus, which operate over a two-week cycle before review/change, were observed on dining room tables for Residents’ perusal. Residents informed the Inspector that should they prefer something other than the choices on the published menu kitchen staff willingly accommodate their requests. They also reported the food to be of good quality and, to quote one Resident “…plenty of it”. Of particular note is the establishment of an additional ‘Kitchen Assistant’ post providing input from 4.00pm to 7.00pm seven days per week. This enables greater flexibility in the tea-time/evening meal menu for Residents, as well as relieving care staff of involvement in meal preparation. South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 15 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): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system with evidence that Service Users and relatives feel their views are listened to and acted upon. Robust procedures and practices are in place to ensure that individuals are protected from abuse. Service users are provided with up to date information about adult protection. EVIDENCE: The Home’s complaints procedure is displayed within the entrance lobby and included in documents held in a Document Holder placed in the entrance hall near to the front door. A review of the complaints log demonstrated there had been no recorded complaints since the previous Inspection. Similarly, the Commission has received no complaints. Information on making a complaint, including the contact details for the Commission for Social Care Inspection, is included in the Service Users’ Guide. Residents and Visitors, consulted during the inspection, stated they would raise any matters of concern with the Manager, and were confident issues raised would be dealt with properly. South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 16 Information highlighting ‘…Adult abuse is everybody’s business…’, published by Worcestershire Vulnerable Adults Protection Committee, was prominently displayed within the home. Training records evidenced that during 2006 staff undertook relevant training in the management of challenging behaviour. South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 17 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 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a reasonably comfortable, generally safe, environment. However, some areas of the Home are in need of refurbishment/upgrading. Specialist equipment, consistent with meeting the assessed care needs of Service Users, and the demands of tasks carried out by Care Staff, is available, and appropriately serviced and maintained. EVIDENCE: A Requirement outstanding from previous Inspections and re-issued at the previous Inspection was – “All areas of the home must be well maintained.” South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 18 The Home has now satisfactorily addressed many issues raised within the Requirement, including: Redecoration, and laying of new carpets, in several bedrooms Replacement dining furniture Eight new chairs for the ‘back lounge’ Safes fitted to all bedrooms New name plates on all bedroom doors Repainting of front porch Replacement of lounge television with a plasma screen model Attention to the outside of the property including o Painting of the front door, kitchen door, and side-gate o Pruning of overgrown shrubs and trees A second Requirement in this area was “Any remaining uncovered radiators must be suitably covered to prevent accidental scalding.” During the tour of the Home it was observed all previously uncovered radiators now benefit from satisfactory protection. This Requirement is met. As a general comment, it is clear the need to ensure a good quality of environment is now being addressed more positively, and effectively, than previously. In addition to work completed thus far the Inspector was made aware of arrangements in hand to undertake full redecoration/refurbishment of the ‘back lounge’. The Manager explained how currently underused communal areas will be pressed into greater use to minimise any disruptive impact on Residents during the necessary work. It is expected the work will be completed by early November. However, whilst indications of progress are promising, current progress must be maintained before the ‘judgement’ for ‘environment’ is moved from ‘adequate’ to ‘good’. To ensure progress is maintained it is ‘Recommended’ that an on-going redecoration/refurbishment programme, including proposed completion dates, be established. South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 19 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 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels have shown improvement and are currently more able to ensure the provision of safe care to Residents. However, care cover at night time is at risk of being insufficient should Resident numbers (or dependency) increase above current levels. Recruitment procedures had a number of short falls, which could potentially place Residents at risk. EVIDENCE: An on-going Requirement from previous Inspections was “Sufficient staff must be on duty throughout the day to meet the care needs of residents. At the previous Inspection the Inspector reported …“The level of staff on duty was assessed to be insufficient to meet the care needs of residents and potentially left residents at risk of not having care needs addressed appropriately.” It should be noted this concern was set against the backdrop of permitted reduced numbers of Residents, i.e. from 48 to 30 – as reflected in the ‘Conditions of Registration’ set out on page 5 above. South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 20 However, a serious reservation, held by the Inspector, is that should the maximum number of Residents be increased (as currently proposed), from 30 to 35 Residents, existing care staff cover might not prove sufficient at night time, when only two care staff only are on duty, and are required to service three floors. Furthermore, the Registered Manager should review current levels of care staff, against Resident numbers/dependency, and staff numbers/skill-mix should be increased as judged to be appropriate to ensure a safe level of care. For the current level of Residents (i.e. 26) it is considered the above Requirement is considered met. Of particular note is the establishment of an additional ‘Kitchen Assistant’ post providing input from 4.00pm to 7.00pm seven days per week. The duty rota identifies members of staff who have completed either Level 2 or Level 3 National Vocational Qualification (NVQ). Review of Staff personal files confirmed 5 staff have attained Level 3 NVQ, and 3 attained Level 2, which equates to just over 50 of carers, and, therefore, have met the required minimum level. It is anticipated the number of qualified carers will increase as some staff are currently awaiting their certificates, while others are undertaking either Level 2 or Level 3 training. A second Requirement cited at the previous Inspection was “Staff recruitment must be robust to safeguard residents from potential harm.” Staff employment files relating to the three most recently employed staff were reviewed. These demonstrated recruitment practices at the home to be satisfactory, with all elements required by Care Homes Regulations being completed, and evidence retained on file. This Requirement is met. A further Requirement was “The induction training provided at the home must be checked against the Skills for Care specifications to ensure it meets the required standards.” Training records were viewed including a current matrix of training, which recording training completed and training planned. These evidenced the majority of staff have undertaken appropriate induction training, and further mandatory training including - moving and handling, medication administration, dementia awareness (including management of challenging behaviour), adult protection, care planning, risk assessment, infection control, and fire awareness. This Requirement is met. South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 21 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A suitably qualified, and experienced person manages the home. However, whilst management of the organisation has improved there is a need for increased support for the Manager to ensure continued progress. The systems for consultation with Residents have improved, with evidence suggesting their views are acted upon. However, the frequency of questionnaire use (annually) is not sufficient. Health, safety, and welfare of service users, and staff, are promoted fully by safe working systems being in place. South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Registered Manager is a Registered General Nurse and Registered Mental Nurse and, in addition, holds the Registered Managers Award. Since the previous Inspection the Manager has led the staff team effectively in making good progress towards meeting Requirements made by the Commission, with some being outstanding over several inspections. At the immediately previous ‘Key’ Inspection the Inspector noted “The home does not have a deputy or a senior staff structure resulting in the registered manager needing to be on call each evening.” No progress can be reported in respect of this concern beyond that plans to recruit a suitable candidate to fill the yet to be established post of ‘Deputy Manager’. It is recommended this intention be pursued, with some urgency, so as to ensure evident current improvement in the quality of care can be maintained, and further developed. A Requirement from the previous Inspection was “A quality assurance programme must be developed in accordance with Regulation 24 and Standard 33.” In addition to the monthly Residents’ meeting the Home issues an annual questionnaire seeking the views of Residents and visitors as to the quality of care provided. The Home also issues questionnaires to visiting health, and social care, professionals. Results are collated and available for interested parties to view. Whilst progress has been made in this area, and the Requirement is considered to be met, it is Recommended the annual frequency should be increased to at least twice, preferably three times, per year. The Home does not hold money in safe keeping for Residents, preferring relatives to carry out this function or for Residents to make use of the safes that are now available in all bedrooms. Where Residents do not have available funds to meet sundry costs, e.g. hairdressing, toiletries, this is met initially by the Home and invoices then issued to Residents, or their representatives. Three Requirements, all ‘unmet’ from earlier Inspections, relating to ‘health, safety, and welfare’ components under this Outcome Group, were reissued at the previous ‘Key’ Inspection, with revised timescales for completion. South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 23 These were “The fire risk assessment must be reviewed and action taken recorded.” “Appropriate action must be taken in the event of high hot water temperatures becoming apparent. Action taken must be recorded.” “Suitable documentation demonstrating the safety of the mini bus must be in place and carried out before each use involving residents.” Evidence was seen which demonstrated the Manager has now completed the necessary action in relation to all three Requirements, i.e. Fire doors are now in place in all areas where required by the fire risk assessment carried out by an external consultant, with smoke seals or intumescent seals around door edges, inserted where necessary. The records regarding the testing of emergency lighting within the home are now in line with guidance issued by Hereford and Worcester Fire Authority. The temperature of hot water supplied to outlets accessible to Residents is regularly tested and records maintained. Random samples of hot water temperatures, tested at several outlets during the Inspection, were found to be satisfactory. Risk assessment documentation relating to outings (including use of the minibus) has been revised, is in use, and appears satisfactory. Containers of antibacterial hand rub were located around the home for use by staff and visitors. Paper towels and liquid soap were in place within toilets and the laundry maintained in line with infection control procedures. Residents consulted confirmed that the home is kept clean. A director of the Company undertakes regular visits to the home and prepares written reports as required under Regulation 26. These reports are held at the home and copies are provided to the Commission on a monthly basis. At the previous Inspection the Inspector noted “Formal supervision is not taking place in line with the national minimum standard, however appraisals are reported to of happened. The frequency of formal supervision is therefore in need of improvement; the registered manager is aware of this and intends to address this shortfall.” South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 24 The Manager has reviewed practices in relation to Staff supervision. Staff records showed that formal staff supervision is now conducted in accordance with the related Standard. At the time of this inspection no potential hazards were identified and a review of relevant records provided evidence that Health and Safety Policies/ Procedures/Practices are satisfactory, with all COSHH requirements met. Records were seen which provided evidence the Home has satisfactorily undertaken appropriate maintenance of equipment including electrical, lifts, hoists, and gas appliances. Window restrictors are in now in place, where necessary, to prevent falling from them. Evidence was seen of a monthly check of restrictors to ensure their integrity. In summary, the Manager has ensured good progress in ensuring the Home has met a number of Requirements, many of which had been outstanding from several earlier Inspections. This positive response to meeting these Requirements enables the Inspector to move the rating for this section from the previous ‘poor’ rating to ‘good’. It is of vital importance that this progress is maintained to ensure the quality of care provision does not slip back to previous levels. An important adjunct to that will be the successful completion of plans to revise the staffing and management structure, including the appointment of a ‘Deputy Manager’. South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 25 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 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 3 South Hayes Care Home DS0000004144.V348508.R01.S.doc Version 5.2 Page 26 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. 1. Refer to Standard OP10 Good Practice Recommendations The reduction in the numbers of double rooms should be considered to ensure residents privacy and dignity is maintained. This recommendation is on-going until the number of registered places is fully resolved. It is Recommended an ongoing written redecoration/ refurbishment programme (with proposed completion dates) be established and a copy sent to the CSCI for information. It is Recommended the use of formal Questionnaires seeking Resident/Visitors views on service quality should be increased to 2 or 3 times per year. It is Recommended the Registered Manager, undertakes a review of current levels of care staff, against Resident numbers/dependency, and staff numbers/skill-mix. DS0000004144.V348508.R01.S.doc Version 5.2 Page 27 2. OP19 3. OP33 4. OP27 South Hayes Care Home Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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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