Inspection on 03/01/08 for 99 -105 Durham Care Homes

This inspection was carried out on 3rd January 2008.

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

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

Other inspections for this house

99 -105 Durham Care Homes 23/11/06

99 -105 Durham Care Homes 28/02/06

99 -105 Durham Care Homes 03/11/05

99 -105 Durham Care Homes 16/02/05

99 -105 Durham Care Homes 21/10/04

Similar services:

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE 99 -105 Durham Care Homes 99-105 Durham Street Holderness Road Hull East Yorkshire HU8 8RF Lead Inspector Janet Lamb Key Unannounced Inspection 3rd January 2008 08:10 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 99 -105 Durham Care Homes DS0000000845.V357666.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. 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 99 -105 Durham Care Homes Address 99-105 Durham Street Holderness Road Hull East Yorkshire HU8 8RF 01482 229766 F/P 01482 229766 duhamcarehomes@yahoo.co.uk 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) Durham Care Homes Mrs Joan Langfield Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23/11/06 Brief Description of the Service: Durham Care Homes is situated to the east of the city of Hull, on Durham Street, which runs off a main road into the city. The home is registered to provide care and accommodation for twenty older people who may also be suffering from dementia. Charges this year for accommodation fees are £334.50. There are fourteen single rooms and three shared rooms. A large lounge and a dining room are available on the ground floor of the home, and a small lounge is available on the first floor. A small car park and patio/garden area is available to the rear of the premises for residents use, and this area is secured with wrought iron gates that are kept closed during the day and padlocked at night. Shops, churches and local health facilities are all accessible within a small distance, public transport is also available close to the home on the main road. 99 -105 Durham Care Homes DS0000000845.V357666.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 3 star. This means the people who use this service experience excellent quality outcomes. The Key Inspection of 99-105 Durham Care Homes has taken place over a period of time and involved sending an ‘annual quality assurance assessment’ (AQAA) document to the home in early September 2007 requesting information about people and their family members, and the health care professionals that attend them, as well as asking for numerical data held in the home. We received the requested information on 28th September 2007 and survey questionnaires were then issued to a selected number of people and their relatives, their care manager, their GP and any other health care professional with an interest in their care. This information obtained from surveys and information already known from having had contact with the home over the last few months, was used to suggest what it must be like living there. A site visit was made to the home on 3rd January 2008 to test these suggestions, and to interview people, staff, visitors and the home manager. Some documents were viewed with permission from those people they concerned, and some records were also looked at. A total of three people, five staff, and the manager, were spoken to or interviewed during the site visit and two visitors and several more people living in the home were observed. All of the information collected, in conversations, through observation and in survey questionnaires was collated to determine what it must be like living in the home. What the service does well: People are well assessed on entry to the home and are provided with a good care plan for staff to follow. They are well supported with health care that meets their needs and their expectations. They are protected from possible harm due to taking the wrong medication, because they have their medication handled by the staff in the home, and the staff follow robust practices and procedures. 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 6 People experience good levels of privacy, have their dignity maintained, and their right to make decisions respected. They are encouraged to maintain contact with family members and friends and enjoy visits from these people any time of the day, and they are encouraged to exercise choice and control over their lives. People enjoy good food, which matches their expectations and preferences, but also offers a satisfactory level of nutrition. They are confident their complaints will be listened to and acted upon. People are protected from abuse by robust recruitment and selection procedures and practices. People experience a safe, clean and well-maintained environment. A sufficient number of care staff work in the home on each shift to meet the needs of people. The manager runs the home in the best interests of people living in the home, safeguards their financial interests, and maintains their health, safety and welfare. What has improved since the last inspection? What they could do better: The manager and provider need to address the quality of the information they provide to us in our AQAA document, to ensure it contains details of e.g. actual numbers and dates of training courses staff have undertaken and what the courses involved, how many people have care plans, what they cover and when they were last reviewed, and such as dates and company names for any maintenance and service visits to lifts, fire systems etc. All key standards on the AQAA must have detailed information to them. The provider could install a computer for the manager’s use so that all documentation, recording and production of templates are facilitated, so people are confident their personal information is well protected and more easily monitored. 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 7 The provider and manager could make sure all staff update their safeguarding adults’ training on an annual basis, and where possible try to obtain it from an external source, so that people know they are being well protected from abuse and harm. 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. 99 -105 Durham Care Homes DS0000000845.V357666.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 99 -105 Durham Care Homes DS0000000845.V357666.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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home, so they are confident their needs are met. EVIDENCE: Three people were interviewed informally and asked if they would give permission for their files to be viewed. Two only had a vague understanding of what assessments and care plans are, but were happy for their files to be read. The third had more understanding. One person said, “I don’t remember coming here or having all my details taken for a care plan, but I am not really bothered about it all.” Another said, “Yes I have a file and I know there is information about me.” 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 10 Files seen contain copies of assessments done by local authorities as well as copies of assessments done by the home: an assessment of prospective people on initial contact, and a DMA (David Mason Associates) skills assessment document. The home’s assessment document is very detailed and varied and covers such as language, religion, GP details and address, skin integrity, any allergies, social contact, weight, likes, next of kin details, chiropody needs, etc. to mention some of the areas. All documents show evidence of people and family member involvement and contain signatures where possible. All have a date, contain relevant information, and show where differences in particular needs require special attention or action to meet them. There are no obviously different needs in respect of culture or race, but gender, disability due to age and religion do feature. These are clearly understood and met. The manager confirmed that systems have not changed since the last key inspection, just over a year ago. The assessment process remains the same and a care plan is produced from all of the information obtained on individuals. Care plans are comprehensive in the information they hold. People also have contracts on files and where possible they or their relative signs them. There is information available in the form of ‘statement of purpose’ and ‘service user guide,’ for people to make a decision about the home before they consider moving in. These documents are held in peoples’ rooms and are labelled for easy recognition. There are contracts of residence but these are held at the sister home and could not be seen. Standard 6 is not applicable, as the home does not take people for intermediate care. 99 -105 Durham Care Homes DS0000000845.V357666.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. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. People receive very good health and personal care and support, so their needs are well met. They benefit from good medication administration and from good levels of privacy and dignity within the home, so their health care needs are also well met. EVIDENCE: All people in the home have a care plan from which staff take their instruction on how to meet assessed needs. People showed little interest in these, but gave permission for them to be viewed. Care plan copies held in files are compiled by the local authority and by the home. The home ones are very comprehensive and relevant at the time of compilation. They have been changed to a new format since the last inspection, and now follow the Standex system. Details held include issues relevant to equality and diversity for those people with particular and different needs, whether they be physical, religious, or sexual etc. 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 12 Care plans are reviewed monthly within the home to maintain relevance and annually with the local authority to ensure continuity of service is being provided. Peoples’ differing needs are well met. People spoken to are not fully aware of the systems of care plan review, but do remember meeting with their family and the manager on occasion. They are quite clear about their medication though. They are satisfied their needs are being met. One said, “I’ve been here two years now and I’m happy. The staff are good and they look after us well. My tablets are brought to me, I don’t look after them myself.” Another said, “We are looked after pretty good. People go out if they want to. It’s good that my tablets are looked after for me because I might take some I don’t really need.” Health care needs are very well monitored for individuals and information is carefully ‘trawled through’ and passed on to help health care professionals determine problems and illness. Daily diary notes show details of peoples’ behaviour and conditions and any responses to medication or care practices. All health care needs are recorded in care plans and are supported by risk assessment documents that cover skin integrity and pressure care, moving and handling, nutrition, hygiene, etc. There are records of GP and nurse visits, as well as food and fluid intake charts if necessary. All people spoken to are satisfied with the arrangements for contacting a GP or visiting the hospital. Observation of interaction between people and staff shows there are some caring relationships, and between people that there are some tolerant ones. Staff are very understanding of peoples’ needs and emotional states, while some people tend to forget what problems others have, but reminders are polite and considerate. The home presented a caring, homely atmosphere in which to live. There are no people in the home that self-medicate. Everyone receives medication from only those staff trained to administer it, usually senior staff. Staff confirm these arrangements in interviews and people spoken to are satisfied the responsibility to look after their medicine lies with the home. There are medication administration policies and procedures for staff to follow, and practices are robust and safe. Systems inspected are satisfactory. The home uses a monitored dosage system, which has been changed since the last inspection to one with a smaller packaging, and for which medication administration sheets are maintained and completed upon giving medicines to people. These records are accurately maintained. Storage is adequate, and disposal of any unused medicines is according to safe procedures. There are no controlled medicines held in the home at the moment, and the visiting District Nurse takes away any sharps s/he uses, after each visit. People spoken to are satisfied with the levels of respect that staff show them concerning their privacy and dignity. Visits from their GP and assistance with 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 13 personal care are carried out in the privacy of bedrooms. Observation of staff revealed they are sensitive and discreet when dealing with personal issues. There are very few changes in systems and care practices since the last inspection. Outcomes for people are still the same, if not better. Discussion with the staff group confirms the systems and practices remain much the same as at the last inspection and satisfactorily meet peoples’ needs in a sensitive and respectful manner. 99 -105 Durham Care Homes DS0000000845.V357666.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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Outcomes for people regarding daily life and social activities are good so they enjoy doing the things on offer, see visitors regularly, make their own decisions as much as possible and are positive about the food provision. EVIDENCE: People and staff spoken to indicate there are some set routines within the day, which people generally accept as being necessary for consistency and management of the volume of tasks to be carried out. Some flexibility exists though, as some people make their own decisions about bathing, rising or going to bed, about what they will and will not engage in etc. Preferences are recorded in care plans whenever possible and choices are respected, especially in respect of equality and diversity needs. There is no set activity programme in operation, but the staff usually undertake impromptu quizzes or bingo etc. in the afternoons. One person was looking forward to the bingo planned on the day of the site visit. Another person explained how some of the people in the home go on outings with relatives at their will. People also have some opportunity to go for walks out or rides in their wheelchair, to the local shops on Holderness road, or to a local 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 15 pub. Other pastimes include sewing, knitting, reading newspapers or books and watching television. A new flat screen television has been purchased and wall mounted since the last inspection. This has proven to be very popular with everyone as more people can now view it. People spoken to are satisfied with the arrangements and freedom exercised around receiving visitors to the home and to their rooms if they wish. Several visitors came into the home on the day of the site visit, though none were spoken to. Individuals’ diary notes and the visitor’s book contain evidence of visitors to the home. Comments on peoples’ and relatives’ survey questionnaires are all positive, with no adverse statements made. One relative said, “Durham Care Home is a clean and well run care home. The staff are very good and efficient. My mother is looked after very well. Could not ask for a better run care home.” Another said, “Never had a problem. Aunty seems very happy and well looked after. Very friendly, good rapport with aunty. Staff always helpful.” There is evidence of people acting independently and according to their personal choice in diary notes as well, and those spoken to confirm they can make their own decisions on most things. One or two explained they are all dependent people and therefore their choices may be limited, but generally they enjoy freedom of thought, word and deed. There are few people that handle their own finances, most preferring their family to deal with such affairs. These arrangements are satisfactory, according to the people spoken to. Management explain that some people have small amounts held in safekeeping for which receipts are given and records are maintained. These were not seen. There is no computer within the home so financial and other business matters are not electronically monitored. Other work cannot be recorded in this way either and the service would benefit greatly from a computer. This is recommended at the end of the report, under standard 37. The home manager and the cook compile menus after consulting people, and although meals are set each day with no named alternative, people do not see this to be a problem. Lunch always consists of a soup starter, main meal and a dessert. Observation of the lunchtime meal revealed an appetising and nourishing main meal of braising steak, stuffing, potatoes and broccoli, with egg custard tart for pudding. The dining room is very pleasantly decorated and tables are properly set with cloths, placemats, cutlery, condiments and a floral centrepiece. There are no complaints about any aspect of the food provided. One person observed to need greater assistance with eating than anyone else is assisted sensitively and afforded time to eat at her own pace. Anyone that is unwell is provided 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 16 with food in his or her room. At least two people were seen to be spending time in their room because of illness. 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Complaint management and protection of service users are good, so service users are listened to and they are confident they will be protected. EVIDENCE: The home has clear and detailed policies and procedures in place for making complaints and maintaining protection of people. There is a complaint record held, which shows five complaints made in the home over the last twelve months, four were serious enough to warrant referral to either the safeguarding adults team or the police, and four of the five were resolved without there being any safeguarding action taken. One remains unresolved and is unlikely to be resolved, because no information is available to inform a decision. None of the complaints had any ill and lasting effects on people living in the home. People spoken to about making complaints are very confident about approaching the manager or any of the staff. One said, “We are well treated and I should tell people off if not. If I have a complaint I would tell my daughter.” Another said, “I tell staff if I have a problem.” Staff spoken to are confident about handling complaint information and confirm the manager deals with issues quickly and sensitively. All staff 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 18 submitting information on questionnaires stated they had confidence in approaching the manager for any reason. Safeguarding adult issues are not fully understood by people, but those spoken to state they would go straight to the manager or deputy if they were unhappy about anything. Staff are aware of their responsibilities and have done abuse awareness training with Hull and East Riding Safeguarding Adults Board, as well as seen a video and completed a questionnaire on the subject. They present as competent in interview. The manager confirms training undertaken by the staff, but it is recommended that where this training is more than two years old staff should complete updated training. Safeguarding adults’ training should be update annually as one of the mandatory training courses to be completed. The two staff files inspected with permission, show training was done in January and April 2005. Therefore a recommendation is being made. There have been no changes in the systems for handling or recording complaints and safeguarding issues since the last inspection. 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is suitable for its stated purpose, and both cleanliness and maintenance are good, so people enjoy a safe, homely environment. EVIDENCE: There has been an improvement in the environment since the last inspection, as a result of a grant allocated to the home last year and a private donation from a relative. The service has been able to purchase, at the request of people, a flat screen television that is mounted on the lounge wall, so that everyone has better viewing. New dining room chairs have also been purchased. The service has also been able to redecorate and refurbish ten of the single bedrooms in the home, to include wardrobe, chest of drawers, curtains, carpet and new bed linen. 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 20 A tour of the premises revealed all rooms are clean, comfortable and very personalised. The property is well maintained and suitable for its stated purpose. Individual and collective needs are satisfactorily met by the property with the exception of the dining room having limited floor space. This would not be a problem if all service users were fully ambulant without the aid of frames and wheelchairs, but because almost all of them now require such equipment the dining space cannot cope. Those people that are hearing impaired have fire safety lights in their rooms to alert them to the fire alarms going off. There is a pleasant garden to the side of the home overlooking the car park. The home complies with the requirements of the local fire service and environmental health departments, made at visits to the home in April 2005 and July 2006 respectively. The home meets requirements of standard 26 in respect of laundry equipment and hygiene facilities. The laundry is clean and tidy and wall and floor surfaces are of a good impermeable quality to ensure safe cleaning etc. The laundry equipment meets the Water Supply (Water Fittings) Regulations 1999. People spoken to are satisfied with the cleanliness of the house and their personal space. Comments on surveys are positive about the cleanliness and the comfort within the home. 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The staffing complement of the home is sufficient to meet peoples’ needs, and there are enough staff with the recommended qualifications, so peoples’ needs are being met. Recruitment and selection practices and training opportunities are good and so people are well protected. EVIDENCE: Discussion with the manager and staff and inspection of the contract hours list and the duty rosters reveal there are 423.5 contracted care hours per week: excluding the manager’s hours and the deputy’s. The deputy’s is 40 hours minimum, so there is a total of 463.5. The Residential Staffing Forum requires there to be 353.48 care hours per week for 1 high, 10 medium and 8 low dependency people currently in the home, as stated by the manager on the day of the site visit. Therefore the home is meeting the recommendations of the forum. Of the 26 care staff in the home, including the deputy, twelve have achieved NVQ level 2 or 3, and another 3 are completing it, giving a figure of 58 . Staff spoken to confirm they had done the course and information in their training files is available. All new staff follows the ‘Skills For Care’ course and booklets are used to record their progress. Other mandatory training is 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 22 completed and evidence of courses done is available in training files and on the homes staffing list. There is a recruitment and selection policy and procedure in place, and practice is good in respect of ensuring the requirements of schedule 2 are being followed. Staff discussed the recruitment process they followed and files confirm the information obtained to determine their identity and acquire a Criminal Records Bureau check. The manager also confirms how the home recruits new staff, although many of the current staff are long standing employees, and three of the five interviewed have left work at Durham in the past and returned to work there a second time. 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. The management of the home is effective and the health, safety and welfare of people and staff is very well maintained, so that people know the home is safely run and in their best interests. EVIDENCE: Information taken from the previous year’s inspection report and discussion with the management and staff shows the manager already has the required qualifications to do the job. She has several years experience working in care homes and especially in a managerial role. Therefore she is qualified, competent and experienced to carry out the role of Registered Manager. 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 24 Discussion with staff and people in the home and information obtained from questionnaires shows the manager is considered to be a very approachable person that effectively and efficiently resolves problems for them and people in the home, and quickly deals with issues for action. Staff have a lot of respect for the registered manager and are consequently willing to do that little extra for her in their roles. The home has a system in place for monitoring the quality of the service it provides to people. This includes some daily, weekly or monthly audits on all areas of the home from the premises and equipment available for use to the health and safety in the home, to the care given to people and reviewing of care plans etc. People and relatives meetings are held on an informal basis, and regulation 26 visits are made and reported on, daily verbal consultations are carried out and written surveys are carried out on various issues at least twice a year, all to determine the performance of the service. An annual report is also published. The only requirement still to be met, is to send a copy of any report issued under schedule 24 to the Commission, if and when the quality assurance systems are reviewed. There is a policy and a procedure for handling peoples’ finances within the home, and staff understand their responsibilities regarding protection of people. There are very few people that handle their own finances, most have family members that do so. Two people receive personal allowance from the home and this is receipted where possible and recorded at the company headquarters. There are more people that have small amounts of money held in safekeeping, which is satisfactorily recorded and receipted in or out. Records are satisfactorily maintained under standard 37, usually in paper format and almost always hand written. The service would very much benefit from having access to a computer to enable records and document templates to be produced. Four areas of health and safety were looked at during the site visit: fire drills/safety equipment tests and systems, passenger and hoist lifting equipment, Control Of Substances Hazardous to Health (COSHH) regulations and water temperature controls. The home has fire safety policies and procedures and a fire risk assessment, carries out weekly checks on the system and periodic training drills to ensure all staff receive three or four a year. There is also a fire hazard analysis document, which looks at various areas of the home and includes the kitchen, the laundry and all uses of chemicals. Staff are aware of their responsibilities and confirm they receive appropriate training and instruction in fire safety. Training files hold certificates etc. 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 25 There is no passenger lift in the home, but a stair lift, a bath hoist and a mobile hoist. All are serviced by a contractor, LMB Engineers, and were last checked on 12/10/07, 04/01/08 and 14/11/07 respectively. Staff have policies and procedures to follow in respect of moving and lifting people, and are trained in moving and handling and the use of hoists. Evidence is available in training files and on the staff list. There is a risk assessment document held for each product in the home. All cleaning products used in the home are stored in a locked cupboard and have accompanying information for safe use under the COSHH regulations. One cleaner spoken to is competent in her role and knows the health and safety responsibilities of the job. Care staff greatly appreciates her efforts and her willingness to assist them when necessary. The handyman undertakes temperature checks on the hot water outlets on a regular basis and records the findings. A full legionella water test was carried out on 14/06/06. Overall there is good evidence to show that the home is well managed and people and staff have their health, safety and welfare well protected. 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X 3 4 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 27 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. Refer to Standard OP18 Good Practice Recommendations The registered provider should update staff safeguarding adults’ training on an annual basis, and where possible try to obtain it from an external source, so that people know they are being well protected from abuse and harm. The registered provider should make computerised systems available to the manager and staff, so that all documentation, recording and production of templates are facilitated, so people are confident their personal information is well protected and more easily monitored. 2. OP37 99 -105 Durham Care Homes DS0000000845.V357666.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Builidng 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. 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