Inspection on 04/07/06 for 39 Harvard Road

This inspection was carried out on 4th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

39 Harvard Road 12/12/05

39 Harvard Road 28/07/05

39 Harvard Road 11/01/05

39 Harvard Road 13/09/04

Similar services:

Ridgemount

Wingham Court

Old Hastings House

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE 39 Harvard Road Ringmer Nr Lewes East Sussex BN8 5HH Lead Inspector Judy Gossedge Key Unannounced Inspection 4th July 2006 12:15 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 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 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. 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 39 Harvard Road Address Ringmer Nr Lewes East Sussex BN8 5HH 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) 01273 812125 01273 814468 www.eastsussex.gov.uk/socialcare East Sussex County Council Mrs Heather Pauline Wilson Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The maximum number of service users to be accommodated is thirtyseven (37). One (1) service user to be accommodated in the self-contained flat in the home. Service users must be older people aged sixty-five (65) years or over on admission. Four places are available for service users between the age of fifty-five (55) and sixty-four (64). Three places are available on the Hampton Unit providing rehabilitation and the one place in the self contained flat can accommodate service users between the age of fifty (50) and fifty-four (54). 12th December 2005 Date of last inspection Brief Description of the Service: 39 Harvard Road is run by East Sussex County Council (ESCC) and is a purpose built property on two floors, set in its own grounds in Ringmer, with the village centre nearby. Service user accommodation comprises of thirty-six single bedrooms, one of which can be used as a double bedroom where service users have chosen to share and there is a self contained flat. Divided in to three units within the home each with dining and lounge facilities, situated on both floors with level access facilitated in the home with the provision of a passenger lift. Two units are for service users receiving respite care or short term care for periods of up to six months. One unit is for service users on the Living at Home Programme, a rehabilitation scheme run by ESCC to work with service users to return home within an agreed timescale of up to six weeks. There is a conservatory and garden for service users to access. Fees charged are in accordance with ESCC policy and procedures and at the time of the inspection the charges are £94.45-£501.06. The level of fees charged will depend on the outcome of a financial assessment. Where intermediate care is provided the service is free for up to six weeks. Additional charges are made for hairdressing, chiropody and newspapers/magazines. The Statement of Purpose and a copy of the last inspection report are available to view in the main reception area at the entrance to 39 Harvard Road. A copy of the Service Users Guide is available to read in each of the service users bedrooms. 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six hours on 4 July 2006 and a further visit was made on 6 July 2006 for six hours to obtain further information and give feedback to the Manager. Prior to the inspection a pre-inspection questionnaire was sent to the home to be completed with information required as part of the inspection process. This was returned and information detailed is quoted in this report. A tour of the premises took place to look at communal areas and a selection of service user’s bedrooms, rotas and care records were inspected. Twenty-nine service users were resident and ten were spoken with individually in their bedroom or in the communal area. Of these ten for four of the service users the care they had received during their stay was reviewed as part of the inspection process. The opportunity was also taken to observe the interaction between staff and service users in the communal areas. Ten service user surveys were sent out to the home to be distributed to service users and thirty-one came back completed. The Manager, a senior care officer, the cook and kitchen assistant, a member of the housekeeping team, an occupational therapist, physiotherapist and physiotherapist assistant, administrative assistant, a relief member of staff who also works at night in the home and seven care staff, one of whom also co-ordinates the leisure activities provided in the home were all spoken with. An agency member of staff who works in the home was spoken with prior to the inspection. Eleven staff questionnaires were sent out prior to the inspection and three completed questionnaires were returned. Three relative’s, regular visitors to the home were subsequently spoken with on the telephone. Two General Practitioners comment cards were sent out and one completed comment card was returned. Three District Nurses comment cards were sent out and all three completed comment cards were returned. What the service does well: Staff were observed to deliver care in a way that ensured service users dignity and privacy was maintained. The relatives and all service users commented that they were pleased with the overall care provided in the home. Comments included ‘I have been agreeably surprised at the care and attention I have received’, ‘I never realised that these care homes existed. A wonderful, wonderful place’ and ‘excellent care, patient, careful and thoughtful staff’. Staff work with service users to regain their independence and where possible return home. There is good support from healthcare professionals on the Living at Home Scheme. 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 6 The meals in the home offer both choice and variety and special dietary needs can be catered for. The home continues to hold the Clean Catering Award by Lewes District Council. 83 of the homes care staff hold NVQ level 2 in care or above. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admissions process needs to be improved to ensure staff are always being provided with adequate information prior to admission, so that each service users care needs can be met in the home or prepare for any specific care needs prior to admission. There is good support from healthcare professionals working to enable service users to regain their independence and work towards returning home. EVIDENCE: The Statement of Purpose and a copy of the last inspection report are available to read in the entrance of the home. The Service Users Guide is available to read in service users bedrooms. Not all the service users spoken with had read the information but were aware that it was available to reference. The service users surveys indicated that the majority of service users felt they had received enough information about 39 Harvard Road prior to admission the 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 9 home. Four service users did not feel they had had enough information and one service user stated, ‘only heard by word of mouth that it was excellent’. The service user surveys indicated that the majority of service users felt they had received a contract. Contracts were seen to be in the process of being completed during the inspection and for the nine service users documentation viewed, six had a completed contract in place. Service users have an initial assessment completed by an assessor working for one of ESCC’s Adult Service Departments Assessment Teams. Staff spoken with and documentation viewed confirmed that a copy of this assessment is not always sent to the home for reference or that enough information is always received to prepare for an admission. Of the fourteen service user files viewed, five did not have a copy of an initial assessment and for a further four the detail provided in the assessment did not provide adequate information for staff to reference. Feedback received through the inspection process and documentation viewed indicated that since the last inspection there have been a number of service users admitted in to the home where subsequently it was found that service users care needs could not be met in the home. Staff spoke of more robust admission procedures, which have been put in place in the home and which staff felt were helping to improve the admission process. But staff should also receive adequate pre-admission assessment information to reference. Where service users are being provided with regular respite care the assessment should be subject to regular review. Where service users are admitted between reviews staff stated verbal confirmation of the current situation is sought prior to the service user being admitted for the next period of respite care. There was some evidence of updates received and recorded for staff to reference, but this needs to be further developed. The home accommodates service users for a period of rehabilitation for a period of up to six weeks. Occupational therapy and physiotherapy staff were spoken with and observed working on the unit during the inspection and working with service users to return home. Service users spoke of activities they had participated, home visits and had range of equipment, which had been provided to assist their mobility. On the second visit the Inspector sat in with a group of service users participating in a chair based exercise activity. There was a pleasant atmosphere and good interaction between staff and service users was observed. 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by an individual plan of care where their personal and health care needs are identified at the start of their stay and which informs staff of the care which needs to be provided, but the information recorded could benefit from continued refinement. Much improvement in the management of medicine was noted. EVIDENCE: Seven service users files were viewed. The content of the individual care plans read demonstrated that the detail included on the care plans has been greatly improved, but should continue to be refined to ensure that all service users care needs are recorded and give staff guidance on all areas of care as required. Recording was in place to demonstrate that care plans had been reviewed. A number of supporting risk assessments were seen, but where service users smoke a generic risk assessment was in place which did not identify any individual risks to the service user. Three service users had been admitted late the previous day, which had not enabled staff to complete all the admission process with individual service users. During the afternoon of the 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 11 next day not all of the required admission procedures had been completed with not all care plans commenced or risk assessments completed. This was discussed with the Manager during the inspection for a resolution. Service users religion is not always recorded and where possible this information should be sought to ensure where a death occurs appropriate actions are taken in line with service users or relative’s wishes. Medication policies and procedures are in place and the administration of medication was observed on one unit at lunchtime. The storage and a sample of the recording of the administration of medication were also viewed and were adequate. A number of service users were responsible for their own medicines and policies and procedures are available to facilitate this. Two service users were spoken with, who were self-administering their medication. A risk assessment was only in place for one service user, for the other who had been admitted the previous night this had not been completed. This was shared with the Manager during the inspection for a resolution. Staff confirmed that a pharmacist regularly visits. Staff spoken with confirmed they had received the first part of the medication training to be provided to meet requirements. The response from the service user surveys completed was varied and stated that the majority of service users felt that their medical care needs were always met, but some also stated usually or sometimes met in the home. Feedback from visiting healthcare professionals was that they were satisfied with the overall care provided and that the home worked in partnership with them. But further comments were received that it was felt there had been some inappropriate placements to the home where service users had required nursing care and which had resulted in some readmissions back in to hospital. Staff was observed to deliver care with dignity and respect. The relatives and all service users commented that they were pleased with the overall care provided in the home. Comments included ‘I have been agreeably surprised at the care and attention I have received’, ‘I never realised that these care homes existed. A wonderful, wonderful place’ and ‘excellent care, patient, careful and thoughtful staff’. 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are enabled to exercise choice and control over their lives whist resident in the home, with opportunities to participate in social and recreational activities, with a varied diet provided which offers choices at every meal. EVIDENCE: A weekly activities programme is available to read in the home. On the first day of the inspection a word game was organised in one of the lounges. When asked if activities are provided the response from the service users surveys was varied and stated activities were always, usually or sometimes arranged. Two of the four service users whose care was reviewed confirmed activities took place and other service users spoken with also spoke of activities they had participated in. Two relatives were able to comment on activities provided as had visited at a time when activities occured. One commented that they had observed their relative and other service users really enjoying activities provided, but that it it would be nice to see more opportunities for service users to participate in activities and opportunities to go out. The sample activities records viewed, observations on the day, staff spoken with and service users comments evidenced that more activities are being organised for 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 13 service users to participate in, with more opportunities for service user’s to go out if they wish. But the range and frequency activities are provided should continue to be developed. Relative’s spoken with and service users who had had visitors commented that there was flexible visiting and that staff are very welcoming. The care and support provided was observed to enable service users where possible to exercise choice whilst at 39 Harvard Road. The seven service user files viewed including the four service users whose care was reveiwed confirmed this. The home continues to hold the Clean Catering Award by Lewes District Council. The cook working on the day stated he held an advanced food hygiene certificate and the kitchen assistant a basic food hygene certificate. Both confirmed attendance on a range of training opportunities. There is an eight -week rotating menu in place, which is seasonally varied. This detailed a choice at all meals and service users spoke of choosing from the choice available on the day. Special diets are catered for. Lunch on the first day was chicken curry and rice, egg and bacon flan, potatoes, peas and carrots, followed by jelly and ice cream. Homemade cake was been provided with afternoon tea. Fresh fruit was observed to be available on the units. Detailed records had been maintained of individual food consumption to help ensure service users have had an adequate diet. On the second day of the inspection a cooked breakfast was available for service users if they wished to choose this option. A number of service users told the Inspector how much they had enjoyed this. The feedback from the service users survey stated that the majority always liked the meals and the rest usually. Comments received were, ‘Sometimes the assorted cakes lack inspiration’, ‘food menus are excellent’ and ‘the fruit is not always the freshest’. All service users spoken with spoke well of the food and comments were ‘I couldn’t grumble about the food. When I leave I am coming back for my meals’ and ‘food very good’. One relative who had seen the meals provided stated, ‘the food is brilliant’. 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to enable service users or their representatives to raise any concerns about the care being provided and to ensure that service users are protected from abuse. EVIDENCE: ESCC has a detailed compliments and complaints policy and procedure in place. Any complaints received are monitored through the line management arrangements in place within the organisation. No complaints have been received at the home since the last inspection and the CSCI has not received any concerns since the last inspection. The response from the service users surveys was varied and the majority stated they always,and some usually or sometimes know how to make a complaint. The four service users whose care was reveiwed confirmed they had not made any complaints, felt it was an environment where they would feel able to raise any issues and knew who they should speak to. All the relatives confirmed that they would feel comfortable raising any concerns with the staff or the Manager. Where two relatives had raised concerns about the care provided they had felt listened to and were happy with the outcome. There are detailed policies and procedures in place in relation to the protection of vulnerable adults and a whistle blowing policy. The three completed staff questionnaires all confirmed they had an awareness of adult protection procedures. Staff training records detailed staff attendance at this training. 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A maintenance plan has been put in place to ensure that the standard of the environment continues to be improved so that service users are provided with an attractive and homely place to live. EVIDENCE: The standard of décor, carpeting and furnishings in the home continues to be variable. The Manager has put a new maintenance programme in place in the home to work towards improving the environment. There are thirty-six single bedrooms, one of which could be used as a double bedroom. Only two of the bedrooms meet the minimum space requirements. Service users are able to control the temperature in their own bedrooms. All bedrooms have an emergency call bell system and the four service users whose care was reviewed confirmed a prompt response by staff when this 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 16 facility had been used. Some of the bedrooms seen reflected a range of individual styles and interests. There are no en-suite facilities, but there are separate toilets on each of the units and close to the communal areas. There are four communal assisted baths are within the home, which is the same ratio as provided at 31.03.02. The bathing facilities should be kept under review to ensure that adequate facilities are available for service users use. Service users are able to control the temperature in their own bedrooms. The service users spoken with confirmed that there was adequate heating and access to hot water. The homes records of checks of the hot water supply were viewed and eight hot outlets used by service users were checked on the day and were all close to the recommended safe temperature of 43°C. The Water Supply Regulations 1999 are met and a risk assessment in relation to Legionella is in place. There is a dining room and lounge areas on each unit. One room is designated for the use of service users who wish to smoke. There is a passenger lift between the ground, and first floor within the home. The home was clean and free from offensive odours. The response from the service users surveys stated the majority felt the home was always fresh and clean with four stating usually. One comment received was ‘spotless’. All service users spoken with and relatives feedback confirmed the home was kept fresh and clean. One member of the housekeeping team was spoken with who confirmed she had attended training on infection control policies and procedures within the home and that there was good availability of disposable gloves and aprons. There is a laundry facility in the home. One comment received was that for one service user concerns had been raised that some of their clothes had gone missing after having been sent for washing. Not all the items of clothing had been returned. This issue had been discussed with sataff in the home. There is an attractive garden, which service users spoke of using which has a level access walkway. But the flower beds at the front of the home were very overgrown and in need of some attention. 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate staffing was in place on the day, but staffing levels need to be kept under review to ensure service users care needs continues to be met. Robust recruitment procedures were demonstrated to be in place. EVIDENCE: On the day of the inspection staffing was adequate to meet the needs of the service users resident. Discussions with staff and records viewed confirmed that improved staffing levels and deployment of staff in the home have been put in place and maintained. But there is still a high reliance on agency and relief staff to work in the home. As the majority of service users are only resident for short periods of care there is a high number of admissions and discharges. The dependency and care needs of individual service users continually changes and the number of care staff on duty should be continually kept under review to ensure adequate staffing to meet the needs of the all the service users resident. The service users surveys stated that service users felt they always or usually received the care and support they needed. Comments received were, ‘staff are very helpful’ and ‘staff are very kind’. When asked if staff are available when you need them and if the staff listened and acted on what service users say the response was varied with the majority stating yes, but some stated usually or sometimes. One comment received was, ‘when enough staff are 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 18 working’. All the service users spoken with confirmed there appeared to be adequate staff. Relatives stated that they felt there were adequate numbers of staff on duty during their visits. Staff feedback from the completed questionnaires received was, ‘this is a happy care home to work in and a happy caring home for the service users’, ‘at 39 Harvard Road we care for the service users well and they enjoy staying with us’ and ‘we endeavour to provide as homely an atmosphere as possible. Service users are treated as individuals and as important members of society’. The Inspector received feedback from staff during the inspection, which indicated a good and supportive team. Standard 28 has been met as the pre-inspection questionnaire detailed that 83 of the homes care staff care staff hold an NVQ level 2 in care. All recruitment of ESCC staff is co-ordinated by the Personnel Section at ESCC’s head office. Evidence of the recruitment process followed for staff is now held at the home. The Manager was able to confirm that all staff have completed a Criminal Records Bureau check. Five staff files were viewed which evidenced the recruitment practice in place. It was not possible to confirm on the day with staff they were in the process of completing the required induction. The Manager stated and detailed in the pre-inspection questionnaire that it is ensured that all new staff are supported to complete the required induction programme. There is a staff appraisal process in place, which is in the process of being completed. 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall management of the home is good with effective systems to protect service users being put in place. EVIDENCE: The Registered Manager has worked for East Sussex County Council for a number of years as a senior manager participating in a range of training opportunities and holds a Certificate in Management Studies, and HNC Care (Elderly) and is seeking clarification that this meets the training requirements for a Registered Manager. ESCC has a quality assurance plan in place, which has been fully implemented in the home. There are some opportunities for service users and carers to put forward their views about the home and the care that they receive through 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 20 service users forums and a questionnaire, which can be completed at the end of each stay in the home. A sample of minutes from these forums were viewed and it is recommended that the frequency of the service user focus groups are reviewed as service users are resident short periods in the home and currently may miss the opportunity to participate in this forum. ESCC had confirmed that feedback from the quality assurance process undertaken at 39 Harvard Road was being collated to be available to read in April 2006. Also that a formal process to gain feedback from other stakeholders has been developed. This was not evidenced to have been completed and ESCC have been asked to confirm completion and how stakeholder feedback will be sought. Regular quality assurance visits by a representative of ESCC are completed and recorded to meet the requirement under Regulation 26 and are regularly sent to the CSCI. Where a small ‘float’ of money is held for some service users the financial records to support this activity were adequate. One service user who had used this facility confirmed they had received a receipt to confirm what was being held for them. The three staff questionnaires, staff spoken with and records viewed confirmed that staff supervision and team meetings occur on a regular and ongoing basis. Staff spoken with had attended a range of training opportunities and spoke of good access to training opportunities for personal development. Staff training records completed evidenced where staff had received moving and handling updates, first aid, basic food hygiene and fire training. A system has been put place to ensure staff training needs are highlighted and provided. First aid signs in the home need to be updated. Fire policies and procedures have been updated. A detailed check of the environment and fire precautions had been carried out to meet the timescales as detailed in ESCC’s policies and procedures. The organisation has a system in place to evidence that the maintenance of equipment and services has been carried out. Accident records were viewed and filed so that any trends can be been identified and monitored. Fire records were viewed and it is required that that the recording of the regular testing of the fire alarms and the emergency lighting be developed to ensure that it was clear the tests that had been undertaken. 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 21 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 1 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 2 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 22 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 OP3 Regulation 14(1b) Requirement That a copy of the initial assessment/review is available for staff to reference. Where service users are being provided with regular respite care the assessment should be subject to regular review. Where service users are admitted between reviews the updates of individual service users care needs should be evidenced and recorded for staff to reference. That leisure and social activities continue to be developed. That the results of service user surveys are made available to service users, and feedback sought from other stakeholders. This issue is outstanding since 28.02.06. That the recording of the testing of fire equipment is more detailed to evidence the tests completed. Timescale for action 30/09/06 2. 3. OP12 OP33 16 (2) (m) 24 (1) (2) (3) 30/09/06 31/08/06 4. OP38 23 (4) (c) (v) 31/08/06 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 23 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. Refer to Standard OP7 OP33 Good Practice Recommendations That service users religion is recorded. That service user forums are held more frequently. 39 Harvard Road DS0000041389.V292050.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 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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