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Inspection on 10/04/08 for Tithe Farm Nursing Home

Also see our care home review for Tithe Farm Nursing Home for more information

This is the latest available inspection report for this service, carried out on 10th April 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.

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

There is information available to potential residents and their diverse social and care needs are identified with them, prior to their move to the home, to ensure that they can be met. The home has an up to date statement of purpose and resident`s guide, which is on display. Residents have contracts or statements of their terms and conditions, irrespective of their funding source. Residents and their families said that their needs had been assessed before they moved to the home. Resident`s personal, healthcare and medication needs are met, promoting their dignity and wellbeing. Each resident has a personalised care plan, which has been agreed with him or her or with a family member. Residents are complementary about the care they receive saying `staff are very approachable and know their residents and families`. The home offers flexible care, in line with resident`s abilities and supports their autonomy. There is an activities coordinator who plans a range of daily and weekly activities. The meals are of a high standard and meet resident`s nutritional needs. Residents said that the food is good and that they enjoyed it, commenting `the meals are well chosen and served properly` and `the food is good`. The chef takes a personal interest in individual resident`s likes anddislikes and can provide menus to meet resident`s specialist healthcare or cultural needs. The complaints and protection policies and procedures work well, giving residents, and their families, confidence that their concerns will be addressed and any safeguarding issues will be addressed, in conjunction with the local authority. The Commission for Social Care Inspection has received one concern since the last inspection. This was from a care manager and related to staffing levels. The staffing levels have been reviewed since then. The Commission for Social Care Inspection has not been notified of any safeguarding allegations made to the local authority, which is the lead agency in these matters. The home is an older building, which is clean and well maintained, providing an attractive and safe home for residents. Most rooms are single and some have ensuite facilities. The gardens are attractive and new pathways have been laid this year to improve access for residents with disabilities. One family member commented that `the home is always homely, warm and never has any unpleasant odours`. Residents and families said that carers were caring and understood them well. One said that `the atmosphere is one of a caring team doing their best for residents`. There is an experienced interim manager running the home at the time of the inspection and she was supported by staff. Families said that they found her approachable. There are quality assurance and monitoring systems in place, which include seeking the views of residents and their families.

What has improved since the last inspection?

Care planning and medication management has improved. There have been ongoing improvements to the environment and to the gardens.

CARE HOMES FOR OLDER PEOPLE Tithe Farm Rest Home Park Road Stoke Poges Bucks SL2 4PJ Lead Inspector Chris Sidwell Unannounced Inspection 10th April 2008 11:30 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 Tithe Farm Rest Home DS0000023030.V361092.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. Tithe Farm Rest Home DS0000023030.V361092.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tithe Farm Rest Home Address Park Road Stoke Poges Bucks SL2 4PJ 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) 01753 643106 01753 642141 matron@tithefarm-home.co.uk Pressbeau Ltd Mrs Pushpalata Saraogi Mrs Alexandra Radford Care Home 35 Category(ies) of Dementia (6), Old age, not falling within any registration, with number other category (35) of places Tithe Farm Rest Home DS0000023030.V361092.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 2006 Brief Description of the Service: Tithe farm is a home for older people with nursing needs. It is registered to provide care for up to thirty-five service users. It is owned by Pressbeau Ltd which has a number of homes in the south of the country. It is situated in large grounds next to the golf course in Stoke Poges. Access to the home is via a long drive leading up to the front of the home into a small car parking area. Pressbeau Limited also has their main offices in the grounds, close to the main house. There is limited public transport with an infrequent bus service to the vicinity of the home. Fees are £520 to £890.00 per week. Additional charges are made for hairdressing, chiropody, newspapers and toiletries. Tithe Farm Rest Home DS0000023030.V361092.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 stars. This means the people who use this service experience good quality outcomes. The inspection was conducted over the course of five days and included a one day unannounced visit to the home. The key standards for older people’s services were covered. Information received about the home since the last inspection was taken into account in the planning of the visit. Prior to the visit, the manager completed an annual quality assurance self-assessment and surveys were distributed to service users, relatives, visiting health and social care professionals and staff. Eight residents or their families, one healthcare professional and four staff members returned the questionnaires. Residents and families were also spoken to on the days of the unannounced visit. Discussions took place with the manager, nursing, care and ancillary staff. Care practice was observed. A tour of the premises and examination of some of the required records was also undertaken. The homes approach to equality and diversity was considered throughout. What the service does well: There is information available to potential residents and their diverse social and care needs are identified with them, prior to their move to the home, to ensure that they can be met. The home has an up to date statement of purpose and resident’s guide, which is on display. Residents have contracts or statements of their terms and conditions, irrespective of their funding source. Residents and their families said that their needs had been assessed before they moved to the home. Resident’s personal, healthcare and medication needs are met, promoting their dignity and wellbeing. Each resident has a personalised care plan, which has been agreed with him or her or with a family member. Residents are complementary about the care they receive saying ‘staff are very approachable and know their residents and families’. The home offers flexible care, in line with resident’s abilities and supports their autonomy. There is an activities coordinator who plans a range of daily and weekly activities. The meals are of a high standard and meet resident’s nutritional needs. Residents said that the food is good and that they enjoyed it, commenting ‘the meals are well chosen and served properly’ and ‘the food is good’. The chef takes a personal interest in individual resident’s likes and Tithe Farm Rest Home DS0000023030.V361092.R01.S.doc Version 5.2 Page 6 dislikes and can provide menus to meet resident’s specialist healthcare or cultural needs. The complaints and protection policies and procedures work well, giving residents, and their families, confidence that their concerns will be addressed and any safeguarding issues will be addressed, in conjunction with the local authority. The Commission for Social Care Inspection has received one concern since the last inspection. This was from a care manager and related to staffing levels. The staffing levels have been reviewed since then. The Commission for Social Care Inspection has not been notified of any safeguarding allegations made to the local authority, which is the lead agency in these matters. The home is an older building, which is clean and well maintained, providing an attractive and safe home for residents. Most rooms are single and some have ensuite facilities. The gardens are attractive and new pathways have been laid this year to improve access for residents with disabilities. One family member commented that ‘the home is always homely, warm and never has any unpleasant odours’. Residents and families said that carers were caring and understood them well. One said that ‘the atmosphere is one of a caring team doing their best for residents’. There is an experienced interim manager running the home at the time of the inspection and she was supported by staff. Families said that they found her approachable. There are quality assurance and monitoring systems in place, which include seeking the views of residents and their families. What has improved since the last inspection? What they could do better: The infection control practices should be reviewed and the action plan following a recent audit fully implemented. Residents should not share hoist sling or sliding sheets. Staffing levels should be monitored carefully to ensure that they meet resident’s needs in a timely way. The training programme should be developed to ensure that staff have the specialist knowledge and skills to meet the needs of people with disabilities or illness. The standard of record keeping of the recruitment files should be improved to ensure that it is possible to verify that Tithe Farm Rest Home DS0000023030.V361092.R01.S.doc Version 5.2 Page 7 all staff have had the required checks before they start work and to protect residents from unsuitable carers. A permanent manager who registers with the Commission for Social Care inspection should be appointed. The health and safety procedures should be reviewed to ensure that they meet the guidance described by the Health and Safety Executive in their guidance entitled ‘Health and Safety in Care Homes’ and available on their website www.hse.gov.uk. 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. Tithe Farm Rest Home DS0000023030.V361092.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 Tithe Farm Rest Home DS0000023030.V361092.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, 2, 3 and 6 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. There is information available to potential residents and their diverse social and care needs are identified with them, prior to their move to the home, to ensure that they can be met. EVIDENCE: The home has an up to date statement of purpose and service users’ guide. All of the residents, or families, who returned the questionnaire, said that they had received information about the home and the families spoken to said that they had been made welcome at the home and invited to look around before their family member moved to the home. All residents who fund their own care have a contract and these were seen in their files. Those residents who are supported by the local authority or health services also have statements of their terms and conditions. Families confirmed that someone had visited their relative to assess their needs before they moved to the home and copies of the assessment were seen in the files. Residents’ social, cultural and religious needs had been had been identified at the initial assessment for all residents. Tithe Farm Rest Home DS0000023030.V361092.R01.S.doc Version 5.2 Page 10 Resident’s gender specific needs had also been identified and they were asked whether they wished to be cared for by a staff member of the same sex. The home does not offer intermediate care. Tithe Farm Rest Home DS0000023030.V361092.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. Resident’s personal, healthcare and medication needs are met, promoting their dignity and wellbeing. EVIDENCE: The care of five residents was followed through. Their files contained comprehensive care plans and there was evidence in some files that both residents and families are involved in planning their care. The staff spoken to were knowledgeable about residents’ care wishes. The care plans had been reviewed regularly and updated when appropriate. The residents and family members who returned the questionnaires and those spoken to on the day of the unannounced visit said that they were involved in planning their care and that the staff were responsive to their wishes. Those who returned the questionnaires were complementary about the standard of care offered. Comments included ‘The atmosphere is one of a caring team, doing their best for residents’ and ‘residents are treated with great care and attention’. Tithe Farm Rest Home DS0000023030.V361092.R01.S.doc Version 5.2 Page 12 The care plans had a section entitled ‘social wellbeing’. This was used to identify resident’s social needs and to identify whether they were at risk of isolation or loneliness and the steps that should be taken to try to reduce this. This is good practice. Residents had had assistance with their personal hygiene. All had had their hair dressed recently and gentlemen were shaved. Resident’s risk of acquiring pressure damage due to immobility had been assessed and appropriate equipment was available. One resident had pressure damage on the day of the unannounced visit to the home. The care plan showed that this was improving. The advice of the tissue viability nurse had been sought and the resident had the appropriate pressure-relieving mattress. Nutritional risk assessments had been undertaken. The staff and cook were aware of residents’ dietary needs and could provide special diets to meet residents’ health and cultural needs if necessary. Four of the five residents whose care was followed through had maintained their weight on moving to the home. One had however lost weight although the weight loss had now stabilised. The records showed that the practice of weighing residents regularly had been allowed to slip, although this had been recognised by the new manager and is now reinstated. Residents register with a local general practice and a general practitioner visits the home regularly. There are medication management policies and procedures in place and the staff spoken to were aware of these. Storage facilities are satisfactory. Records are kept of medication entering and leaving the home. The medication administration records were accurately completed. Controlled drugs were stored satisfactorily and all entries to the controlled drug register were signed. A contract is held for the disposal of unused medication. The registered nurses spoken to said that medication was not administered covertly. If a resident refused medication this would be recorded. If the medication was essential and the resident lacked the capacity to make the decision, the doctor and family would be informed and a way forward agreed. The staff were observed to be respectful towards residents and to protect their dignity. All care is given in residents’ rooms. Residents and relatives who returned the questionnaires and those spoken to on the day said that staff were kind and caring and always asked residents what they would like to do and gave them a choice. Tithe Farm Rest Home DS0000023030.V361092.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 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. The home offers flexible care, in line with resident’s abilities and supports their autonomy. The meals are of a high standard and meet resident’s nutritional needs. EVIDENCE: There is a newly appointed activities’ coordinator. She has enrolled with a national organisation which promotes and trains staff to provide activities for older people, to improve her knowledge. She is in the process of developing comprehensive life stories for each resident. She organises a weekly activities plan with daily activities to bring interest and diversion to the day. Speaking books have been ordered for one resident who is partially sighted. Visitors are welcome at any time and those who returned the comment cards said that they were made to feel welcome. Residents have a choice as to when they go to bed although some residents and their families said that this was sometimes compromised by staffing levels. The food is of a high standard. Menus are changed regularly. There was evidence that fresh fruit and vegetables are available daily. A cooked breakfast is available if residents wish. There is a choice of main meal at Tithe Farm Rest Home DS0000023030.V361092.R01.S.doc Version 5.2 Page 14 lunchtime and a light cooked supper or soup and sandwiches. The chef supervises the serving of meals and visits each resident individually to establish their likes and dislikes and to ensure that the menus offered reflect these and if they do not, to prepare an individual meal. One resident who had moved to the home recently needed a special diet for medical reasons and this was provided promptly. The staff were observed to be helping those who could not eat unaided discretely. Residents and families all said that the food was good and that they enjoyed it, commenting ‘the meals are well chosen and served properly’ and ‘the food is good, plenty of variety’. Tithe Farm Rest Home DS0000023030.V361092.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 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. The complaints and protection policies and procedures work well, giving residents, and their families, confidence that their concerns will be addressed and any safeguarding issues will be addressed, in conjunction with the local authority. EVIDENCE: There are complaints policies and procedures in place. The manager said that she would record both verbal and written complaints. All the families and residents who returned the questionnaires said that they knew who to speak to if they were unhappy. One family member commented that she had raised a concern, which was dealt with immediately. The home has an up to date copy of the local multi agency strategy for safeguarding vulnerable adults. Most staff have had safeguarding training and those spoken to said that they would have no hesitation in reporting any concerns about resident’s welfare. There are whistle blowing policies and procedures in place. The home is secure and the manager said that restraint was not used. None was observed. The Commission for Social Care Inspection has received one concern since the last inspection. This was from a care manager and related to staffing levels. The staffing levels have been reviewed since then. The Commission for Social Care Inspection has not been notified of any safeguarding allegations made to the local authority, which is the lead agency in these matters. Tithe Farm Rest Home DS0000023030.V361092.R01.S.doc Version 5.2 Page 16 Tithe Farm Rest Home DS0000023030.V361092.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 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 an older building, which is clean and well maintained, providing an attractive and safe home for residents. EVIDENCE: The home is a listed building set in attractive gardens. Most rooms are single and those that are double have curtain screening to provide privacy for individuals. Some rooms have ensuite facilities. Residents are encouraged to personalise their rooms and some had chosen to do so. Some of the furniture in resident’s rooms was in need of replacement or repair. The manager said that she was addressing the issues in the annual development plans. All residents had height adjustable beds and the manager said that she was gradually upgrading the beds to provide profiling beds. New pathways have been laid in the gardens, to improve access for residents with disabilities, and an attractive sheltered pergola has been built. One Tithe Farm Rest Home DS0000023030.V361092.R01.S.doc Version 5.2 Page 18 resident who had recently moved to the home and who was a keen gardener had been helped to walk around the garden, which he clearly enjoyed. The Fire and Rescue authority last visited the home in May 2007 when all fire safety matters were satisfactory. The Environmental Health Officer also visited the home in May 2007 and the manager said that the recommendations following that visit have been implemented. There are infection control policies and procedures in place, which have been updated in line with the Department of Health’s guidance issued in June 2006. The home has participated in an infection control audit undertaken by the local Primary Care Trust (PCT). Some shortfalls have been identified and an action plan is being developed to address them. Staff were observed to be wearing protective clothing and were observed to wash their hands and some had had training in infection control. Alcohol hand rub was not yet available but had been ordered to help prevent cross infection. The manager said that residents had their own sliding sheets where they needed them and that they would have their own hoist sling if they had an infection. She said that hoist slings are washed regularly. She said that they were working towards all residents having their own sliding sheet and hoist sling. The latest Department of Health guidance is that residents should not share slings. This should be implemented in the home. The laundry is well managed and the home was clean and tidy on the day of the unannounced visit. There were no offensive odours. Tithe Farm Rest Home DS0000023030.V361092.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 and 30 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. Staffing levels are sufficient to meet resident’s care needs although they should be monitored carefully to ensure that needs are met in a timely way. There is a training programme in place, which is being updated to ensure that staff have the necessary knowledge and skills to care for frail elderly people. The recruitment procedures meet statutory requirements although record keeping could be improved, to ensure that residents are protected from unsuitable carers. EVIDENCE: The home has experienced a shortfall in staffing levels during the last year. An experienced operational manager has been appointed as interim manager to the home and she has addressed this. The staffing levels have been reviewed and the way in which staff are allocated in the mornings has been revised. She is monitoring this to evaluate whether this results in residents needs being met in a more timely way. The resident and family questionnaires were completed at the time the staffing levels were lower and reflected this. Residents said that the staff were caring but ‘very rushed in the mornings’. Families when asked what the home could do to improve said ‘employ more carers’. One resident spoken to on the day said that the situation had improved but that she sometimes had to wait for what appeared to be an ‘age’ before anyone came. The staffing levels should be monitored carefully to ensure that resident’s needs are met in a timely way. Tithe Farm Rest Home DS0000023030.V361092.R01.S.doc Version 5.2 Page 20 The interim manager has also begun to update the training programme in the home. Seven of the seventeen carers hold the National Vocational Qualifications in Care at level 2 or above and a further five are undertaking this qualification. Three of those who hold Level 2 are undertaking Level 3. The manager said that a further five carers would be starting the course soon and that she would be implementing the Skills for Care Induction programme for new staff who did not hold National Vocational Qualifications in Care. Whilst the home does not yet meet the standard that fifty percent of carers hold National Vocational Qualifications in Care at level 2, there is a plan for the home to achieve this. The interim manager has updated the training matrix, which shows the level of training undertaken by each member of staff and has a plan to address the shortfalls. In addition to the mandatory training in safe working practices, some specialist training is available. Some staff have had training in caring for people with dementia. Training in the home could be improved by including more training in specialist topics, which give carers greater insight into how to meet the needs of people with disabilities or illness. The recruitment files of three recently recruited members of staff were reviewed. All had the required documentation to show that checks as to the potential staff member’s identity and suitability to work with vulnerable people had been undertaken. All had submitted an application from, which showed their work history. Interview records had been kept. One had gaps in her work history, which had not been explored at interview. Two references had been sought and Criminal Records Bureau checks had been undertaken before the staff member commenced work. Although the required documentation was in the files, they were loose leaf and untidy and it was difficult to establish whether the correct recruitment procedures had been followed. This should be addressed and all files audited to ensure that the required checks have been undertaken for all staff. Tithe Farm Rest Home DS0000023030.V361092.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 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 by an experienced interim manager, who values the views of residents, their families and staff. There are quality assurance systems in place to ensure that residents receive a good standard of care and that their views are taken into account in the running of the home. EVIDENCE: The previous manager left in February 2008 and the organisation has appointed an experienced operational manager to act as interim manager, whilst a new manager is recruited. She is a qualified nurse and holds the National Vocational Qualifications in Management at level 4. The lines of accountability within the home are clear. The staff spoken to were complementary about the manager and said that she was approachable and had made positive changes to the home. There is an experienced deputy manager who has provided continuity during the managerial changes. Tithe Farm Rest Home DS0000023030.V361092.R01.S.doc Version 5.2 Page 22 The manager was developing the annual development plan at the time of the inspection. There are quality assurance and monitoring systems in the home. The organisation employs an independent consultant to visit the home on a regular basis to monitor the quality of care offered. He speaks with residents and their families. Records of his visits are kept. Regular staff and resident/ family meetings are held and minutes are displayed for those who cannot attend. The manager has an evening ‘open surgery’ weekly for relatives who may not be able to visit during the day. A residents and family satisfaction survey was undertaken in December 2007 and the results are currently being collated. The home does not manage any resident finances. The administrator has recently taken over the safekeeping of resident’s personal allowance, which they may wish to keep on the premises. She is setting up a dedicated bank account and keeps records of all monies left with the home for safekeeping and of all expenditure. Receipts are kept. These records are available to residents and their families. There are health and safety policies and procedures in place. The manager said that regular health and safety meetings would be established which involved staff to ensure that safe practices were implemented. The health and safety procedures should be reviewed to ensure that they meet the guidance described by the Health and Safety Executive in their guidance entitled ‘Health and Safety in Care Homes’ and available on their website www.hse.gov.uk. The training matrix showed that most staff had had mandatory training in safe working practices, with updates where necessary. A plan was in place to continue with this training. The Annual Quality Assurance self-assessment (AQAA) sent by the organisation showed that maintenance of essential services and equipment was undertaken on an annual basis. Dangerous substances were seen to be stored in a locked cupboard. Tithe Farm Rest Home DS0000023030.V361092.R01.S.doc Version 5.2 Page 23 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 3 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 2 X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Tithe Farm Rest Home DS0000023030.V361092.R01.S.doc Version 5.2 Page 24 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 2 3 4 5 Refer to Standard OP26 OP27 OP30 OP31 OP38 Good Practice Recommendations The infection control practices should be reviewed and the action plan following a recent audit fully implemented. Residents should not share hoist sling or sliding sheets. Staffing levels should be monitored carefully to ensure that they meet resident’s needs in a timely way. The training programme should be developed to ensure that staff have the specialist knowledge and skills to meet the needs of people with disabilities or illness. A permanent manager who registers with the Commission for Social Care inspection should be appointed. The health and safety procedures should be reviewed to ensure that they meet the guidance described by the Health and Safety Executive in their guidance entitled ‘Health and Safety in Care Homes’ and available on their website www.hse.gov.uk. Tithe Farm Rest Home DS0000023030.V361092.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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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