Inspection on 08/07/08 for St Kitts

This is the latest available inspection report for this service, carried out on 8th July 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Kitts 25/07/06

St Kitts 09/02/06

St Kitts 10/05/05

St Kitts 14/12/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Revelstoke 88 Promenade Bridlington East Yorkshire YO15 2QL Lead Inspector Diane Wilkinson Key Unannounced Inspection 8th July 2008 11:00 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 Revelstoke DS0000062592.V368163.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. Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Revelstoke Address 88 Promenade Bridlington East Yorkshire YO15 2QL 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) 01262 678253 Pennine Care Services Ltd. Mrs Julie Thomson Care Home 22 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (22) of places Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users admitted for respite care in the category (DE(E)), OP is limited to a maximum of four (4) service users at any one time. 19th July 2007 Date of last inspection Brief Description of the Service: Revelstoke is a care home that is owned by a small private company; it is registered to provide care and accommodation for a maximum of 22 older people, including four people at any one time for respite care. It is situated close to the seafront at Bridlington, in the East Riding of Yorkshire and is close to local amenities including transport, shops, health care and leisure facilities. Private accommodation is provided in eighteen single and two shared rooms; nine of these have en-suite facilities. Communal accommodation is provided in a large lounge and a dining room, and there is a patio area at the front of the property. All areas of the home are accessible to service users via the provision of a passenger lift and ramps. Information about the home is provided in a statement of purpose and a service user’s guide; these inform service users and others about the scope and nature of the care and facilities on offer. The registered manager informed the inspector that fees charged are currently between £325.00 and £355.00 per week, and that chiropody, hairdressing, transport and outings are not included in this fee. Revelstoke DS0000062592.V368163.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 inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last Key Inspection of the home on 19th July 2007, including information gathered during a site visit to the home. The unannounced site visit was undertaken by one inspector over one day. It began at 11.00 am and ended at 5.00 pm. On the day of the site visit the inspector spoke on a one to one basis with two residents, two members of staff, the registered manager and the registered provider. Inspection of the premises and close examination of a range of documentation, including three care plans, were also undertaken. The registered provider and registered manager submitted information about the service prior to the site visit by completing and returning an Annual Quality Assurance Assessment (AQAA) form. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. Comments from discussions with residents and staff were positive, for example, ‘we work well as a team’. Other anonymised comments are included throughout the report. At the end of this site visit, feedback was given to the registered manager on our findings, including requirements and recommendations that would be made in the key inspection report. What the service does well: Service users are supported to retain their independence and encouraged to maintain their chosen lifestyle. Meal provision at the home is good; residents have a three course meal each lunchtime and there is ample choice. The home is clean, well maintained and comfortably furnished. The registered manager has the leadership skills to support staff in working well as a team, and to ensure that residents receive a well planned service. Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 Page 6 Staff undertake a thorough induction programme and tell us that they have ample opportunities for training. Health and safety is promoted at the home by the systems in place and via staff training. Staff follow good hygiene practices. What has improved since the last inspection? What they could do better: People having respite care at the home must have a full needs assessment and this information should be used to develop an individual care plan. This is needed to ensure that everyone living at the home, including those having respite care, receive the care needed to meet their individual needs. Water temperatures at outlets accessible to residents must consistently be at around 43°C to protect them from the risk of scalding. Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 Page 7 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. Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 was not assessed, as there is no intermediate care provision at the home. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Permanent residents (but not those having respite care at the home) are assessed prior to their admission to the home and only admitted if it is considered that their assessed needs can be met. EVIDENCE: We examined the records for a married couple that were having respite care at the home. The registered manager told us that they normally receive a care plan from the local authority that commissions the placement, but on this occasion, one had not been received. The details recorded for this couple were brief, i.e. their next of kin, medical history and details of their personal care requirements. The registered manager was informed that there must be an Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 Page 10 assessment of a person’s individual needs for all new residents, including those that have respite care at the home, and that the assessment must be used to develop an individual plan of care. The registered manager told us that she has already developed a pro forma for a briefer version of the care plan used for permanent residents; this was seen by us on the day of this site visit. No new permanent residents have been admitted to the home since the last key inspection. We checked the records for three of the permanent residents living at the home; these all included an assessment of care needs and an individual care plan. Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Health care needs are met in a way that respects a person’s privacy and dignity; this is recorded in and supported by well-maintained care planning documentation. EVIDENCE: We examined the care records for three residents; these included an individual care plan that was based on the care needs assessment undertaken by the home as well as information gathered from care management and family members. Care plans include risk assessments for moving and handling, pressure care and the risk of falling, as well as more specific risk assessments pertinent to the individual resident. There is evidence that residents and/or relatives are involved in the care planning process. We noted that care plans include a photograph of the resident concerned; a photograph assists new staff Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 Page 12 to identify residents and assists the emergency services should someone go missing from the home. The registered manager told us that a senior carer has just checked all care plans to ensure that the relevant documentation is in place and up to date; they identified some minor omissions and have informed the relevant key workers of how and when they should bring the care plans up to date; this information was seen by us on the day of this site visit. Care plans include a record the areas where a person is able to self-care and information about the level of assistance needed with personal care and continence care. Daily records include information on food/fluid intake and how and where residents choose to spend their day; we observed that night staff write a separate report. We noted that care plans are reviewed in-house on a regular basis - key workers, link workers and a senior carer make regular reports to update the care plan. Any changes to a person’s care plan are recorded in red pen so that they are made clear for staff. Care plans are also review formally every year by care managers when a resident is funded by the local authority. The registered manager gave us an example of how they arrange an annual review of the care plan for residents who are self funding. Care plans include a record of a person’s nutritional requirements, such as a diabetic diet and any food allergies. Residents are also weighed on a regular basis as part of nutritional screening. There is a record of any visits from or contacts with health care professionals, including the reason for the contact, and detailed information is held regarding advice given by health care professionals following surgery or hospital visits. We observed that residents had been provided with pressure care equipment to assist with tissue viability, such as pressure care mattresses. Accidents and incidents involving residents are recorded in their individual care plan. The procedure on the administration of medication has been updated since the last key inspection of the home. This was examined by the inspector and it was felt that there may be some omissions in the procedure; the inspector agreed to take advice on this and advise the registered manager accordingly. Care plans include a record of a person’s current prescribed medication and there are risk assessments in place to record a person’s wishes to self medicate and if it is safe for them to do so. Some care plans evidence that a resident’s GP has undertaken a review of the medication they are prescribed. On the day of this site visit we observed the administration of medication by a senior carer – they wore disposable gloves to promote infection control. We noted that they signed medication administration records after they had seen the person take their medication, and that there were no gaps in recording. We noted that any additions made to medication administration records were Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 Page 13 recorded and signed by one member of staff and then signed by a second member of staff to reduce the risk of mistakes occurring. There is evidence that staff that administer medication have undertaken accredited training and there are sample signatures held for this group of staff to enable medication administration records to be checked for authenticity. There is an additional sheet included with medication administration records that records ‘special events’, for example, any homely remedies that are administered; this is good practice. Medication is stored securely in a trolley that is fixed to the wall. Temperatures are taken and recorded in the trolley on a daily basis to ensure that medication is stored at a suitable temperature. A senior carer checks the medication cabinet daily to ensure that medication is stored securely and safely, and that the cabinet is clean and hygienic. Controlled drugs are stored in a metal cupboard that is attached to a wall; the registered manager agreed to find out if this cabinet meets new guidelines on the storage of controlled drugs. There is a controlled drugs book in use and medication administration records are also used for controlled drugs; both are signed by two members of staff. We saw evidence that unused medication is returned to the pharmacist. We observed on the day of the site visit that residents are spoken to sensitively with regard to personal care, and that staff respect a person’s privacy by knocking on bedroom doors and by closing doors when people were using the toilet and bathroom. We observed that resident’s are treated as individuals, with consideration given to their personal relationships and particular lifestyle choices. Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to maintain their chosen lifestyle and to continue with their hobbies and interests, and visitors to the home are made welcome. Meal provision at the home is of a high standard and is enjoyed by residents. EVIDENCE: Care needs assessments and care plans include information about a person’s life history and previous lifestyle, including details of family and friends, their interests and their religion. Care plans record information about a person’s preferred time to get up and go to bed and about likes and dislikes regarding their diet. Residents confirmed that they can get up and go to bed as a time chosen by them, and that this can vary from day to day, depending on their preference. Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 Page 15 Most residents are accommodated in single rooms so are able to meet with visitors in private. Discussion with service users and information seen in care plans evidenced that those service users that have friends and relatives are supported to remain in contact with them, and that their visitors are made welcome by staff at the home. Some residents have had a telephone installed in their own room; they told us that this helps them to remain in contact with family and friends. Residents have particular interests that the staff try to encourage, such as bird watching and embroidery. Each care plan includes an activities report and this records how a person has spent their day; entries include reading the papers, drawing, motivation class and communion. Two or more members of staff are able to drive the home’s mini bus and this is used to take people on trips out. Another member of staff takes service users out in their car as part of their daily duties. One resident has a mobility scooter; the home has identified storage space for this and supports the resident to arrange for the vehicle to be properly maintained. They told us that they like to go out into the town and that staff support them to do this. Details about advocacy services are made available to residents and visitors in the information booklet displayed in the entrance hall. Residents are able to make choices about where and how to spend their day and where to take their meals, and are encouraged and supported to retain their level of independence. Service users are encouraged to bring some of their personal items into the home, including small items of furniture. Care plans record a person’s likes and dislikes regarding food. On the day of the site visit we observed that the menu was displayed in the hallway and that this recorded two choices of main meal at lunchtime. We observed on the day of the site visit that there were actually three different choices of meal available. Lunch is a three-course meal and a cooked breakfast is available every day. The registered manager told us that special diets are catered for, although the only special meals currently needed by residents are ‘soft diets’. One resident had transferred to a care home in another area but did not settle and has returned to Revelstoke. They told us that they missed the wonderful meals provided by Revelstoke. We observed that meal times are a social event, with staff offering appropriate assistance and allowing people to take their time. The registered manager told us that one resident sometimes has their breakfast and occasionally their lunch in their room, but that most residents come to the dining room, as they enjoy meeting with their friends; we noted that residents chatted to each other and to staff whilst in the dining room. The registered manager told us that some people have tea at a later time than others if it suits them. For example, some of the men like to watch the racing on the TV so they have their tea when it has finished. Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents know how to use the complaints procedure and residents say that staff listen to them. Residents are protected from the risk of being abused by the training and skills of the staff group. EVIDENCE: There are appropriate complaints policies and procedures in place, and the complaints procedure and a complaints book are displayed in the entrance hall. Residents told us that they know how to make a complaint and that they know who to speak to if they are dissatisfied with any aspect of care. They told us that they were confident that their complaints would be listened to and acted upon. Staff told us that they would advise residents and others to use the complaints procedure if they had a concern or complaint. No complaints have been made to the CSCI since the last key inspection of the home. There is a complaints log in place and this records that there have been no complaints made to the home since November 2006. The log is designed to record the nature of the complaint and the outcome. There are appropriate policies and procedures in place regarding safeguarding vulnerable adults from all forms of abuse. The members of staff that we spoke Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 Page 17 to were able to explain about possible types of abuse and about the purpose of whistle blowing; this information is also displayed throughout the home. One member of staff told us, ‘I would report any abusive behaviour to the manager and would tell the member of staff concerned that I will be doing so’. The training and development plan recorded that thirteen staff have undertaken training on this topic. We noted that some of this training was done in 2004 and asked the manager if any refresher training was planned. We were told that a new company trainer has been employed and that this is one of the training courses that they would be arranging. Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is clean, well maintained and well furnished and provides comfortable surroundings for residents. EVIDENCE: There is a maintenance plan and a repairs book in place, and we noted that all service and maintenance certificates were readily available at the home for inspection. We observed that the home is well maintained and that equipment is replaced as necessary; there is an equipment book in place to evidence this. Since the last key inspection of the home, a further three bedrooms have been refurbished and now include en-suite accommodation; some of these include a shower. All areas of the home provide a light and bright atmosphere for Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 Page 19 residents, especially the dining room. Bedrooms are furnished and decorated to reflect the needs of the resident concerned, and many residents have brought small items of furniture from their own home. Some service users (particularly those having respite care at the home) have the use of a bedroom and a small lounge, and use their accommodation more like a flat than a bedroom. Laundry facilities at the home are satisfactory. The laundry room is clean but we advised the registered manager that the floors should be tiled (or similar) so that they are impermeable and easy to clean. The walls should also have a surface that is easily cleanable. These measures would help to reduce the risk of cross infection. There were no strong odours identified on the day of the site visit and the home was seen to be clean and hygienic; we observed that staff follow good hygiene practices. Domestic staff are employed on six days per week and there is a dedicated laundry assistant. This allows care staff to concentrate on personal and social care tasks, and reduces the risk of cross infection. Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care staff are recruited in a safe way and receive induction and on-going training to ensure that they are qualified and skilled to care for the residents living at the home. EVIDENCE: There is a staff rota in place that records the role of each member of staff and we observed that, on the day of the site visit, the staff rota was a true reflection of the actual staff on duty. Catering staff and domestic staff are employed in addition to care staff; this allows care staff to concentrate on personal care duties and enhances infection control at the home. Seven care staff have completed National Vocational Qualification (NVQ) Level 2 in Care or above and a five care staff have been working towards NVQ Level 2 for about six months. The home has almost achieved the requirement for 50 of care staff to have completed this award. It should be possible for the 50 requirement to continue to be met, as most care staff have either achieved this award or are working towards it. Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 Page 21 The inspector examined the recruitment and selection records for a new member of staff. These evidenced that prospective employees complete a satisfactory application form that includes details of their employment history, their previous experience and their training achievements. A POVA first check and two written references had been obtained prior to the person commencing work at the home. The registered manager was reminded that, in normal circumstances, a satisfactory CRB check should be obtained prior to staff commencing work at the home, and that a POVA first check should only be used in exceptional circumstances. We saw that new staff are issued with a job description and are provided with a contract of employment. We examined the training and development plan that is displayed on the wall of the manager’s office – this is very detailed and evidences that new employees have induction training when they are first in post and that this meets Skills for Care standards. The plan evidences that staff have undertaken training on fire safety, health and safety, food hygiene, moving and handling and safeguarding adults. In addition to this, staff undertake more specialised training such as managing challenging behaviour. Training achievements are also recorded in individual staff files, and this includes copies of training certificates. We noted that the training and development plan records the date that training was achieved; this assists the registered manager to identify when refresher training is needed. We discussed the need for some refresher training with the registered manager. She told us that the company have employed an in-house trainer and we saw evidence that refresher training had been organised on fire safety, food hygiene and medication for the month of July. A member of staff told us that they had recently had refresher training on medication and had found the training very useful. Another care worker said that they had, ‘regular training opportunities’. Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and the health, welfare and safety of residents and others are usually protected by the systems in place. EVIDENCE: The registered manager has the qualifications, experience and skills to carry out her role, and all residents and staff spoke highly of the registered manager. The registered manager keeps her practice up to date by attending in-house training courses alongside the staff group, and by using the CSCI Professional website; she referred to this during our site visit to the home. Staff said that they felt well supported by the manager, and records evidence Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 Page 23 that they receive regular supervision and appraisals. Staff also told us that they are encouraged to make suggestions and ask questions at staff meetings, that they have a stable staff group and that they work well as a team. The registered manager is now informing the CSCI of any accidents or incidents that may affect the well-being of residents, as requested at the last key inspection of the home. On the day of the site visit we observed that the registered manager is very organised and that staff supervision, resident reviews, staff training and health and safety information was up to date and readily available. The home has achieved the Quality Development Scheme (QDS) Part 1 and intends to apply for Part 2; this is a quality scheme operated by the local authority. The quality assurance systems in place at the home enable residents and others to affect the way in which the home is operated. Surveys are distributed to residents and others and the results of these are evaluated. These are discussed at residents meetings, staff meetings and managers meetings; the registered manager was advised that a copy of collated QA information should also be forwarded to the CSCI, and that the results of quality surveys should be used to formulate an annual development plan. There is evidence that policies and procedures are updated on a regular basis; these are updated by the organisation’s head office and distributed to all of the homes within the organisation. We examined the records for monies held on behalf of residents and crosschecked these with actual monies held - both were found to be accurate. Receipts are obtained for any purchases made on behalf of residents but we noted that receipts are not always given to relatives when they hand money to staff. We recommend that a receipt be given to relatives when they hand money to staff for residents for safekeeping, to protect all parties concerned. Residents now have lockable storage facility in their bedrooms; this enables them to hold money, valuables and medication safely. We examined health and safety documentation held at the home. There is evidence that weekly fire tests take place as well as regular fire drills. All other health and safety documentation was seen to be in order, such as a gas safety certificate and maintenance certificates for mobility hoists, bath hoists and the passenger lift. We noted that the annual fire test was due on the 6th July 2008 – this, along with fire training for staff, was booked for the 18th July 2008. At our request, the registered manager brought the date of the annual fire test forward. On the day of the site visit we saw evidence that water temperatures at outlets accessible to residents are tested on a regular basis to reduce the risk of scalding; these are done on a weekly basis. Temperatures were seen to be consistently between 44 – 52°C; 43°C is the recommended temperature to ensure safety for residents. The registered manager contacted a plumber on Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 Page 24 the day of the site visit and he arrived on the premises before the site visit ended. An immediate requirement notice was issued in respect of this breach of regulation and the registered manager confirmed within the required timescale that the work needed to protect residents from harm had been undertaken. Staff undertake appropriate training on health and safety topics, and this training is updated on a regular basis. There is a written statement of the policy, organisation and arrangements for maintaining safe working practices in place, including relevant risk assessments. Revelstoke DS0000062592.V368163.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 X X 2 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 2 Revelstoke DS0000062592.V368163.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. 1. Standard OP3 Regulation 14 Requirement All prospective residents must have a thorough needs assessment prior to their admission to the home, and this information should be used to formulate an individual plan of care. Water temperatures at outlets accessible to residents must be at around 43°C to ensure their safety. An immediate requirement notice was left at the home due to a breach of regulation. The registered manager arranged for the work to be undertaken to reduce water temperatures whilst we were still present at the home. Timescale for action 08/07/08 2. OP38 13(4) 08/07/08 Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 Page 27 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 OP26 Good Practice Recommendations The laundry room should be refurbished so that floors have an impermeable surface and that both floors and walls are easily cleanable. This would reduce the risk of cross infection. The registered manager was reminded that a POVA first check should only be used in exceptional circumstances, not routinely. The registered manager was advised that the outcome of any quality surveys should be sent to the CSCI, and that this information should be used to produce an annual development plan. Receipts should be given to relatives when they hand money over to the home for residents for safekeeping, to protect all parties concerned. 2. 3. OP29 OP33 4. OP35 Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Revelstoke DS0000062592.V368163.R01.S.doc Version 5.2 Page 29 - 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. 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