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Inspection on 14/05/08 for St Mary`s Residential Home

Also see our care home review for St Mary`s Residential Home for more information

This is the latest available inspection report for this service, carried out on 14th May 2008.

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

Residents told us that they like living at the Home and that the staff are kind to them. They said that staff respect their privacy and dignity and that the staff listen to them and ask for their opinions. Comments were made such as: "staff are kind" "nowhere is like home but this is the closest thing to it" "staff are kind and helpful" Relatives said that staff are good at keeping them informed about issues affecting their relative and that the staff provide good care. They said that improvements have been made since the Manager started working at the Home. Residents spoke very highly of the meals provided and the choices that they are offered. Comments were made such as: "We are very proud of our cook" "we get lovely food, lots of choice and it is good quality" " the food is the best" " the cook knows just what we like" The management team carry out appropriate recruitment checks to ensure that staff are safe to work with the vulnerable residents. The physical and personal needs of the residents are met by the staff who receive appropriate training and supervision to carry out their roles.

What has improved since the last inspection?

Improvements have been made to the medication system so that it now provides increased safeguards to ensure that residents receive their medication at appropriate times. The Manager has liased closely with the Environmental Health Department to ensure that standards of hygiene are good. The Environmental Health Officer confirmed to us that the staff followed appropriate procedures during a recent outbreak of illness and that they are satisfied with the standards of hygiene within the Home. The recent appointment of an activities co-ordinator means that a lot more meaningful activities are being provided for the residents to take part in if they wish to. Organised activities such as Boules, quizzes and crafts take place every morning and afternoon during the week with film showings taking place during the afternoons at weekends. Residents said that they really enjoy the increase in activities and that they are consulted about what should be provided. Some improvements have been made to the environment, such as the refurbishment of the kitchen and decoration of some of the bedrooms. Additional care staff are now on duty during each shift. This means that in general it is easier to meet the needs of the residents. Staff, residents and relatives all said that this is an improvement.

CARE HOMES FOR OLDER PEOPLE St Mary`s Residential Home North Walsham Road Crostwick Norwich Norfolk NR12 7BQ Lead Inspector Lella Hudson Unannounced Inspection 14th May 2008 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 DS0000027467.V364553.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. DS0000027467.V364553.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Residential Home Address North Walsham Road Crostwick Norwich Norfolk NR12 7BQ 01603 898277 01603 891105 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) None provided County Healthcare Ltd, a wholly owned subsidiary of Four Seasons Health Care Ltd Deborah Johnson, application for registration pending Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places DS0000027467.V364553.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Forty-four (44) Older People of either sex, not falling into any other category, may be accommodated. 2nd May 2007 Date of last inspection Brief Description of the Service: St. Marys is a large single storey building situated in the village of Crostwick. The accommodation consists of thirty-two single and six double bedrooms. Thirty-three bedrooms have an en suite facility. There are a variety of communal areas for the use of service users as well as an enclosed garden. St. Marys is situated in its own grounds with a large car park to the front of the premises. Fees are currently £388 - £477 per week. Information about the Home, including the last Inspection report, is available in the reception area. DS0000027467.V364553.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 TWO STAR. This means that the people who use this service experience GOOD quality outcomes. This report contains information gathered about the Home since the last Inspection in May 2007. It includes information provided by the manager, such as the completed Annual Quality Assurance Assessment, and through notifications to the Commission. It also includes information gathered during an unannounced visit to the Home which was carried out on the 14th May 2008 between 9.35am and 4.30pm. During the visit we looked around the accommodation, inspected records, spoke to staff, residents and relatives, observed staff supporting residents and also spoke to the Manager and administrator for the Home. Completed surveys were received from relatives and staff in April 2008. The Home has a Manager and a deputy manager. The Manager has been in post for thirteen months and is in the process of applying to be registered with the Commission. The Manager receives support from the area manager. What the service does well: Residents told us that they like living at the Home and that the staff are kind to them. They said that staff respect their privacy and dignity and that the staff listen to them and ask for their opinions. Comments were made such as: “staff are kind” “nowhere is like home but this is the closest thing to it” “staff are kind and helpful” Relatives said that staff are good at keeping them informed about issues affecting their relative and that the staff provide good care. They said that improvements have been made since the Manager started working at the Home. Residents spoke very highly of the meals provided and the choices that they are offered. Comments were made such as: “We are very proud of our cook” “we get lovely food, lots of choice and it is good quality” “ the food is the best” “ the cook knows just what we like” The management team carry out appropriate recruitment checks to ensure that staff are safe to work with the vulnerable residents. DS0000027467.V364553.R01.S.doc Version 5.2 Page 6 The physical and personal needs of the residents are met by the staff who receive appropriate training and supervision to carry out their roles. What has improved since the last inspection? What they could do better: The organisation needs to ensure that appropriate equipment is provided to meet the needs of the residents. There are only two hoists in the Home and none of the toilets have assisted seats or rails. The Manager agreed to review this situation. There are currently no kitchen staff employed during the afternoon/evening which means that a member of the care staff is responsible for organising tea and clearing up afterwards. This reduces the number of care staff available at these times. . Some areas of the Home are still in need of redecoration/refurbishment and the Manager said that the communal areas will receive this attention in the next few months. DS0000027467.V364553.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. DS0000027467.V364553.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 DS0000027467.V364553.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): 1&3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents and their relatives feel that they received clear information about the Home prior to the resident moving in. Pre admission assessments provide information for staff about how to meet residents needs when they first move into the Home EVIDENCE: The Home has a Statement of Purpose and a Service User Guide which contain information about the services that the Home provides for older people. Relatives and residents said that they had been provided with these documents and that these had enabled them to have a general idea about what the Home would be like once. Each resident also has a copy of a document entitled DS0000027467.V364553.R01.S.doc Version 5.2 Page 10 “Welcome to St Marys” which contains more detailed information about what life is like on a daily basis at the Home. Residents said that this is a good source of reference as it contains information about things such as how to arrange to see the hairdresser. Residents said that the Manager had met them to carry out a pre admission assessment prior to them moving into the Home. We saw two of the care plans and these contain quite detailed information about the residents needs. This document provides the basis for the care plan with additional information being added to it as staff become aware of it. Staff said that they have access to this information a few days prior to the resident moving into the Home and that it helps them to be able to meet the residents needs. DS0000027467.V364553.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, & 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The care plans are adequate to ensure that the staff have clear information about how to meet individual residents needs Medication is well managed which means that residents receive their medication in a safe and timely way Residents feel that they are treated with respect EVIDENCE: We saw two of the care plans and these contain a lot of information about the residents needs and how these should be met. The care plans contain assessments of individual needs such as continence, mobility and pressure care as well as risk assessments relating to a variety of issues. There is evidence of regular reviews taking place of the care plans. The use of language within the care plans is respectful and is individual to the resident. DS0000027467.V364553.R01.S.doc Version 5.2 Page 12 For example one of the care plans includes a range of options that should be offered to one of the residents if she chooses not to comply with a request from staff. This is written in a very respectful manner and recognises that the resident sometimes finds situations difficult to understand. The standard of recording, for example, of monthly weights, is variable and the Home needs to ensure that this information is recorded consistently for all residents so that any problems can be more easily identified. The care plans contain evidence that a range of health professionals are involved in the residents care and that their advice is incorporated into the care plans. For example, the district nurses are involved with residents with diabetes and have recently provided some training to staff. The continence advisor carries out assessments of residents continence needs and the care plans contain detailed information about how staff should assist residents to meet these needs. The care plans would benefit from improved social histories which would provide information about the residents interests and hobbies, their employment history and information about their families. This would enable staff to have a better understanding of the resident as an individual and also enable staff to better plan activities for residents. In May/June 2007 we received three concerns/complaints about the poor staffing levels in the Home and the poor state of the toilets. In March 2008 we passed a concern on to the organisation to investigate. This was with regard to poor staffing levels and lack of attention to the residents continence needs. The organisation could find no evidence to back up this concern. Evidence gathered during the visit to the Home shows that the staffing levels have improved over the last few months and that the staff have a better understanding about the residents continence needs. During the visit to the Home residents and relatives said that the number of staff on duty has increased and that the use of agency staff has reduced. They are much happier with this situation as it means that residents do not have to wait so long for a response when they use the call bell and that staff get to know them and have a good understanding of how to meet their needs. We were told that approximately ten of the residents at the time of the visit to the Home need the hoist to assist them with mobility. The Home only has two hoists and residents said that occasionally they have to wait for this to be free when they require assistance. The organisation needs to ensure that they have the appropriate equipment to meet the residents needs. Residents told us that the staff are kind, that they work very hard to meet their needs and that they provided an extremely high standard of care during the recent bout of sickness that was present in the Home for several weeks. DS0000027467.V364553.R01.S.doc Version 5.2 Page 13 The Manager liased with the Environmental Health department and other relevant health agencies with regard to the presence of sickness and diahorea which affected many of the residents and the majority of the staff. The Environmental Health officer told us that the Manager and staff had acted appropriately and had followed all advice given to them. During the visit to the Home we saw lots of evidence that staff are working hard to ensure high standards of hygiene are maintained at all times. Residents receive care in their rooms if they are unwell, there are plenty of protective aprons, gloves and hand wash around the Home and the staff have a good understanding of good hygiene procedures. Residents told us the following comments about the staff: “staff are kind” “nowhere is like home but this is the closest thing to it” “staff are kind and helpful” “A member of staff wasn’t kind and I told the manager and the staff member has gone” We spoke to several staff during our visit to the Home. They all said that they receive good information about the needs of the residents and that they are encouraged to read the care plans on a regular basis. They are all aware of the importance of spending time with residents on an individual basis and of respecting their privacy and dignity when supporting them with personal care. They gave examples of how they do this. Five requirements were made about medication at the last Inspection. We had a look at the system in use in the Home to look after and administer medication. Several improvements have been made to the system and all of the requirements have been met. A record is kept of medication received at the Home and that returned to the pharmacy. Accurate records are kept of the administration of medication to residents. Audits are carried out on a regular basis and action is taken to address any issues that may arise from these. The staff receive appropriate training with regard to the administration of medication and to individual health needs of residents, such as those with diabetes. There is also additional written information available to staff about specific health issues. DS0000027467.V364553.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 & 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are supported to take part in meaningful activities on a regular basis Residents are supported to maintain contact with relatives Residents are helped to exercise choice and control about issues affecting them Residents receive meals which are appetising, tasty and which they enjoy EVIDENCE: The Manager identified within the Annual Quality Assurance Assessment that the residents would benefit from additional activities and the appointment of an activities co-ordinator. This has now taken place and we saw lots of evidence of the enjoyment that the residents are gaining from the additional activities. The activities co-ordinator organises activities herself but also liases with the staff about activities that will take place on the days when she is not working. DS0000027467.V364553.R01.S.doc Version 5.2 Page 15 The programme of activities is on display around the Home and shows a different activity taking place during each morning and afternoon during the week. During the week of the visit these included board games, Boules, a quiz, exercise to music, crafts. During the afternoon at weekends there is a ‘film club’ with dvds being shown in one of the lounges. Residents said that they have been consulted about the range of activities available and are asked for their choices for the film club. As well as group activities staff are encouraged to spend more time with individuals doing things such as nail care/hand massage and just spending time talking to residents. The Home has two caged birds and one of the residents told us that she is responsible for feeding these and taking care of them. A game of Boules was taking place during the morning of the visit and this generated much hilarity and fun for the large group of residents taking part. Thought has been given to the seating in the smaller lounges and reception area so that small groups of residents are encouraged to sit together and chat. There are books and magazines around the Home for residents to read. The radio was on loudly in the reception area during the visit but the station chosen was not the choice of the residents who were sitting near to the radio. The relatives survey said that the staff are welcoming and that they keep them informed about issues affecting their relative. This was confirmed by the relatives who spoke to us during the visit to the Home. The relatives spoke positively about the care provided to their relative and said that the staff have worked hard to ensure that their needs are met. The Home was closed to visitors during the recent bout of illness there and we received two telephone calls from relatives who were concerned about this. However, the Manager was following the advice of health professionals in limiting visitors to the Home at that time. Residents told us that the staff do ask their opinion about issues affecting them and that they are given choices as far as is possible. Residents said that they are able to get up and go to bed when they choose although sometimes they may have to wait for the hoist if they need this to mobilise. The care plans contain information about the residents individual preferences about how they receive care and the staff who spoke to use were aware of these. The information within the residents surveys is positive about the quality of the meals provided. This was confirmed by the residents who spoke to us during the visit. Comments were made such as: “We are very proud of our cook” “we get lovely food, lots of choice and it is good quality” “ the food is the best” “ the cook knows just what we like” DS0000027467.V364553.R01.S.doc Version 5.2 Page 16 Discussions with the kitchen staff confirmed that they are given information about residents dietary needs and individual preferences. They also speak to the residents on a daily basis about the meals and about any changes that could be made to the menus. The cook recently attended the residents meeting to discuss any issues that they wished to raise about the meals. The kitchen staff receive appropriate training to enable them to carry out their roles effectively. They said that the Manager is supportive. The residents can choose whether to have their meals in the dining room or in their bedrooms. The dining room tables are attractively set with small groups of residents eating together. The menus are displayed on the tables and staff ask each resident for their choice. Residents are offered snacks in between mealtimes. Residents said that they are always able to have a drink or snack whenever they wish to have one. Jugs of squash and glasses are situated in each communal area of the Home so that residents can help themselves. There are staff working in the kitchen during the morning and early afternoon but no kitchen staff during the evening to prepare or clear up after tea. The cook prepares tea before leaving when this is possible but the care staff then have to carry out all other tasks associated with tea. There are less care staff on duty during the afternoon than the morning and no additional care staff are employed despite one of them having to undertake catering tasks. Staff and residents said that this means that it can be difficult to provide assistance to the residents in a timely manner. The organisation needs to ensure that there is adequate staff on duty at all times to meet the needs of the residents. DS0000027467.V364553.R01.S.doc Version 5.2 Page 17 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. Residents and relatives are confident that their complaints are listened to and acted upon Appropriate training increases the protection that residents have from abuse EVIDENCE: The Home has a complaints procedure which is displayed around the Home. There are also leaflets available in the reception area about advocacy groups that could support residents to make complaints if they wished to do so. As already mentioned in this report we have received concerns/complaints about the Home which have been passed to the organisation to investigate. The Manager said that there have not been any further complaints that have not already been notified to us. The Manager dealt appropriately with an allegation of theft and liased with the appropriate Safeguarding team about this. The situation has not yet been concluded. Residents and relatives who spoke to us said that they have confidence in the Manager to listen to any concerns/complaints that they may have and to take action to address these. One of the residents gave an example of having told DS0000027467.V364553.R01.S.doc Version 5.2 Page 18 the Manager that one of the staff was rude to him and that he was satisfied with the action that the Manager took. The Manager arranges residents meetings and the minutes show that residents are encouraged to raise any issues that they may wish to and includes information about action that is taken as a result. Staff who spoke to us have an understanding about the issue of abuse and are aware of the appropriate procedure to raise concerns if they have any. They are confident that the Manager will deal with any concerns appropriately. The training matrix shows that not all staff have attended Safeguarding training recently but the Manager said that further training has been organised for those staff later this month. The Homes procedure relating to Safeguarding needs to be reviewed and some parts need clarifying to ensure that it provides very clear guidance for staff in the event of concerns. DS0000027467.V364553.R01.S.doc Version 5.2 Page 19 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. Some areas of the Home are in need of redecoration and refurbishment to ensure that the residents live in a homely attractive environment which meets their needs EVIDENCE: The Annual Quality Assurance Assessment contains information about the improvements that have been made to the environment. These include the upgrading and redecoration of the kitchen, the replacement of crockery and cutlery and the redecoration of some of the bedrooms. Relatives told us that they had been disappointed that the planned redecoration of the Home has not taken place. However, the Manager said that there are now plans to go ahead with some of this work in the communal DS0000027467.V364553.R01.S.doc Version 5.2 Page 20 areas. The handrails in the corridors were being painted on the day of our visit. Concerns had been raised with us last year about the lack of cleanliness in the Home. No evidence of this was seen during the visit to the Home and the Manager said that the general levels of cleanliness and hygiene in the Home have been greatly improved. The Environmental Health department said that they are satisfied that appropriate hygiene procedures are being followed. The Home is decorated and furnished in a homely manner with small lounges as well as the very large lounge. There is a small secure garden and the Manager said that there are plans to make some of the extended grounds more easily accessible to the residents. Despite a previous requirement it was seen that the flooring in the shower rooms are stained and in need of replacing. The shower rooms are very bare and not attractive or homely bathrooms for the residents to use. It was also noted that some of the beds have plastic mattresses and no mattress covers under the sheet. Additional mattress covers would increase comfort for the residents. None of the toilets have any form of assisted seating and the Manager agreed that the provision of this would assist some of the residents. The organisation must ensure that appropriate equipment is provided to meet the needs of the residents. Following a visit by the Fire Officer last year the fire doors have been replaced throughout the Home. However, the closures on these are not all working satisfactorarily. We received a concern from a relative about the risks posed by the closure pushing the bedroom door shut very fast. We saw the three bedroom doors which are posing a risk. The Manager described the action that has been taken to try to address the situation but which have not been successful. Immediately following the Inspection the Manager discussed the situation further with the area manager and a risk assessment was completed for the residents concerned which resulted in the closures being removed on a temporary basis until a suitable alternative can be put in place. DS0000027467.V364553.R01.S.doc Version 5.2 Page 21 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 good This judgement has been made using available evidence including a visit to this service. The residents needs are met by the numbers and skill mix of staff Residents are protected by the robust recruitment practices The needs of the residents are met by staff who receive appropriate training and supervision EVIDENCE: Following a requirement made at the last Inspection the numbers of staff on each shift have been increased. However this requirement will be repeated due to the reduced availability of care staff in the afternoons as there are no kitchen staff on duty. The Manager said that the minimum staffing levels is for there to be six care staff on duty in the morning and five in the afternoon. On occasions there are more staff on duty. This was confirmed through discussions with the staff and residents and a look at the staffing rota. The Manager said that recently the use of agency staff has reduced due to the amount of recruitment that has taken place for permanent staff. However, there are currently two vacancies DS0000027467.V364553.R01.S.doc Version 5.2 Page 22 to which the Manager is seeking to appoint permanent staff as soon as possible. Staff and residents said that staff are very busy in the mornings when there are only six staff on duty as one of the staff is busy with the administration of medication and one is assisting residents to have breakfast in the dining room which only leaves three care staff to assist residents to get up. Some of the residents need two staff to assist them with mobility. The Manager needs to regularly review the staffing levels to ensure that the residents needs are being met. This is particularly important as more admissions take place and the number of residents increases as currently there are only 37 residents living at the Home. The training matrix shows that the staff receive training with regard to mandatory subjects such as Fire Training, Safeguarding and Moving and Handling. The Manager provided us with the dates for forthcoming training in these subjects which will ensure that all staff have received updated training in these subjects. Training is also provided with regard to additional health needs such as diabetes. The Manager said that she intends to increase the amount of training with regard to dementia and health and safety. Training is provided through a mixture of internal and external trainers. Three staff have completed ‘training the trainers’ courses so that they can provide training to their colleagues about Moving and Handling and Fire Safety. The Annual Quality Assurance Assessment states that five staff have completed NVQ Level 2 with three undertaking this. The Manager said that an additional two staff are currently undertaking this NVQ. Staff who spoke to us said that the morale within the staff team has greatly increased over the last few months and that they feel that they work in a supportive team which provides a good quality of care to the residents. Staff said that they receive appropriate induction and training. One of the staff explained the induction that she is currently receiving and this involves her shadowing more experienced staff prior to supporting residents on her own. Staff described the recruitment process that was carried out when they applied for a job and this confirms that the Home follows their own recruitment procedures which include obtaining appropriate references and checks on the suitability of staff to work with vulnerable adults. Staff meetings take place on a regular basis. A handover takes place at the beginning of each shift and so the staff coming on duty arrive at work approximately fifteen minutes early to attend handover. However, they do not get paid for this. DS0000027467.V364553.R01.S.doc Version 5.2 Page 23 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, 32, 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. The residents benefit from the Home being run by a competent and caring Manager The views of the residents are regularly sought and taken into account Good health and safety policies and awareness of staff ensures that residents are protected EVIDENCE: The Manager has been in post for thirteen months and is in the process of applying for registration with the Commission. Relatives, residents and staff DS0000027467.V364553.R01.S.doc Version 5.2 Page 24 told us that there have been many improvements made at the Home since the Manager has been in post. They also said that the Manager listens to what they say and that she takes action to address issues. Staff also said that the deputy manager is very approachable and that they feel confident in raising issues with her. The Manager and deputy provide ‘on call’ support to staff if neither of them are on duty. Comments made by staff about the Manager and deputy include the following: “you can talk to her and she is fair” “she is approachable and is always asking if we are okay” “can talk to manager” One of the residents said that: “Debbie deals with things when you tell her” The Home has an administrator who works at the Home on a part time basis. Amongst other things, she is responsible for maintaining the system for looking after residents money. She showed us the system that is used and a quick audit was carried out which showed that the cash held for one of the residents was accurate according to the receipts and records kept. The Manager notifies us of deaths and incidents as required by regulations. She also liases with other professionals as necessary, such as the Environmental Health Officer, Fire Officer, District Nurses and GP. The Manager and staff have recently carried out an annual quality assurance audit. The Manager asked a different member of staff to carry out each audit. These cover a large range of issues relating to the quality of the service provided. The Manager has not yet collated the responses and produced an action plan but this is the next step in the process. The minutes of the resident and relatives meetings show that they are kept informed of issues affecting the running of the Home, such as the recent allegation of theft, and that they are encouraged to raise any issues that they wish to. The Manager said that she regularly receives formal supervision from the area manager. She said that she is currently providing supervision to all of the staff but that this can be difficult to meet the agreed dates and so the deputy manager will be also be carrying out some of these to ensure that staff receive supervision on a regular basis. Staff told us that they do receive supervision and that the Manager and deputy are approachable so they feel confident that they could speak to them at any time. We saw a selection of records relating to the maintenance and servicing of equipment. These show that this takes place on a regular basis and that action is taken to address any problems. Staff receive regular updates with DS0000027467.V364553.R01.S.doc Version 5.2 Page 25 regard to Fire Safety training and we saw the Fire Risk Assessment which has was completed last year and which has recently been reviewed and updated. The Manager had taken appropriate action to try to address the problem with the fire door closures (as previously mentioned in this report) and has now completed risk assessments which indicate the need for the closures on three bedroom doors to be removed temporarily and other systems put into place to provide protection in the event of a fire. DS0000027467.V364553.R01.S.doc Version 5.2 Page 26 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 X 3 DS0000027467.V364553.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 23.2 (n) Requirement Appropriate equipment must be provided to meet the needs of the residents The stained flooring in the shower rooms/bathrooms must be replaced This requirement is repeated as the previous date of 01/07/07 was not met Adequate numbers of staff must be on duty at all times to meet the needs of the residents Timescale for action 01/08/08 2. OP21 23.2 (b) 01/08/08 3. OP27 18.1 (a) 01/07/08 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 3 Refer to Standard OP7 OP7 OP18 Good Practice Recommendations It is recommended that regular audits of the care plans is carried out to ensure that recording is consistent and accurate It is recommended that the social history section of the care plans is further developed It is recommended that the Safeguarding procedure is reviewed to ensure that it is clear and unambiguous DS0000027467.V364553.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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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