Inspection on 17/04/08 for Waynes The

Some improvements to the environment have been made to make it safer for people. Staff now complete an application form before they are interviewed so that the registered person has written information about their previous employment history. This helps her to ask the right questions when staff are interviewed so that for instance any gaps in employment can be discussed and understood. Separate hand washing facilities have been provided in the laundry area. This helps to minimise the risk to people from cross infection.

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

CARE HOMES FOR OLDER PEOPLE Waynes The 7 Marton Road Bridlington East Yorkshire YO16 7AN Lead Inspector Anne Prankitt Key Unannounced Inspection 17th April 2008 09:15 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 Waynes The DS0000019759.V362685.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. Waynes The DS0000019759.V362685.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Waynes The Address 7 Marton Road Bridlington East Yorkshire YO16 7AN 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 672351 Mrs Ann Louise Benson Mrs Ann Louise Benson Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Waynes The DS0000019759.V362685.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd April 2007 Brief Description of the Service: The Waynes is a privately owned care home that provides care and accommodation to a maximum of 30 older people; this includes respite care. The home is a detached property set in large secluded grounds. It is conveniently located for all of the main community facilities including the public transport network. There is ample communal accommodation that includes lounges and dining rooms, plus several smaller areas where people can have private meetings with family and other visitors. Private accommodation is located on the ground and first floors; the first floor is accessible via the use of a passenger lift. The majority of bedrooms are single, and some have en-suite facilities. There is a ramp to the main entrance and level access to the side entrance. Internally the home has been designed to take into account the needs of people with poor mobility. The home has its own mini-bus and the registered person endeavours to provide trips out for people on a daily basis. The registered person confirmed on 17 April 2008 confirmed that the weekly fees range from £300 - £405. Items not covered by the fees include hairdressing, newspapers, chiropody, nail beauty care and optical fees. People are given written information about the home in the service user guide and brochure before they are admitted, and they can ask to see the inspection report if they wish to. Waynes The DS0000019759.V362685.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. Before the site visit, the registered person. Mrs Benson, returned a self assessment called an ‘Annual Quality Assurance Assessment’, which provided information about The Waynes. Surveys were sent out to a selection of people who live at the home (six returned), their families (none returned), and some visiting professionals (one returned). A record has also been kept about what has been happening at the home since the last key inspection took place. All of the information, including that which was gathered at the site visit, was used as part of this key inspection. Four hours preparation took place before the site visit, which lasted for approximately seven hours. The registered person was provided with feedback at the end. The site visit included an inspection of the communal areas, and a sample of private bedrooms. Kitchen and laundry services were also looked at. A selection of documents were looked at, including a sample of care plans, health and safety records, and staff records. The way that the registered person collects information about the quality of the home was also discussed. Some people living at the home, some staff and two relatives were spoken with, and observations of daily life at the home were made discreetly. All of the information was used to get an impression about what it is like to live at The Waynes. What the service does well: People are not admitted to the home until both they and staff at the home agree that their needs can be met successfully. People said ‘I came on short stay – I came for one week and stayed for two’, ‘I came on holiday before I moved in’, ‘We came on holiday to The Waynes’, ‘I’m so lucky to be here – I’m just so fortunate’. People are cared for by staff who respect their right to receive care in a dignified way, and who recognise their individual choices and wishes. People said ‘I am very happy here. I always feel safe knowing there is someone about. I’m happy with everything and everybody’, ‘I am always well looked Waynes The DS0000019759.V362685.R01.S.doc Version 5.2 Page 6 after, and what I want I get’, ‘I am very happy at The Waynes’, ‘On the whole I am very happy, and would not like to be anywhere else’, ‘I consider myself so fortunate to be here’. A visiting professional commented that ‘the standard of care is excellent’. They said that that the home encouraged ‘choice, dignity and wellbeing’. People are offered a range of social activities, including regular trips into the local community, and they can maintain important links with family and friends. A visiting professional commented that ‘the one to one time and outings are commendable’. They can choose what they want to do with their time. They don’t have to mix with others if they do not want to. One person said ‘I can get up when I want, go to bed when I want, watch TV when I want, eat where I want’. People are satisfied that their concerns would be dealt with properly. They think that the registered person and her staff are approachable. Their comments included ‘All staff are willing to help’, ‘There is never a cross word’, and that ‘there is always someone to talk to’, ‘Minor ‘ticks’ are dealt with straight away – no major problems’. Staff know what to do if they are concerned about people’s safety and well being, and who to report to if they think this is not being upheld. This helps to keep people protected from harm. The environment is warm and comfortable, and people can treat it as their home. It is kept maintained. Staff get training so that they know how to give care in a safe way. People are satisfied that there are enough of them to assist when they need support. What has improved since the last inspection? What they could do better: Risk assessments could be looked at more formally each month so that there is a clear record about where and why needs have changed, and what has been done about it. Waynes The DS0000019759.V362685.R01.S.doc Version 5.2 Page 7 Fire doors could be kept closed where hold open devices approved by the fire officer have not been fitted. This will make sure that people have better protection should there be a fire. The registered person could request fresh references from the referees of prospective staff, including one from their current employer where this is applicable. This would make sure that she has up to date information about the applicant, including any reason why they are leaving their current employment, and their suitability to provide care. People’s collective response to surveys could be displayed for everyone to read. This way people would be able to see where the home excels, and the action to be taken by the registered person where people think that improvements could be made. Staff could be given an update about how to use the hoist so that if they need to use it in an emergency, they are able to do so with confidence. 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. Waynes The DS0000019759.V362685.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 Waynes The DS0000019759.V362685.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 and 6 People who use the service experience good outcomes in this area. People are not admitted to the home until both they and staff at the home agree that their needs can be met successfully. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Wherever possible, the registered person makes sure that each person referred to the home is visited before they are admitted so that a check can be made about what their needs are, and whether the home will be able to meet them. And the registered person confirmed that she now lets people know in writing that the home can meet their needs. Information is also gathered from other professionals who have been involved in the person’s care. This helps to give a more detailed picture about what input will be needed to continue meeting the person’s needs once admitted. All of the information is written down, and is discussed with staff, so that they have some idea what people’s needs will be before they arrive. This will help to makes sure that people get the right care straight away. Waynes The DS0000019759.V362685.R01.S.doc Version 5.2 Page 10 People are also invited to look round the home, and many have a trial stay before they have to make a decision as to whether they want to live at the home permanently. They also get a copy of the service users’ guide and brochure about the home. The registered person does not charge people for the first week’s trial so that people ‘can get a feel of the home’. This gives everyone an equal opportunity to make a sound decision about whether the home will be right for them. Where people are unable to visit, their families are welcome to look round on their behalf. All four people who returned their survey said that they were given enough information before they moved in. The registered person explained that often people who are admitted for long term care have often already visited for holidays, and for short stay care, so they and the staff know each other already. Comments included: ‘I came on short stay – I came for one week and stayed for two’, ‘I came on holiday before I moved in’, ‘We came on holiday to The Waynes’, ‘I’m so lucky to be here – I’m just so fortunate’. The home provides a number of respite places, but does not provide intermediate care. Therefore standard six does not apply. Waynes The DS0000019759.V362685.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 outcomes in this area. More formal update of people’s risk assessments would help staff to check that any risk to people has been fully addressed and minimised. But people have their needs met in a kind and dignified way by caring staff. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The staff are in the process of completing new care plans for people. They are much more person centred than those previously completed. They identify people’s strengths as well as those areas where they need help with their care, and cover their physical, social and emotional needs. Each care plan is reviewed with the person each month to check that the care described still meets their needs. A more formal review takes place six monthly when family may also be present. Where people have a care manager, they also review the care plan, to check that it looks at the person’s identified needs. One such review congratulated the home on the care that staff had provided for the person concerned. Waynes The DS0000019759.V362685.R01.S.doc Version 5.2 Page 12 Risk assessments are completed when the care plans are first written up, and scores given, so that staff can assess what level of risk people are at. These scores are not recalculated each month unless staff have identified that the risk to the person may have increased. It would be good practice to do this. Instead they are looked at generally as part of the monthly review. There was no information to help staff understand what the scoring meant, and at what point they should ask for further help and advice from the doctor or district nurse. The registered manager has agreed to ask the district nurses for further advice about how this could be improved upon. This will help to minimise the risk of misinterpretation. Despite this, the care plans showed that people have regular access to the community services to which they are entitled, and that help and equipment is asked for and provided when risk to them has been identified. People admitted for respite care had a care plan in place. One plan seen had been updated since the previous admission, but there were no risk assessments completed. The registered person agreed that it is important that these are completed for everyone, and has agreed to update the plans to include these. This will help to make sure that any risks to the person’s health whilst they are staying at the home can be recognised and minimised throughout their stay. People on the day spoke positively about their care. And everyone who returned their surveys thought that they get the care and support that they need, that staff listen and act on what they say, and that they get the medical support that they require. Their comments included ‘I am very happy here. I always feel safe knowing there is someone about. I’m happy with everything and everybody’, ‘I am always well looked after, and what I want I get’, ‘I am very happy at the Waynes’, ‘On the whole I am very happy, and would not like to be anywhere else’, ‘I consider myself so fortunate to be here’. A visiting professional commented that ‘the standard of care is excellent’. They said that that the home had worked with the person they support, and their family, ‘to encourage choice, dignity and wellbeing’. Staff spoke to people with respect, and demonstrated that they knew what people’s needs were. People knew staff and the registered person well, and appreciated the care that they got. One person commented ‘There is never a cross word here’. These are very positive comments, which demonstrate people’s satisfaction with the service that they get at their home. Appropriately trained staff look after people’s medication. The records that staff keep showed that staff make sure that people get the right dose at the right time. The staff member responsible for the management of the medication checks that the systems are running smoothly, and said she would speak informally to staff if she identified any shortfalls in practice. However, the registered person has introduced additional recording checks to make sure that the risk from error is kept to a minimum. Waynes The DS0000019759.V362685.R01.S.doc Version 5.2 Page 13 People can look after their own medication if they would like to after staff have completed a risk assessment to check that it is safe for them to do this. As with other risk assessments, this assessment needs to be reviewed with the person monthly, to check that they are still happy and able to carry on with this. This was not the case in the care plan seen, although assurance was given that the person concerned is very able to manage. There was no up to date record of medication in the records of one person who chooses to self medicate. This information should be available so staff can see in an emergency what the person is prescribed. The staff member spoken with said that this was an oversight, and pointed out that other people who look after their own medication had such records for staff to refer to. She agreed to make sure that this information was made available for the person concerned. Waynes The DS0000019759.V362685.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 excellent outcomes in this area. The strong focus on preserving individual’s lifestyles means that people can continue to enjoy choice, flexibility and independence. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: There is a regular selection of activities which the registered person reviews, taking into account the views of the people living at the home. Trips out in the home’s minibus are organised six days each week. Many people living at the home look forward to these. They include trips down to the seaside, and to the local supermarket, where they have the opportunity to shop for themselves. The registered person is currently looking at the activities provided in house, and has provided more of these to meet with people’s requests. For instance, she has introduced an ‘afternoon club’, where people can join in craft activities. The mobile library visits regularly, and talking books are delivered to assist people who have poor sight. A visiting professional commented that ‘the one to one time and outings are commendable’. People knew that they need not join in the activities if they do not wish to, and some chose to remain in their room to watch television or to read. People’s interests were recorded in their plans of care, and weekly records showed that their key workers had spent one to one time with them. People get lots of Waynes The DS0000019759.V362685.R01.S.doc Version 5.2 Page 15 choice in their daily lives. One person said ‘I’m not a great mixer – I don’t have to join in – I like my room. I can get up and go to bed when I want – I’m very happy’. Another concluded ‘I can get up when I want, go to bed when I want, watch TV when I want, eat where I want’. Through no fault of the home they are without the regular services of the local Church of England priest. The registered person is keen to arrange for these to be resumed as soon as possible. However, the Roman Catholic priest and Methodist representative visits regularly, and people are assisted to go to church in the community if they wish to attend. This helps to make sure that their spiritual needs are met. People can have visitors whenever they wish. One person was very pleased that their relative, who travels a long distance to visit, can stay with them at the home. The registered person also told us that they will take people to visit their relatives if this is possible. This helps people to keep meaningful contact with family and friends outside the home who are an important part of their lives. Everyone said that they always liked the meals at the home. One person said ‘We couldn’t wish for better’. On the day, a choice of menu was seen. The cook knew people’s likes and dislikes, and they were provided with information about people’s special dietary requirements. They said that the registered person likes people to have a choice of fresh produce, and therefore deliveries of fresh meat, vegetables and fruit are made to the home daily. The cook explained that only care staff who have completed training in the safe handling of food are allowed to prepare the tea time meal. She and the registered person confirmed that a recent visit from the Environmental Health Officer had commended them, and that no requirements or recommendations had been made following the visit. Waynes The DS0000019759.V362685.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 outcomes in this area. People can complain, and are protected by staff who will report any concerns which affect their welfare. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: People get a copy of the complaints procedure in their service user’s guide. As part of the ongoing plan for improvements at the home, it is the registered person’s intention to review the procedure with people by including it on their meetings agenda. There have been no complaints made to the home, nor to the Commission for Social Care Inspection, since the key inspection last year. Everyone who returned their surveys said that they knew how to complain, and that they all know who to speak to if they are not happy. Comments were made that ‘All staff are willing to help’, ‘There is never a cross word’, and that ‘there is always someone to talk to’, ‘Minor ‘ticks’ are dealt with straight away – no major problems’. Staff knew what they must do if they ever suspected that someone living at the home had not been treated properly. They knew that, to protect everyone in the home, they could not keep secret any allegations made to them. The registered person knew about the role of the local authority in investigating such allegations, and who to report to if she was given information which suggested that a person was being abused. She also knew what immediate Waynes The DS0000019759.V362685.R01.S.doc Version 5.2 Page 17 action she would need to take at the home to keep people safe from further risk. All staff are currently being given training in safeguarding, in line with these procedures, and have been given a telephone number in case they are not able, or do not wish, to report an allegation to the registered person. These systems help to keep people safe from unnecessary risk to their health and well being. Waynes The DS0000019759.V362685.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 adequate outcomes in this area. People live in a warm and comfortable environment which is kept maintained. Fire safety management needs closer monitoring to make sure people are not put at risk. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The environment is very homely and comfortable. The premises are set on two floors. There are a selection of communal areas. Some of these are quiet areas. There is a lift to the first floor of the home for easy access. People’s bedrooms are located on both floors. Ramps are provided to make is easier for people who use wheelchairs to get in and out of the home. There is a pleasant garden area for people to enjoy. There are a number of assisted bathing facilities from which people may choose. The building is kept maintained, and outside contractors are used so that equipment is serviced regularly to keep it fit for use. Matters raised at the last inspection have been addressed. For instance, the carpet to a ramp has been Waynes The DS0000019759.V362685.R01.S.doc Version 5.2 Page 19 replaced, and the vinyl in the toilets has been replaced with carpet tiles. There were no unpleasant smells, and everyone agreed that the home was always or usually fresh and clean. People said that they liked their bedrooms. They contained their personal belongings. People can lock their rooms to keep them private. A staff member explained that they have a key for each room in case they need to get in quickly in an emergency. One person said ‘I like to do my own dusting’. This helps them to remain independent. The fire door to one bedroom was held open with a wedge, and another with a piece of furniture. This means that they would not close automatically if fire broke out. The fire officer has just visited, and although he did not give written permission, the registered person said that he permitted this practice during the day time. But this practice had not been considered in the fire safety risk assessment, and the registered person accepted that it increases the risk to people from the spread of fire. She made a decision to fit a hold open device to one door on the day of the site visit. She explained subsequently that the second door had been opened by a visiting relative, but that this was normally kept shut. People need to be reminded that doors should not be held open in this way, because of the extra risks to people that this poses. The fire officer made three recommendations, two of which have already been addressed. He has set timescales for the third recommendation to be met, and the registered person is confident that this work will be completed in line with their instruction. This will help to keep people safe from the risk of fire. People’s clothing looked well cared for. The laundry is situated away from the kitchen preparation area. There was equipment available to reduce the risk from cross infection, such as gloves and aprons, and special bags to hold soiled linen. There have been no outbreaks reported since the last inspection, which could be attributed to poor infection control. All staff are in the process of receiving updates in training. This will help keep unnecessary risk to people from poor infection control to a minimum. Waynes The DS0000019759.V362685.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 adequate outcomes in this area. Effort is made to make sure that people are cared or by staff who are properly trained. Recruitment processes could be improved upon to minimise the risk from unsuitable staff being employed. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The registered person explained that she has listened to people’s views, and has looked at how staff are allocated, to free up some extra time for social activities, which are a big focus at the home. People who returned their surveys said that they always get the care and support that they need, and that staff are always available when they are needed. One person spoken with said that they sometimes have to wait when they press their bell for assistance. But they said that at this point it was not causing them a problem. However, another said ‘Staff are good – I just ring the bell – it’s OK’. The registered person has recruited an outside agency to keep staff mandatory training and induction up to date. This training is currently in progress. Staff were aware that where training was needed, it was planned. Although there were no inductions to see, the registered person confirmed that they meet current standards. Waynes The DS0000019759.V362685.R01.S.doc Version 5.2 Page 21 Staff files showed that they receive additional training to help them in their work, such as palliative care and continence management. And they receive ongoing supervision and appraisal. The registered person has had difficulty in finding an organisation to provide National Vocational Qualification training in care. However, she has recently recruited the services of a new company, which will help to maintain the current high percentage of care staff with a National Vocational Qualification. This collective training and support for staff will help to promote continued good care practice. Delays in the awaited return of Criminal Record Bureau (CRB) checks for newly recruited staff members have meant that they have been allowed to start work after their POVAFirst has been returned, but before the full CRB check has been received. The registered person understands that this should only be the case in extreme circumstances, and that all other checks need to be in place to satisfy her that the new staff member is suitable to work at the home. However, the staff recruitment files contained some references which had not been requested by the registered person, but which had been brought to the interview by the applicant. These were addressed ‘To Whom it May Concern’, and were not always from the previous employer. One was five months old at the point that it was accepted. This practice, also noted at the last key inspection, does not provide sufficient assurance as to the fitness of the applicant, nor of the reasons as to why they have left their most recent employment. There is also a risk that the person who has written the reference will not know the type of work for which the applicant is applying, and for what purpose their reference is being used. This practice needs to be improved, to make sure that every effort has been made to protect people from unsuitable workers. Waynes The DS0000019759.V362685.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 outcomes in this area. The home is run by a registered person who cares about the views of the people who live there. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The registered person has many years experience in the care of older people. She has underpinned this experience by achieving formal qualifications in management. Staff and people living at the home value her contribution, and the ‘open door’ policy that she operates. One person said ‘Ann (the registered person) is good’. Another person, who had lived at the home for some time, commented that The Waynes is ‘very homely’ and that the registered person has ‘managed to retain this over the years’. Others said ‘You should get your name down!’, and ‘There’s communication all over the place between staff.’ Waynes The DS0000019759.V362685.R01.S.doc Version 5.2 Page 23 The registered person listens to people’s views, and aims to run the service in their best interests. In support of this, the home has achieved part 1 of the quality award which is awarded by the local authority. A relative said ‘I’ve seen a lot of homes and this home is good. My relative is well looked after’. Another said ‘We can’t fault the place – Ann (the registered person) keeps us informed about everything – the staff are marvellous – what you see is what you get’. Staff commented that ‘Ann (the registered person) is one of the best bosses you could ever have’, and that ‘The management deals with problems’. One said that the home was ‘family run’, that it was ‘flexible’, and that people’s needs and wishes were ‘anticipated’ and ‘understood’. People’s files contained a copy of the annual quality assurance survey most recently completed by them. The majority of those seen were entirely positive, and confirmed that people were happy with the service that they get at the home. The registered person explained that results are not published, as relatives visit regularly and feedback is given to them. It would be good practice to collate and publish the collective results, as this would give an overall perspective of people’s views of the home, identify agreed areas of excellence, and what is happening where improvements could be made. This would give additional reassurance that the home continues to be run taking into account people’s views. Visiting professionals tend not to respond to their surveys, because they visit the home on a regular basis. However, it was agreed that by continuing to send them out, the registered person can show that she is giving everyone with an interest in the home the opportunity to comment about it. The home does not deal with any monies belonging to people. However, they have somewhere in their room to lock away their personal valuables. The information provided by the registered person showed that the home is kept maintained. Shortfalls identified at the last inspection had been addressed. Staff confirmed that nobody at the home currently needs the use of the hoist. They said that it was some time since the equipment has been needed, and staff were not clear about how it could help someone who had perhaps fallen to the floor and couldn’t get up. The registered provider has agreed to give staff a training update on how the hoist works, and what assistance it is capable of providing, as she was quite clear that it does indeed help people from the floor. Waynes The DS0000019759.V362685.R01.S.doc Version 5.2 Page 24 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X N/A X X 2 Waynes The DS0000019759.V362685.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 OP9 Regulation 13 Requirement In order to keep risks associated with people’s health and welfare to a minimum, risk assessments must be completed for everyone living at the home, including those admitted for short term care. To protect people from the spread of fire, fire doors must remain shut unless fitted with hold open devices approved by the fire authority, which will shut automatically should fire break out. There must be two written references that have been requested by the registered person in place prior to staff commencing work at the home. Timescale of 03/04/07 not met Timescale for action 17/04/08 2 OP19 23 17/04/08 3 OP29 19 17/04/08 Waynes The DS0000019759.V362685.R01.S.doc Version 5.2 Page 26 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 OP7 Good Practice Recommendations Risk should be formally reviewed on a monthly basis, using a tool which tells staff the severity of the risk, and what action needs to be taken, based on the results of the assessment. This will help to identify any changes needed to their care at the earliest point. To keep people fully informed, consideration should be given to the collation and publication of the results of the annual quality assurance surveys, so that people can see where the home excels, and what action is going to be taken where areas for possible improvement have been identified. So that the hoist is used correctly, and to minimise the risk from unsafe manual handling, applicable staff should be given a refresher course about how and when to use the hoist. 2 OP33 3 OP38 Waynes The DS0000019759.V362685.R01.S.doc Version 5.2 Page 27 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 Waynes The DS0000019759.V362685.R01.S.doc Version 5.2 Page 28 - 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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