Inspection on 19/10/06 for Amber House

This inspection was carried out on 19th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Amber House 01/07/09

Amber House 15/10/08

Amber House 03/11/05

Amber House 17/08/05

Amber House 20/01/05

Amber House 10/08/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Amber House Martin Way Brunswick Village Newcastle Upon Tyne Tyne & Wear NE13 7EZ Lead Inspector Elaine Malloy Key Unannounced Inspection 09:40 19th October 2006 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 DS0000059015.V289399.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000059015.V289399.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Amber House Address Martin Way Brunswick Village Newcastle Upon Tyne Tyne & Wear NE13 7EZ 0191 236 8205 0191 236 2162 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) Helpcare Ltd Mrs Anna Blakey Care Home 30 Category(ies) of Dementia - over 65 years of age (13), Dementia registration, with number under 65 years of age (1), Old age, not falling of places within any other category (16) DS0000059015.V289399.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One bed can be used to accommodate a named service user with dementia under pensionable age. 3rd November 2005 Date of last inspection Brief Description of the Service: Amber House is a registered care home for older people, including people with dementia. The home is located within a residential area of Brunswick Village. Accommodation is over two floors and a passenger lift is available. 24 single and 3 double bedrooms are provided, 6 of which have en-suite facilities. There is access to local facilities and public transport. A guide to the home’s services and inspection reports are readily available at the home. The current weekly fees for residents who are funded by Local Authorities or who are privately funded range from £355 to £365. An additional charge of £7 weekly is made for en-suite rooms. DS0000059015.V289399.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection. It was carried out by one inspector over 1 day and took 7½ hours. The manager completed a questionnaire on information about the home. This was returned to the Commission before the inspection. Key standards were inspected through discussion with the manager, staff and residents, examining the home’s records and touring the building. Surveys were made available to residents and their relatives/visitors to get feedback on the service. Areas that needed improvement from the previous inspection were checked. A random inspection of the home was previously carried out on 26th April 2006. The findings from the visit were sent to the owner and manager and are available at the Commission office. What the service does well: Residents and their relatives said they are satisfied with the service. They gave very positive comments about life in the home, the care provided and how relatives are kept involved. Staff were described as pleasant, approachable and caring. Residents have their privacy and dignity respected during personal care. Residents have their health, personal and social care needs assessed. Care plans are recorded that shows how these needs will be met by support from staff. There are arrangements to access medical professionals to meet resident health care needs. A good range of social activities, entertainment and outings is organised and relatives are welcome to take part. Contact with relatives, friends and the local community is encouraged. Residents are supported to make choices and decisions. If this is not possible due to their mental frailty then relatives are consulted. The menus offer choice of meals and residents said they enjoyed the food. There are procedures for making complaints and protecting vulnerable people from abuse. Resident personal finances are safeguarded. The home provides comfortable and clean accommodation. The health, safety and welfare of residents are promoted. DS0000059015.V289399.R01.S.doc Version 5.1 Page 6 Good staffing levels are provided to meet residents needs. Staff receive training relevant to the work they do and many have completed care qualifications. An experienced and qualified manager manages the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000059015.V289399.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000059015.V289399.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. People who are considering moving into the home have their care needs assessed before they are admitted. EVIDENCE: The care records of the last two residents admitted to the home showed the manager had thoroughly assessed their care needs before admission. Social workers assessments were obtained, though not always before the resident’s admission. Health professionals had provided information for a resident who was previously in hospital. Care plans were drawn up as a result of care needs identified from the assessments. One person who completed a survey commented, “Anna (manager) and her staff made sure we had a visit to Amber House and had all our questions answered and any queries we had were addressed before any commitments were made”. A relative said, “I visited the home beforehand, everything DS0000059015.V289399.R01.S.doc Version 5.1 Page 9 appeared to be clean, bright and cheerful. When actually resident everything came up to my expectations – really good”. DS0000059015.V289399.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Residents have well recorded plans that show how their care needs will be met. Residents receive support from staff and medical professionals to meet their health care needs. Residents are protected by the home’s medication system. Resident privacy and dignity is respected. EVIDENCE: A sample of resident care records was examined. The home uses a range of assessments to identify each resident’s health, personal and social care needs. Care plans that demonstrate how residents care needs are to be met were generally well recorded with detailed interventions. Additional charts were recorded to supplement care plans. These included monitoring continence patterns, and food and fluid intake. There were also plans that showed how risks are minimised or managed. An example was a care plan that addressed a DS0000059015.V289399.R01.S.doc Version 5.1 Page 11 resident’s risk of falling. The plans are evaluated regularly and information is used to update care plans where necessary. Advice was given on care plans that address resident mental health and behaviour. Resident files had evidence of assessments and care plans related to health needs. All visits and appointments with health professionals are recorded. Residents use two local doctors practices. The District Nursing Service was visiting daily and had updated resident continence assessments in recent months. Mental health care professionals provide input for residents with dementia. The manager gave a good example of working with health care professionals and keeping behaviour charts to assist reassessment of a resident with mental health issues. There are arrangements for residents to receive visits from an optician, dentist and chiropodist. Each person who completed a survey said they always or usually received the medical support they need. One relative commented, “I am under the impression that at times medical support is not always as prompt as it should be”. It was not clear whether the person meant delays by the home’s staff requesting medical support or delays in medical professionals responding. Another relative said, “Any problems with my mum’s health are brought to my attention immediately, by telephone if necessary. I am never made to feel irrelevant. My comments are always listened to”. A resident commented, “Since coming to Amber House I have received medical treatment whenever there was a problem, for example chiropodist, doctor”. Another relative said, “The doctor is immediately contacted for any health problems”. A resident said, “Doctors are called and consulted whenever I have a medical complaint”. No residents currently administer their own prescribed medication. All staff who deal with medication have received relevant training. At the last inspection the home was required to make improvements to medication records. This had been followed up. Each resident now has a photograph for identification and there were no gaps to signatures or codes in the records. Staff have recorded additional detail to pre-printed charts to make sure directions for medication are clearer. The Controlled Drugs register was recorded appropriately. The home has a policy on respecting resident privacy and dignity. Personal care and any medical examination/treatment are carried out in the privacy of the resident’s bedroom. No bedrooms are shared at present. Residents are asked the name they wish to be addressed by. Preferred gender of care worker is also asked and this is being built into personal care plans. There is currently one male carer employed. The manager gave an example of a resident who prefers assistance from more mature staff. A relative who completed a survey commented, “Having visited my father at Amber house for more than 4 years I DS0000059015.V289399.R01.S.doc Version 5.1 Page 12 know how good the care is. Residents are always treated with respect and are cared for in a loving and gentle manner. They are treated with dignity. Staff know them as individuals and are aware of all their needs. It is always a pleasure to visit such a well run home”. Two residents have their own mobile telephones. Residents can use a pay telephone or the office telephone to make or receive calls in private. Resident clothing is labelled clothing to make sure it can be identified and each person has his or her own laundry basket. DS0000059015.V289399.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Residents are provided with a good range of social activities, entertainment and outings. Residents are supported to maintain contact with relatives, friends and the local community. Residents are encouraged to make choices and decisions in daily living. Residents are offered a varied diet with choice of meals and said they enjoy the food. EVIDENCE: Residents social needs are assessed and care planned. Where necessary relatives are asked to give information on the person’s background and interests. Each person who spoke to the inspector or who completed a survey said activities were always or sometimes arranged that they could take part in. One relative commented, “I think that activities are very difficult to organise which can be accessed by all residents or family members. The staff at Amber House make good attempts to involve residents and their families”. Another DS0000059015.V289399.R01.S.doc Version 5.1 Page 14 relative said, “Sometimes the times are awkward but with so many relatives to accommodate they do well to inform us and include us. The notice board is displayed in a prominent position in the foyer where we can see at a glance what is to be happening”. Another relative said, “We have musical evenings which are very enjoyable”. Another commented, “Lively atmosphere where relatives are welcome to take part in the activities”. One resident said, “It is always good to have the company of singers, entertainers etc and helps everyone to join together socially”. Another resident said, “There are activities but I choose not to participate in outdoor activities”. The home has continued to improve the range of social activities provided for residents to take part in. Diaries are recorded each day and these showed recent activities as games, dominoes, skittles, pampering/beauty, karaoke, reminiscence, crosswords, quiz, armchair exercises, sing-a-long, and one-toone chats. There are weekly ‘pet therapy’ visits. Visiting entertainers are arranged at least monthly. ‘Audio visual’ shows have been introduced and to date there have been shows on Beamish, Alnwick Gardens and a Saxon battle re-enactment. Seasonal events are celebrated and a Halloween Party was being planned. There had been outings to South Shields, Cramlington shopping centre, and two pub trips. The manager explained that some residents do not react well to group outings so some one-to-one outings were arranged. Examples were given of individuals being accompanied on shopping trips and out for meals. Further outings were being planned for Christmas and to the Metro Centre. There is an open visiting policy and residents choose who they wish to see. Visits take place in the resident’s bedroom or lounge/dining areas. Contact with family, friends and the community is supported. The manager said residents have been accompanied to a nearby centre that has a café, either by staff or their relatives. Local clergy visit individual residents and if residents wanted to go to places of worship the staff would assist them. The home has visits from school children and a choir from a local church at Christmas. Relatives/visitors who completed surveys said they are welcome in the home at any time and can visit in private. Each said they are kept informed of important matters and consulted about their relative’s/friend’s care. The home’s manager has Appointeeship responsibility for two residents financial affairs. Relatives also support residents in managing their finances. Cash for personal spending can be held in the safe. Staff assist residents in shopping for personal items and inform relatives when residents need new clothing, toiletries etc. The home has a policy on autonomy that encourages residents to make choices and decisions and take control of their lives. Information on advocacy services is available. In practice many relatives advocate on behalf of residents who are mentally frail. When potential DS0000059015.V289399.R01.S.doc Version 5.1 Page 15 residents and relatives visit the home they are shown bedrooms and told what is provided. Before admission they agree what items will be brought into the home for the resident’s room. Access to personal care records is explained and records are shown and discussed at care reviews. The manager described a good example of a resident participating fully in their care records, including changing one of their care plans. A relative who completed a survey commented, “My father is relaxed and happy in Amber House. The staff are there for him when needed but he still feels he is able to make decisions for himself”. There is a 3-week cycle of menus. These had been reviewed since the last inspection to provide a better range of lunches and teatime meals. The manager said the home’s provisions supplier had also been changed and new food items were being purchased. Preference sheets are completed each day that indicate individual’s choice of meals. Breakfast each day is a choice of cereals, porridge, grapefruit, toast and cooked breakfast daily. There is a choice of main meal at lunch and tea, followed by dessert. Different snacks are provided for supper. The home had followed up on each of the previous Recommendations. Suppers have been included in the menus. Residents assessed as nutritionally at risk are being provided with high calorie snacks between meals. This was built into their care plans. Food and fluid records were being fully completed. Residents’ nutritional needs are assessed and weights are regularly monitored. Catering staff are informed of individuals dietary needs. Two residents have diabetic diets. Independent eating is encouraged and some residents have feeding aids. Staff assist residents at mealtimes by prompting, cutting up food and feeding anyone who is poorly or unable to feed themselves. Each person who completed a survey said they always or usually liked the meals. One resident said, “The meals available are always nice and there is always a choice and plenty of it. If you don’t like one thing you can ask for something different”. Another resident said, “I have always had a good appetite and I enjoy my food”. A relative said, “There is choice and more than enough to eat”. DS0000059015.V289399.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Residents and relatives were confident of being listened to if they have a complaint and any complaints received are investigated. There are procedures to protect residents from abuse and staff receive training. EVIDENCE: The home has a complaints procedure. This is displayed on the notice board in the entrance. Three complaints had been made since the last inspection. These were recorded in the complaints book. One complaint was about laundry and two were about food. In each instance appropriate action was taken to remedy the complaint. No concerns or complaints were made to the Commission about the service. The vast majority of residents and relatives who completed surveys said they were aware of the home’s complaints procedure. Two relatives indicated they were not aware of the procedure. One relative said she had made a complaint in the past and this was resolved satisfactorily within the home. Another relative commented, “Senior staff always ready to listen when needed. Families have good access to senior staff as well”. A resident said, “Anna (manager) has such a good way with her I know I could tell her if I wasn’t happy but she usually can tell. I would tell my family if I felt ill at ease and DS0000059015.V289399.R01.S.doc Version 5.1 Page 17 know we could discuss it”. Another relative said, “Our home manager and assistant manager are always ready to listen but so far I have had nothing to complain about”. There are policies and procedures on prevention of abuse, protecting vulnerable adults, ‘whistle blowing’ (informing on bad practice), and dealing with challenging behaviour. Existing staff have had training on abuse and challenging behaviour. This was being organised for newer staff. The registered person had referred a former carer to the Protection of Vulnerable Adults (POVA) list, for them to consider if she should be included in the list. A resident who completed a survey said, “Since giving up my home I have had a few bad days but on the whole I enjoy the company and feel safe at all times”. DS0000059015.V289399.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. 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 using evidence gathered both during and before the visit to this service. Residents live in a safe, clean, and comfortable environment. EVIDENCE: A programme of improvements to the building had continued. This has included further redecoration of bedrooms, bathrooms, and toilets and new floor coverings. Corridors and staircases were redecorated and had new carpets fitted. The ground floor lounge was also redecorated, has new carpet, furnishings and new television. Additional small tables were being purchased. An unused bathroom on the ground floor was converted for use as a small smoking room for residents. Some new kitchen equipment had been provided. A new sluice machine for commode pots was being ordered. There had also been external painting to home. Records were kept of maintenance and repairs. All parts of the building seen were clean and suitably decorated and furnished. DS0000059015.V289399.R01.S.doc Version 5.1 Page 19 Each person who completed a survey said the home is always or usually fresh and clean. One relative commented, “The décor and cleanliness of the home has improved greatly over the last year”. Another relative said, “I am very happy with the high standard of cleanliness in my father’s room and other access areas”. A resident said, “The routine is very good for washing and cleaning and it does feel very cosy in the lounge”. Another relative said, “Their standards are second to none”. There are procedures on control of infection. Staff receive training on infection control during induction. Supplies of disposable gloves and aprons are provided for staff use. Suitable hand-washing facilities are provided. There are arrangements to dispose of clinical waste. New ventilation has been fitted in toilets. The laundry and sluice are located away from kitchen and dining areas. The Manager has contacted the local Communicable Diseases Unit to arrange attendance at meetings. DS0000059015.V289399.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Good staffing levels are provided to meet the needs of residents. The home exceeds the standard for the numbers of staff who have achieved care qualifications. The recruitment procedure has been improved to make sure all required information is kept. Staff are provided with training that is relevant to the needs of the people they care for. EVIDENCE: All care staff are aged over 18 and staff left in charge of the home are over 21 years of age. At the time of the inspection there was 27 residents. Appropriate care staffing levels are provided. The rota showed that there are 5 carers in the morning, 4 carers in the afternoon and evening and 2 carers at night. Most of the Manager’s hours are additional to these levels. The home has suitable domestic, laundry and catering staff hours. Existing staff provide cover for absences. Each resident who completed a survey said that they always or usually received the care and support they needed. They said staff listen and act on DS0000059015.V289399.R01.S.doc Version 5.1 Page 21 what they say, and are always or usually available when they need them. Residents commented: “The staff are pleasant and try to make each person feel special to them. Any day when things are not going too well personally, the staff help as much as possible to help you feel better. Both day and night staff are available at any time”. “Always receive support when asked for and a helping hand when not asked for. The staff respect my wishes and act on any problems I may have. If I have a problem I can ring my alarm and the staff will come at once”. All relatives who completed surveys said in their opinion there is always sufficient staff on duty and they are satisfied with the overall care provided. Additional comments included: “Staff are invariably approachable”. “Always made welcome by the staff at Amber House. I feel they know my mum and I can confidently leave mum in their care”. “My mother came to Amber House due to me not being able to look after her at home, and from day one the staff have made that transition as painless as possible for me and my mother. Their attitude and caring ways are a comfort to me at all times. I know my mother is happy there and with the care she receives from Anna (manager) and her staff”. “He (my father) is usually very happy there and always clean, shaved and well dressed”. “The demeanour of the management and staff is always pleasant. There is always someone senior available to speak to when I have a problem. I have never, while my mum has been in this home, had to make a complaint or met a member of staff who has been other than pleasant and smiling. The choice of a home for a beloved parent is not an easy decision to make, but in Amber House we feel confident that mum is receiving the best care and we don’t have to worry about her when we are not there”. “Homes at present are getting bad press, but I would like to come out in favour of Amber House. It is well run and fortunate to have a good manageress with excellent staff. Rating 1-10 I give it 11”. “They are very approachable and do listen. Of course there may be a time when things are busy, but it is never long before someone is available”. The home exceeds the standard of 50 of care staff who have achieved National Vocational Qualifications (NVQ) Level 2 in care. There are 15 carers including the deputy manager and seniors. 11 have achieved NVQ qualifications, 7 at Level 2, 3 at Level 3 and 1 at Level 4. A sample of staff recruitment files was examined. All new staff are recruited subject to Criminal Records Bureau (CRB) checks being carried out. The previous Requirement to have a photograph and proof of identification of the DS0000059015.V289399.R01.S.doc Version 5.1 Page 22 person and make sure appropriate references are obtained was not fully addressed in one file. Action was taken straight away to remedy this. New staff undertake induction training. Each staff member has a training file with details of courses and training certificates. All staff had up to date training in safe working practices – fire safety, moving and handling, first aid and food hygiene – or were booked to attend courses. Further staff had completed medication training. There has been emphasis on staff studying for care qualifications. The inspector recommended providing internal training on practical aspects of caring for older people. DS0000059015.V289399.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. An experienced and qualified manager manages the home. A plan is being introduced to show how the quality of the service is monitored. Resident personal finances are safeguarded. The home aims to comply with health and safety requirements. EVIDENCE: Mrs Anna Blakey became the home’s Registered Manager in December 2005. She has 17 years care experience with approximately 10 years in a senior/management role. She has achieved the Registered Manager Award qualification and is in the process of completing NVQ Level 4 in care and DS0000059015.V289399.R01.S.doc Version 5.1 Page 24 management. A number of resident and relative surveys commented positively on Mrs Blakey’s management abilities. The home has a quality management policy. A quality development plan was being introduced that sets standards and details the methods of monitoring the quality of the service. The Registered Person visits at least twice every month and prepares monthly reports on the conduct of the home. All policies and procedures had been reviewed in May 2006. Resident personal finances were checked. These were appropriately recorded and included two staff signatures to transactions. There was evidence of personal spending. Receipts are obtained for purchases. Monthly checks of balances and cash are carried out. A sample of records and cash was checked and this was correct to the penny. The home has a health and safety policy and associated procedures. There are risk assessments for safe working practices and the manager was working on assessments for first aid and food hygiene. Risk management plans are documented according to individual resident’s vulnerability. Servicing and maintenance agreements are in place for facilities and equipment. All fire safety checks, tests and instructions to staff were up to date and recorded. The manager agreed to forward plan dates of fire instructions to staff and record more clearly to show frequency for day and night staff. Accident reporting was well recorded and included recording of injuries where the cause is unknown. DS0000059015.V289399.R01.S.doc Version 5.1 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 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 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 DS0000059015.V289399.R01.S.doc Version 5.1 Page 26 NO Are there any outstanding requirements from the last inspection? 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. 2. Refer to Standard OP3 OP30 Good Practice Recommendations The Care Manager’s assessment should be obtained before the admission of a new resident is agreed. Provision of in-house training on practical aspects of caring for older people should be considered. . DS0000059015.V289399.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000059015.V289399.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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