Inspection on 09/07/08 for Alfriston Court Luxury Care Home

This inspection was carried out on 9th July 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

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Alfriston Court Luxury Care Home Sloe Lane Alfriston East Sussex BN26 5UR Lead Inspector Melanie Freeman Unannounced Inspection 9th July 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alfriston Court Luxury Care Home DS0000071582.V367024.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. Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alfriston Court Luxury Care Home Address Sloe Lane Alfriston East Sussex BN26 5UR 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) 01323 874140 01323 871609 enquiries@chanctonbury-care.com Chanctonbury Healthcare Limited Mrs Madeleine Jean Marshall Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 27. Date of last inspection New service Brief Description of the Service: Alfriston Court Luxury Care Home is a converted Hotel that has been fitted and furnished to a high standard for the purpose of providing a quality living environment. It is registered to provide support and care for up to twentyseven (27) residents in the category ‘older people’. The home is owned and managed by Chanctonbury Healthcare Ltd. The home benefits from a village location overlooking the South Downs, which is well suited to the purpose of providing country house hotel type living for those who wish for, and can afford, a degree of luxury in old age. The community facilities in the village, including tearooms, restaurants, pubs, post office, church, general stores and craft shops, are all within easy walking distance, down the homes private driveway. Residents accommodation is found on the ground, first and second floors. All rooms have en-suite facilities and disabled access is available throughout the home with the provision of ramping and a passenger lift. Varied communal space is available along with outside space for walking and sitting. The homes fees as of the 01 April 2008 vary according to what room is to be occupied and start at £750 rising to £1.025 per person per week. All fees are clearly recorded in the homes brochure and additional charges are made for some services including hairdressing, chiropody, carer accompaniment for hospital visits and telephone rental and call costs. Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 5 The homes mission statement states ‘Chanctonbury Healthcare Ltd strives to provide consistent and high standards of care all the time’. Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 6 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 reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Alfriston Court Luxury Care Home will be referred to as ‘residents’. This was a the homes first key inspection that included an unannounced visit to the home and follow up contact with two health/social care professionals Who have had some recent involvement with the home. The allocated inspector spent approximately seven hours in the home and was able to discuss matters with the registered and regional manager who received the inspection feedback at the conclusion of the visit. During the assessment visits the inspector spent time meeting with residents, staff, and observing practice in the home. A tour of the premises was undertaken and a range of documentation was reviewed including the homes statement of purpose, pre-admission assessment procedures, the systems in place for handling complaints and protecting residents from harm, staff recruitment files, quality assurance systems and some health and safety records. The care documentation pertaining to two residents were reviewed in depth and the inspector ate a midday meal in the dining room. Comments shared by residents included ‘I am very satisfied everything is 100 plus’ ‘I would recommend this home to anyone and I have.’ A visiting professional said ‘the care in the home is excellent nothing can be faulted’. The required Annual Quality Assurance Assessment (AQAA) was completed by the registered manager and returned when requested and was used to inform this inspection report. This inspection has been completed with a proportionate approach and it must be bourn in mind that this is a new service that is operating at approximately a fifth of its full occupancy. The home has therefore been judged on its current provision, service and management arrangements. Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? What they could do better: There is a need to develop appropriate risk assessments that are linked to individual care plans for specific care needs, both long and short term with clear guidance for staff to follow. The systems for handling medicines need to be improved to ensure medicines are stored appropriately and at the correct temperature and that suitable storage facilities are provided so all controlled drugs can be stored in accordance with Misuse of Drugs (safe custody) regulations 1973. Suitable hand washing facilities need to be provided in all communal areas to enable people to wash their hands effectively, therefore reducing any possibility of cross infection. Staff need to follow safe procedures when dealing with any soiled linen or bodily waste products. Further advice on this matter is Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 8 available from the Department of Health in the document ‘Infection control guidance for Care Homes’. The recruitment practice needs to be improved to ensure all the necessary checks are completed before staff are deployed to work in the home. This will ensure robust recruitment practice is followed and safe guard residents. There needs to be effective management arrangements to ensure robust recruitment practice is followed at all times, and that the home adheres to clear procedures that promote and maintain high standards of care and safety for residents. Clear up to date procedures reflecting best practice need to be implemented and followed with regard to the handling of any valuables or money for residents. This will safeguard resident’s property and protect staff by clearly identifying their responsibilities. 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. Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 9 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 Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and relatives, with a good level of information about the home, its facilities, services and the costs involved. The admission procedures ensure that all prospective residents are fully assessed by a competent person before admission and are assured that their needs can be met by the home. Intermediate care is not provided at Alfriston Court Luxury Care Home. EVIDENCE: The homes statement of purpose service users guide was available on request at the reception area. In addition the home has a brochure that was displayed Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 11 with copies available to take away on the reception desk. These documents were informative and contained information on fees and any additional costs. The regional manager confirmed that these are updated and reviewed regularly and that a recent external audit completed had identified some further possible improvements that are to be progressed. An assessment of the admission process followed included the review of the documentation relating to the last two admissions to the home. This confirmed that all prospective residents are assessed by the registered manager; these took into account individuals needs and what the home could offer. She has a clear understanding of the homes admission criteria and explains this to prospective residents. They are therefore aware that any changing needs are subject to constant reassessment that may lead to relocation to another more suitable care home. Although it was noted that the last admissions to the home were not sent confirmation in writing that their needs could be met at Alfriston Court as required. The registered and regional manager advised that this would be the practice in the future and were able to produce a suitable draft letter that would be used for this purpose. Some people have been able to use the home for a holiday or respite breaks as it provides hotel like services in addition to personal care and support. Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Whilst residents needs are being met and individual plans of care are devised these did not reflect a person centred approach to care or take into account all relevant risks. On the whole the homes practice ensure resident’s medicines are administered safely. Care is delivered in such a way that promotes and protects the residents’ privacy, dignity and individuality. EVIDENCE: Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 13 Two individual plans of care were reviewed in depth as part of the inspection process. One of these had a fairly well developed plan of care that did record individual preferences and was based on various assessments. The other needed to reflect more clearly the resident’s choices, preferences and capabilities and record a person centred approach to care. Resident’s involvement in the planning of care was also not well documented. A nutritional screening assessment is not used routinely and was not completed in one case despite this being indicated, with evidence of a low weight. Although risk assessments are used in some areas they are not being used in a systematic way to inform the care and need to be appropriate to the risk being assessed. An example of this refers to self-administration risk assessments and the nutritional screening tools that need to take into account specific areas of risk. Daily records are maintained and these reported clearly on people’s activity, health needs and the care provided, as well as the regular contact with the GP’s and community nursing services. There was also evidence that the plans of care are being reviewed and updated regularly. Discussion with the registered manager and the regional manager indicated that they have already recognised the need to improve the care documentation, and are reviewing what documents are to be used along with a clear criteria for their completion. This will promote a person centred approach to care that is inclusive of resident’s views and agreement. Observation in the home confirmed that staff were meeting residents needs in a flexible way allowing residents to direct the care and support that they need. Discussion with residents also indicated that they were involved in planning their care and were encouraged to identify what they wanted. All feedback from residents was very positive one saying ‘the care is very good here, the best we have ever come across’ ‘the home could not be faulted’ ‘the friendliness and the quality of the caring is what we really like in the home’. Whilst the storage facilities are suitable for the current number of residents it was noted that the room used for this purpose is small and does not have any means of ventilation. The temperature of this area needs to be monitored to ensure all medicines are stored at the correct temperature. This facility also needs to be reviewed to ensure its suitability once the occupancy of the home increases. It was also noted that there are no facility in the home to store any Controlled Drugs. Suitable storage arrangements must be provided and this needs to comply with current legislation, further information on this matter is available on the CSCI Internet within the guidance document ‘The safe management of controlled drugs in care homes’. Practice seen during the inspection visit confirmed that medicines are administered in a safe way by those members of staff who have been trained to do so. A review of the Medication Administration Recording (MAR) charts Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 14 confirmed accurate record keeping. It was however noted that a photograph of each resident is not held in the home and the registered manager said that these were on her camera and would ensure that these are printed as a priority. One resident self-administers their medication the risk assessment completed was not adequate as it did not take into account all the possible risks associated with this activity. Contact with residents confirmed that staff were both kind and attentive and always appropriate in their approach. Residents clearly liked the staff and manager of the home and interaction is positive. Although resident’ rooms are not fitted with locks, these can be provided if they are wanted. Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use this service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are able to live their life in accordance with their own expectations and preferences maintaining strong links with family and friends. Resident’s choices are well respected and the food provided is both appetising and wholesome and served in a way and in an environment to meet hotel standards EVIDENCE: Residents living in the home are very able to direct there own days activity and their choices with regard to this are respected. There are no set routines in the home and this allows the care and services to be flexible. An activities co-coordinator works on a part time basis in the home and is available to support residents in visits to the village. She also provides one to Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 16 one time for each resident and is able to organise any activity or outing that is desired. A recent trip was arranged to Bateman’s, which was greatly enjoyed. Alfriston Court has an open visiting policy and all visitors are warmly welcomed. During the inspection visit it was noted that one visitor stayed to have a meal with a resident. Residents rooms are seen as their own private accommodation and staff always knock on doors and wait for a reply before entering. Most residents deal with their own financial affairs or are supported by a relative and all have complete control over their lives making decisions and maintaining their own autonomy. The registered manager works well with residents and staff to ensure that this freedom and protection of individual’s rights is maintained. The meal eaten in the home was found to be of a very high standard and included roast chicken, roast potatoes, red cabbage, broccoli, roast sweet potato and sliced carrots. The inspector was told that all ingredients are sourced locally from a farm and local meat supplier. The kitchen is well managed and the chefs have regular contact with residents and staff to ensure good quality food that reflects resident’s choices and needs. All residents’ feed back about the food was very positive. It was clear that every effort is made to tailor the food to individual choice and ensure residents satisfaction. Comments included ‘the food is very good and this takes into account your preferences’ ‘I am very impressed with the food and how the chef responds to requests. He comes and sees you and the food is really a’ la Carte’. The dining room is very attractive and looks like a Hotel restaurant. Alfriston Court Luxury Care Home DS0000071582.V367024.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 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are confident that any complaint would be listened to and responded to appropriately. Staff awareness and information in the home ensures that any Safeguarding Vulnerable Adult issue would be responded to appropriately when identified. EVIDENCE: A complaints procedure is available in the home. A review of this documented identified that it needed to be amended to reflect more clearly how the home is going to deal with any complaint raised. The registered manager confirmed that recent audit of the home had raised this issue and that the regional manager was in the process of changing and improving this procedure. Everyone spoken to as part of the inspection process confirmed that they would feel comfortable in raising any concern with the registered manager and were sure that she would deal with any matter in an effective way. One complaint has been received and responded to by the home since it was opened in February 2008. This complaint related to access to the home when the reception area was not manned. This concern was investigated and Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 18 resolved, demonstrating that the organisation takes complaints seriously and ensures that they are used to improve the service. Although there is a Safeguarding Vulnerable Adults procedure this also needs to be amended to clearly reflect the importance of reporting any allegation or suspicion of abuse to Social Services, who are the lead authority, at an early stage. The registered manager acknowledged the need for this update and said that this would be completed. A ‘whistle blowing’ procedure is in place. In addition it was noted that the home did not have the most recent local policies and procedures on Safeguarding Vulnerable Adults and the regional manager said that she would ensure a copy was available in the home as a priority. The registered manager confirmed that she had completed ‘train the trainer’ training on Safeguarding Vulnerable Adults and was able to demonstrate a good understanding of the issues. Although staff have not received formal training on Safeguarding Vulnerable Adults the manager was able to evidence that she had spent individual time with each staff member during supervision, ensuring they had a good understanding and would know what to do if there was an allegation of abuse or if they felt that they had witnessed any abuse. Alfriston Court Luxury Care Home DS0000071582.V367024.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 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Whilst the environment and facilities are excellent, facilities and practice in the home needs further development and improvement in respect of safe infection control. EVIDENCE: Alfriston Court Luxury Care Home is a converted hotel benefiting from a village location overlooking the South Downs. The conversation has been completed to a very high specification with the decoration and furnishings being of a high standard for the purpose of providing a quality living environment for all residents and visitors to the home. Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 20 The whole environment is both very attractive and appropriate to meet the needs of older people who need personal care and support. The home is set in extensive grounds and provides off road parking. There is an attractive patio area with seating and a rose garden. There is scope for further garden facilities to promote the garden areas use. Resident’s accommodation is found on three floors and a passenger lift ensures that disabled access is provided throughout the home for residents. Accommodation seen throughout the home was most attractive and maintained to give the feel of a luxury hotel. The home was found to be clean and fresh throughout. The home does not have a laundry so all sheets and towels are laundered by an outside contractor, and resident’s personal laundry is sent to a sister care home. These arrangements currently provide a quick and good service and this was confirmed by residents spoken to. Discussion with the registered manager however identified that soiled laundry was being hand sluiced in the sluice rooms. This practice is not safe and not in accordance with the homes infection control practice, the registered manager confirmed that she would ensure this practice stops. Residents do not have the facilities to launder any of their own personal items and this was raised with the homes management for further consideration. During the tour of the premises it was noted that communal toilets had not been provided with liquid soap, paper towels and bins. This matter was raised with the registered manager who must ensure suitable hand washing facilities are provided throughout the home. Although the home has sluice rooms these do not provide equipment that disinfects urinals, bedpans or commode pots effectively and safely. These facilities need to be reviewed to ensure suitable disinfection is taking place. The home did not have the most recent Department of Health infection control guidelines and the regional manager took details of this to obtain. Alfriston Court Luxury Care Home DS0000071582.V367024.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 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing numbers and skill mix provides a competent and well-motivated staff team that meets residents health and personal care needs. Residents are not fully protected by the home’s recruitment procedure. EVIDENCE: At the time of this assessment visit five permanent residents were residing at Alfriston Court with another resident receiving respite care. The registered manager was working in the home with one carer an administrator, cleaner and two chefs in the Kitchen. With the current occupancy and dependency of residents the staffing arrangements allow for two carers throughout the waking day, one of which is often the registered manager, with one carer at night supported by a further sleep-in carer. The regional manager confirmed that the staffing is under constant review to ensure suitable staff to meet the needs of residents. Duty rotas are available and confirmed that the staffing ratios are maintained throughout the week. They however did not record the times that the Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 22 registered manager was working on direct care and when she is working on management matters and this was requested. All feedback received about staff working in the home was very positive and comments received included ‘It is extremely good here, staff are excellent without exception they are all kind and considerate, nothing is done in a grudging way they are all a delight’ ‘ the friendliness and the quality of the caring is what we really like about the home ‘Care and Kindness’. The three carers working in the home have been recruited from the Philippines and are qualified nurses in this country and are working on a student visa while completing a BSc in health and social care. The recruitment files pertaining to the three staff were reviewed as part of the inspection process and identified the following shortfalls • • • • • Not all files had a recent photograph of the employee Not all files included terms and conditions of employment Not all files included a job description Full health checks and applications were not in the files for all staff. One staff had not had a Criminal Record Bureau (CRB) and POVA check completed by this employer. These shortfalls were raised with the registered manager. Both she and the regional manager confirmed that the staff member without a CRB and POVA check would not work in the home again until these checks had been completed. The regional manager following the inspection visit confirmed this assurance in writing. Staff training is given a high priority in the Organisation and the regional manager advised that an external training consortium will be contracted shortly to ensure all the mandatory training is provided in all three care homes within the Organisation. There was evidence in the home that staff training was being provided and this had included safe moving and handling, promotion of continence and fire training. Alfriston Court Luxury Care Home DS0000071582.V367024.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 and 38 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered manager is approachable and provides a clear figure head for residents and staff, however appropriate management procedures need to followed at all times. Quality monitoring processes are well developed and take into account resident’s views. Resident’s financial interests are safeguarded although records relating to valuables held on behalf of residents need to be improved. Systems are in place to protect the health, safety and welfare of residents and staff. EVIDENCE: Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 24 The registered manager has relevant experience having worked previously in the same capacity in another home within this Organisation for 17 years. She has completed the Registered Managers Award and is in the process of completing a National Vocational Qualification at level 4 in care and plans to undertake a course in Counselling Skills thereafter. She continues to update her practice by attending regular training and is an ‘Adult Protection’ trainer and a qualified Risk Assessor. It was clear from contact with the residents and social/health care professionals that the registered manager is well liked and respected. Her time for management duties is currently limited while the occupancy of the home is low as she is working to provide direct care most days. The regional manager confirmed that this is a short term arrangement and further staff are to be recruited and will include a deputy manager as occupancy increases. This individual will provide supporting skills to the registered manager as it is recognised that her particular skills are with people. The home uses a variety of quality auditing systems and the registered manager has already completed a survey of residents and staff views, which was reported on in June 08. This now needs to be used to confirm how services can be improved and developed and reported on accordingly. The home does not take any responsibility for any of the resident’s finances and most residents look after their own affairs or have an allocated person to do so. It was however noted that money was being held for safe keeping by the registered manager. There was no record relating to this matter and receipts had not been used. A procedure in respect of holding and receiving money or valuables on behalf of residents is not available in the home for staff to follow. This needs to be provided and followed to safeguard residents and staff. The home has an allocated health and safety officer who does regular audits in the home. The records relating to hot water checks were seen and confirmed that these are maintained. Alfriston Court was completely renovated and refurbished before registration six months ago with all safety checks being completed at this time. The regional manager confirmed that regular environmental risk assessments are to be completed and recorded in the near future. Alfriston Court Luxury Care Home DS0000071582.V367024.R01.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 3 Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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 14 (1) Requirement That the Registered Person ensures that appropriate risk assessments are in place to cover all area of risk and responded to. These should cover those residents who self medicate risks associated with nutrition and skin damage. The medicine storage area needs to have its temperature monitored to ensure medicines are stored correctly and safely. The registered person must ensure that all controlled drugs are stored and handled appropriately in accordance with the Misuse of Drugs (safe custody) regulations 1973. The registered person must ensure suitable arrangements are in place to prevent the risk of cross infection. This should include suitable hand washing facilities and safe procedures for dealing with soiled laundry and disposal of any waste products. DS0000071582.V367024.R01.S.doc Timescale for action 01/09/08 2 OP7 13 (2) 01/09/08 3 OP26 13(3) 01/09/08 Alfriston Court Luxury Care Home Version 5.2 Page 27 4 OP29 19(1) That the registered person operates a thorough recruitment procedure that ensures the fitness of people who work in the home. This must include the completion of a CRB and POVA check. That the registered provider ensures suitable management arrangements are in place for the effective management of the home. 01/09/08 5 OP31 9(1) (2) 01/10/08 6 OP35 16(2) Suitable procedures need to be implemented and followed to ensure residents money and valuables deposited for safekeeping are dealt with appropriately and safely. 01/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Alfriston Court Luxury Care Home DS0000071582.V367024.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Alfriston Court Luxury Care Home DS0000071582.V367024.R01.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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