Inspection on 27/06/08 for Aigburth

This inspection was carried out on 27th June 2008.

CSCI found this care home to be providing an Adequate 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

Aigburth 08/11/06

Aigburth 13/04/05

Aigburth 03/11/04

Aigburth 05/05/04

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Aigburth 21 Manor Road Oadby Leicester Leicestershire LE2 2LL Lead Inspector Keith Charlton Unannounced Inspection 27th June 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 Aigburth DS0000001660.V367208.R02.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. Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aigburth Address 21 Manor Road Oadby Leicester Leicestershire LE2 2LL 0116 2715086 0116 2714288 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) www.mha.org.uk Methodist Homes for the Aged Vacant Care Home 32 Category(ies) of Dementia - over 65 years of age (8), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (8), Old age, not falling within any other category (32) Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service user numbers. No person to be admitted to the home in categories MD(E) or DE(E) when 8 persons in total of these categories/combined categories are already accommodated within the home. 8/11/06 Date of last inspection Brief Description of the Service: Aigburth care home cares for thirty-two older people in a purpose built property. It is set in a quiet residential area close to a variety of amenities in Oadby town centre. The premises consist of three floors. Residents occupy the ground and first floor and staff members and volunteers occupy the third floor. Access to all three floors is by use of the passenger lift or stairs. There are a variety of aids and adaptations throughout the home to enable residents to be as independent as possible. The home has thirty single bedrooms and one double bedroom all with en-suite facilities. There are gardens accessible to residents at the front and rear of the property. The weekly fees for living at the home range from £459 to £536 per week, dependent on individuals’ needs. The Registered Manager supplied this information on the day of the inspection. Residents are supplied with a Service user Guide and the Statement of Purpose, describing the services and organisation of the home, and the last Inspection Report are available on request, thereby giving people information as to whether they wish to live in the home. Aigburth DS0000001660.V367208.R02.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 1 star. This means the people who use this service experience adequate quality outcomes. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they received through looking at their records, discussion, where possible, with them, visitors and care staff and observation of care practices. This was an unannounced Inspection. The Registered Manager was present and helped in carrying out the inspection. Planning for the Inspection included looking at the Annual Quality Assurance Assessment completed by the Registered Manager which describes how services are provided by the home, notifications of significant events sent to the Commission for Social Care Inspection and the issues contained in the previous two Inspection Reports. There have not been any complaints made to the Commission for Social Care Inspection about the service since the last full inspection. There has been one Safeguarding issue regarding a resident’s monies though this did not need police involvement and there are systems in place to deal with any such reoccurrence of such an issue. The Inspection took place between 9.15 and 17.00 and included a selected tour of the building, inspection of records and indirect observation of care practices. The Inspector spoke with seven residents, four members of staff, two health staff and the Registered Manager. Surveys returned from four residents confirmed they were fully satisfied with the standard of care provided by the staff. Surveys returned from two GPs confirmed they were not fully satisfied with the standard of care provided and their comments are reflected in the Report. What the service does well: There was again evidence of promoting the welfare of residents in terms of good relationships between staff and residents with staff listening and consulting with residents. Residents said that the care provided by staff was Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 6 very friendly and respectful. There is a detailed end of life system to meet residents needs and wishes. Residents are consulted about life at the home with residents meetings to meet their choices. Activities are provided as per residents preferences so that residents have lots of opportunities for various activities. There is a relaxed friendly atmosphere in the home. Two choices are offered for lunch every day, as per the National Minimum Standard, so that meal choice is seen to be available to residents. Facilities used by residents are odour free, comfortable and homely. Staff are encouraged to have training to equip them to meet residents needs and have supervision to support them in their jobs. Residents and staff thought that the Registered Manager was doing a very good job in that she was friendly, efficient and ready to listen to anyone who needed her help. The Registered Manager was very enthusiastic about providing a high quality service for residents and open to discuss any area of practice. . What has improved since the last inspection? What they could do better: Residents welfare could be more effectively met by ensuring that: All aspects of care – e.g. dates of medical checks are in Care Plans to assist staff to meet all residents needs and that Care Plans are reviewed monthly. Staff need to ensure that residents health needs are covered at all times, as per the proper Moving and Handling of residents and dealing with all their care needs. The food supply needs to be reviewed to ensure it is of a high quality and that all residents cultural needs are met. The home need to review the signing of the home to assist residents with dementia – e.g. photos of residents on their bedroom doors, and memory boxes with treasured items for individual residents to provide prompts and stimulation to make everyday living clearer for them, particularly for residents Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 7 with dementia. The heating system needs to be repaired to ensure residents are not uncomfortably hot. There were some comments regarding how busy staff were so an increase in staffing would mean swifter care and increased supervision to be able to care for residents with increased care needs – e.g. with dementia or confusion/ residents who wander/were at risk of falls. The Complaints Procedure needs to be clearer for residents and their representatives so that any complaint is dealt with fully. The staff training programme is generally comprehensive though would aid staff understanding if training on all residents conditions – parkinsons disease, diabetes, strokes etc – were added to the programme. 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. Aigburth DS0000001660.V367208.R02.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 Aigburth DS0000001660.V367208.R02.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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are assessed before admission so that staff are able to meet their needs. EVIDENCE: Residents said that someone from the home came to see them before admission to discuss their needs and they were encouraged to visit. ‘’ Someone came to see me before I came here which was good because they asked me what help I would need. I was also invited for a look around to meet the other residents’’. An assessment was inspected and it contained lots of detail of relevant information as to residents needs, as per the National Minimum Standard, Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 10 which helps to ensure that all the care needs of residents is covered from day one of their admission. Residents care agreements were also seen which proved that residents were asked about their care needs. The Registered Provider said in the Annual Quality Assurance Assessment that assessments are carried out for all prospective residents as per the policy contained in information about the service and that a service users guide is provided to describe the home’s services. Assessments were seen on file – this allows staff to be aware of a new resident’s needs. The service does not offer intermediate care. Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The individual needs and choices of residents living in the home are not always well met. EVIDENCE: Some residents spoken with said that they could recall having Care Plans. Some residents need to be reminded they can see their Care Plans and discuss them if they wished to ensure that their needs are accurately recorded. ‘’I think I have something called a Care Plan. If I was interested I am sure they would give it to me’’. Care Plans seen by the inspector contained a good amount of information information as to the physical, social and medical needs of residents. Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 12 Risk assessments were found to be a part of the plans so that staff know how to keep residents safe. Some monthly reviews of residents needs were noted in Care Plans and were kept up to date though the wholescale review of the plan was indicated to be done every six months. This needs to be altered to a monthly basis to meet the National Minimum Standard and to ensure needs are fully up to date to ensure care is relevant. Staff said they had not read all the Care Plans. The Registered Manager said she would ensure that this is carried out. One staff was not fully aware of how often to give fluids to a resident or how often turning in bed was needed. Staff reading all Care Plans and ensuring this information is passed over at handovers will ensure residents receive a consistent service. Residents said when they felt ill then staff would swiftly summon medical assistance – residents contacts with medical personnel were documented in their Care Plans. Two Nurses were spoken with and whilst being positive that staff contacted them when needed and were professional if asked that care needed to be carried out, said that there had been problems in the recent past’.They said the Registered Manager had taken concerns very seriously. This was proved by a special staff meeting being called (the minutes of which were seen to be on file). Nurses said that practices had improved and that generally residents always looked to be well cared for. They said that the end of life process was being well met to meet residents needs. Two GPs in surveys stated the following concerns – there were two occasions where for serious illness the home did not alert Medical Services, some residents could self medicate but were not given this option, some staff are not trained properly, there are some language barriers, a lack of communication between shift leaders and between the home and GPs and that the home accepts some residents who need a Nursing Home. These issues need to be followed up by the Registered Manager. Accident records were viewed which showed that medical services were properly referred to on occasions when there had been a serious injury, e.g. head injury though there was an instance of a fall in June 2008 which had not been recorded on an accident sheet. The Registered Manager said this issue would be followed up. The inspector observed that staff were friendly and respectful to residents and encouraged in a friendly manner at the residents pace. Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 13 The Registered Manager confirmed that all staff issue medication undertaken medication training and this was recorded on staff records. Medication was observed to be properly issued and signed. Medication record sheets were found to be very well completed with only one gap noted. The policy of the home is that residents can handle their own medication if they are safe to do so and choose to do so. The residents spoken with appreciated the staff holding their tablets and giving them at prescribed times. Medication is kept securely in the medication cupboard and controlled medication kept more securely through being kept in a properly robust cabinet. Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents living at the home have a high level of opportunities for activities and meals continue to be seen as good. EVIDENCE: Residents again said that they were generally very satisfied with the range of activities on offer and there were no comments that there should be more activities. ‘’We get lots of activities. There is something to do every day’’. The Activities Organiser described all the activities that he arranges and there was a displayed list on the noticeboard with photos of residents on trips displayed near the dining room and recent photos of a trip to celebrate the anniversary of the opening of the home, which residents said they enjoyed: ‘’J. (the Activities Organiser) speaks to us about what we would like to do.’’ Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 15 ‘’There are activities every day if we want to join in’’. ‘’We like the trips out. There seems to be a lot to do here’’. ‘’We are able to have a good laugh with the staff’’. The Registered Manager said in the Annual Quality Assurance Assessment that the home was a member of the national association for the provision of activities for older people and that the Activities Organiser is to undertake National Vocational Qualification level 3 training. The minutes of Residents Meetings supported the home’s emphasis on activities. There was one comment that staff need to be proactive in encouraging residents – e.g. in telling them there is a video on. Some residents said they liked being outside and enjoying the garden, and there was a list showing who went for a assisted walk in the garden. Staff and residents said residents can go out if they wish and are able to and attend clubs. The Annual Quality Assurance Assessment stated that the home has over twenty volunteers and one volunteer was seen to be chatting with residents. Residents said that prayers and regular church services and communion is held in the home and that they can go out to church if they choose. The Registered Manager stated that the home keeps in contact with families of residents who have passed away and sends Christmas cards every year. Also that if current residents have gone through a difficult time in their lives then the home will send them flowers. These practices are highly commended as providing real support for residents and families. Residents said that their visitors were made welcome by staff and this was supported by the staff comments. Residents said there were no rules, e.g. going to bed and getting up times, whether to stay in their rooms or go to the lounge etc., and staff respected this. The Registered Manager clarified that residents can keep alcohol in their rooms if they chose and there were no risks in them doing so. Staff said that it was important that residents were able to keep their independence so they could still do things for themselves. This was confirmed by comments made by residents. Residents again said that they thought the food was good or mainly good. ‘’Though we don’t have our regular cook at the moment the food is still good’’. There was one comment that the quality of the food supply had gone down – ‘’I think they have started to go to a low cost supermarket’’. Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 16 The Registered Manager said the food supply is reviewed to ensure it is of good quality and will follow up this remark. Residents said there was a choice each day for the main meals and residents knew they could ask for something else if they did not want the meal on offer. Residents preferences were recorded in their Care Plans. It is recommended that a cooked breakfast is added to the breakfast choice so that this is available to people. There was evidence that food choices for a resident from a minority culture was catered for on the Care Plan but this was not recorded. From comments made, although there was satisfaction with the food in general, there needs to be more evidence that foods offered and supplied is based on the wishes of the resident. The Registered Manager said this would be followed up. Food records did not show what variety of vegetables were offered and full food records are not kept to evidence choice and variety. The food tasted was found to be of a good standard in general, though the chips were frozen and tasted like they were (freshly made is recommended) with a two course meal offered with two fresh vegetables followed by a a dessert. Residents are asked their opinion of the food at their meetings, which was recorded in the notes. This gives them the opportunity to comment and the management then can change the menu accordingly as needed. Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents views are listened to and acted upon and they and their representatives can be confident their concerns will be properly attended to. The Complaints Procedure needs to be altered to make it easier to make a complaint. EVIDENCE: Residents spoken with thought that if there was a problem then they were confident the management would sort it out: ’’I had a problem once and the manager acted on it quickly’’. ‘’I have never had any problems but I am sure they would do something about it if I did’’. Complaints records are kept. There have been a number of complaints in the past year and there was evidence of investigations of complaints on file that they had been followed up by management with apologies given when necessary. Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 18 The Annual Quality Assurance Assessment states that complaints are welcome as this will help to improve the service for residents – this is a very positive statement and gives residents the confidence to raise issues. The Complaints Procedure is generally satisfactory but does not give the complainant the opportunity to go to the lead Agency, the local Social Service Department, as per the National Minimum Standard. It also states that all complaints need to be made to the home first – the National Minimum Standard states complainants can choose to go to the lead agency first. The Registered Manager said these issues would be followed up with Head Office. A staff member spoken to was not aware of the procedure regarding all Agencies to contact if the in house arrangement failed if abuse was witnessed or suspected. The Registered Manager said this issue would be put followed up by a short procedural statement being drawn up and displayed to help staff to follow the correct procedure and so be able to fully protect residents welfare if such a situation happens. Aigburth DS0000001660.V367208.R02.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): 19,25,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents see facilities as homely, comfortable and odour free. The heating system means it can be uncomfortably warm for residents. EVIDENCE: Residents all said that they liked their bedrooms and they could bring in their own things. These were observed to be personalised and homely by the inspector, with personal items of residents furniture, pictures, photographs etc. ‘’The bedrooms are quite big so I was able to bring in a lot of my possessions’’. ‘’Staff said I could bring in things I wanted. The home always looks fresh and clean and they have decorated it recently’’. Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 20 The lounges were comfortable and furnished in a homely fashion. The inspector noticed that when he went into a number of bedrooms they still had heating on when it was already a warm day. A resident said that this cooled down later in the day but it was too hot and he needed to keep his windows open to deal with it. Clearly this is not good for residents health or comfort. The Registered Manager said she was aware of the problem and would take this up with head office. The back garden area looked attractive and residents said they walked there and appreciated the fresh air if they chose. There was a comment that the grass needed cutting. The Registered Manager said the gardener had left but this is in hand to be followed up. There is currently little signing to the environment to assist with residents with dementia, e.g. photos on doors to make them more recognisable, same colour doors for bathrooms, notice of time, day, weather in the lounge etc. It is recommended that this is assessed and provided. Odour control was of a good standard with no malodours, which residents positively commented on. There were some negative comments regarding the laundry service, which the Registered Manager said was being followed up. Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels need to be reviewed to ensure they fully meet residents needs. Recruitment procedures are in place to properly protect residents welfare. Staff training systems are in place to plan to equip staff to meet residents needs though more training on residents health conditions needs to be carried out. EVIDENCE: Generally residents thought there were enough staff though there were some comments that staff were very busy and where there are only two or three care staff on duty then it took some time to help residents on occasion. ‘’I think the staff are wonderful but they do seem very busy’’. ‘’If it’s an emergency they come very quickly but we have to wait if they are attending to people who need a lot of care’’. The staffing rota demonstrated that staffing that there are normally four care staff on duty with a senior Care Assistant and the Registered Manager until after lunch. This then drops down to three staff from after lunch to the evening Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 22 period plus a senior Care Assistant, then two waking staff at night with someone on call. It was discussed with the Registered Manager that a staffing review needs to look at whether the current provision meets residents needs, e.g. more than the current level of staff on throughout the day, providing domestic cover seven days a week to help with care staff not being called upon to carry out domestic duties so they can concentrate on residents needs. There is a cook seven days a week so residents nutritional needs are covered. There was a comment that because some staff have some difficulty in speaking English that they approach residents in silence, which can be uncomfortable for residents not being approached in a friendly way. A staff member also said her written English was not good. The Registered Manager said she would look into whether colleges can assist with appropriate classes. Staff said there had been a lot training provided by the management of the home. Records seen by the inspector showed this. There was also evidence of induction training for new staff – the Registered Manager said that the recognised Skills for Care induction pack was being used. Specific training on residents conditions – e.g. stroke care, diabetes, parkinsons disease, hearing and visual impairment etc, is still needed. The Registered Manager said she would add this to the e learning system training in house and that staff training for other issues, e.g. Infection Control is in hand. The Registered Manager has set up a Training Matrix to identify what training specific staff members need so this can be seen at a glance to make planning for this training needs easier to spot and organise. Staff said they were encouraged to undertake National Vocational Qualification level training. The Annual Quality Assurance Assessment stated that with staff completing the National Vocational Qualification level 2 then there will be over 60 of staff with this qualification, which exceeds the National Minimum Standard. Recruitment records were inspected with Criminal Records Bureau /Protection of Vulnerable Adults checks, identification and written references in place to ensure that residents are fully protected from potentially unsuitable staff and have a proper check of competency etc. There was a query with one reference which only stated the person had worked for the employer with out giving details of competence etc. The Registered Manager was recommended to follow up this issue up if it occurs in the future. Aigburth DS0000001660.V367208.R02.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): 31,33,35,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management systems are in place to protect the health and safety of residents. EVIDENCE: The Registered Manager has years of experience in providing care and management in residential care and has a National Vocational Qualification level 4 and Registered Managers Award, which shows commitment to providing a high quality service. Residents, staff and Medical Services staff spoken with said that the home was well run with management showing a commitment to residents and relatives. Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 24 ‘’I think the home is very well run by the manager’’. ‘’Everything is well organised and run here and it it done in a friendly down to earth way’’. There was evidence on records that staff are supervised and supported. Staff also said this was the case. There are also regular residents meetings to ensure that there is a forum to air views and preferences, put forward suggestions etc so that residents feel they have an input into the running of the home. Staff Meetings have been regularly held and recorded so that care issues can be put to staff so that standards are high to benefit residents. There are also senior management meetings, which are useful in reviewing the quality of services for residents. A Quality Assurance system was in place to review services though there were no questionnaires to ask residents about services on a yearly basis. These are recommended to meet the National Minimum Standard and give residents a further input into the running of the home. It is also recommended that they are also given to other interested parties - e.g. GPs, Social Workers, District Nurses etc, and this would be followed up. The results should also be included in the Statement of Purpose so that this information is available to residents and their representatives, with an Action Plan showing how the home has dealt with any issues that arise from the survey, so that residents quality of life is shown to be promoted. Residents monies records were found to be properly kept with running balances and two signatures had been usually recorded to show that transactions are witnessed with receipts available to prove that the home was keeping monies correctly. Fire Precautions: System testing was on carried out for required monthly schedules for emergency lighting and for weekly fire bell testing. Fire drills are carried out on a regular basis of at least every three months. There was also a fire risk assessment on file, which helps to ensure that proper fire safety systems are in place to protect residents. Staff members were asked about the fire procedure and were aware of the procedure. There was evidence on file that hot water temperatures are tested on a regular basis to ensure that residents are protected from scalding water. The Registered Manager sent in Risk Assessments regarding radiator covers to be fitted to some radiators to protect residents from burning. Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 25 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 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 4 X X X X X 1 4 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 26 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. 1. Standard OP8 Regulation 12 Requirement Residents health needs in respect of ensuring all aspects of personal care provided, and proper Moving and Handling must be met at all times. The heating system needs to be repaired so that temperatures are not uncomfortable for residents. Timescale for action 27/07/08 2. OP25 23 27/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Staff need to be aware of Care Plans and they need to be reviewed monthly so that awareness of residents needs is up to date to ensure relevant care is always supplied to residents. Food choices for all residents need to be fully supplied and DS0000001660.V367208.R02.S.doc Version 5.2 Page 27 2. Aigburth OP15 that detailed food records kept to evidence choice supplied to residents. A review of the quality of food is needed to ensure this meets residents preferences. 3. OP16 There needs to be a clear Complaints Procedure to ensure the complainant is given a choice as to how to complain and to the proper lead agency. That the Registered Manager and Registered Provider review the staffing levels to ensure that residents needs are covered at all times. Staff training on all relevant issues, e.g. residents conditions and Infection Control, needs to be supplied. 4. OP27 5. OP30 Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG 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 Aigburth DS0000001660.V367208.R02.S.doc Version 5.2 Page 29 - 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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