Inspection on 15/01/08 for Amberley Hall Care Home

This inspection was carried out on 15th January 2008.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Amberley Hall Care Home 09/07/07

Amberley Hall Care Home 02/04/07

Amberley Hall Care Home 20/06/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Amberley Hall Care Home 55 Baldock Drive King`s Lynn Norfolk PE30 3DQ Lead Inspector Mrs Geraldine Allen Unannounced Inspection 15th January 2008 09:10 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Amberley Hall Care Home DS0000065153.V358194.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. Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Amberley Hall Care Home Address 55 Baldock Drive King`s Lynn Norfolk PE30 3DQ 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) 01553 670600 phillip.davies@hallmarkhealthcare.co.uk Hallmark Healthcare (Gaywood) Ltd Position Vacant Care Home 106 Category(ies) of Dementia - over 65 years of age (60), Old age, registration, with number not falling within any other category (20), of places Physical disability (26) Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The layout in the home will be: Ground Floor Fulmer Way: Rooms 1 - 20 to accommodate twenty (20) Older People who require nursing care. Curlew Crescent: Rooms 21 - 40 to accommodate twenty (20) services users with a physical disability who are under the age of 65 years who require nursing care. Dunlin Drive: Rooms 41 - 46 to accommodate six (6) services users with a physical disability who are under the age of 65 years who require nursing care. First Floor Avocet Avenue: Rooms 47 - 66 to accommodate twenty (20) service users with dementia who do not require nursing care. Lapwing Lane: Rooms 67 - 86 to accommodate twenty (20) older people with dementia who do not require nursing care. Sandpiper Street: Rooms 87 - 106 to accommodate twenty (20) older people with dementia who do not require nursing care. Date of last key inspection 9th July 2007 Brief Description of the Service: Amberley Hall is a care home providing care and accommodation for up to 106 people of varying age and need. These include nursing care, dementia care and people who may be aged under 65 years who have a physical disability. The home is owned by Hallmark Healthcare (Gaywood) Ltd, which has its registered office in Billericay, Essex. The home was first registered on 9 January 2006 and consists of a two-storey building that is purpose built. All the rooms are single with en-suite facilities. Fourteen bedrooms on the ground floor and 12 bedrooms on the first floor have en-suite showers. The home is separated into distinct units, each with their own communal lounge, dining and bathing facilities. Two shaft passenger lifts are installed. There is access to gardens from several points on the ground floor. A hairdressing salon and cinema are located off the main reception. The home is located in the town of King’s Lynn, close to the town centre with all amenities. The full range of fees and additional charges are available on request to the home. Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the day of 15th January 2007. Two Inspectors conducted this inspection. The home manager, Ms Shirley Woods, was present for part of the day and a relief manager, Mrs Linda Sumner, was present throughout the day, providing leave cover for Ms Woods. Two further representatives from Hallmark Healthcare Limited arrived for pre-arranged meetings later in the day and they were present with Mrs Sumner when inspection feedback was given. Information was received from a variety or sources to help make judgements about the quality of care being given at Amberley Hall. An Annual Quality Assurance Assessment (AQAA) was completed and returned by the service. This gave important information about the day-to-day running of the home and its processes and policies. Responses to questionnaires sent out by the Commission were also used to provide information. On the day of inspection, records were looked at, staff and residents spoken to in private and a tour of the premises completed. The way staff looked after and treated people were observed throughout the day. After the inspection had taken place, CSCI has been advised that Ms Woods has resigned from her role as manager. Mrs Sumner will remain at the home as a relief manager until a new manager is appointed and takes up the post. This is a disappointing development as Ms Woods and the staff team have worked very hard to improve the experiences for people at the home. Real progress was seen at this inspection and all involved at the home are commended. It is hoped that the current momentum is not lost with Ms Woods leaving and staff are able to continue to move forward with their good practice and approach to care. People working at the home acknowledge that there is still much to do to ensure that good practice is embedded in everything that occurs at the home. Consolidation of current improvements and future developments will be assessed at the next inspection. As a result of this inspection, five requirements and seven good practice recommendations have been made. Admissions to the home have been suspended for a period due to concerns about aspects of the care given. This inspection was looking to see if sufficient progress has been made to be able to safely allow people to be admitted to the home again. As a result of this inspection, the service providers have been advised that they may resume admissions to the home with immediate effect. A planned admission programme has been requested to ensure that sufficient staff are in place before people are admitted to the home. Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: People, especially on Lapwing Unit, do not always experience good dining. More staff need to be available to give individual support and thought needs to be given to meal times so that they are enjoyable and relaxed experiences for everyone. Care needs to be taken to ensure that procedures about staff recruitment are followed. There were some gaps in the process for recently employed staff. Good recruitment procedures are in place and must be followed so that people using the service are protected. The service needs to continue to work towards achieving 50 NVQ trained care staff. Work is in hand to do this but the momentum achieved must not be lost. Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 7 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. Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service is not currently admitting residents and these standards will be assessed in full at a future inspection. The judgement for this outcome group at a previous inspection was adequate. EVIDENCE: The service is not currently admitting residents and it was not possible to see the admission process in full. These standards will be assessed at a future inspection when the full admission process can be seen. The requirement made on 2 April 2007 is therefore repeated. However, pre-admission assessments have been completed in anticipation of the lifting of the admission embargo and these were seen. A copy of a completed enquiry record and pre-admission assessment was provided. The enquiry record shows that verbal information about fees payable was given at Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 10 the time of the initial enquiry. It also shows a brochure was sent to the enquirer and an assessment visit arranged. The pre-admission assessment took place where the person was currently living and gives good general information about the person, their current condition and needs. The assessment included questions about the person’s physical, social and emotional needs and preferences. Part of the admission process included the prospective resident being invited to visit the home and have lunch with residents. This service does not provide intermediate care. Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People receive care and support that is individual to their needs and preferences. There are gaps in records about people’s social and emotional needs. Health needs are monitored and appropriate action and intervention is taken. The home has a medication policy that is followed by staff. People are treated with respect and their dignity protected. EVIDENCE: Ms Woods confirmed there were forty-eight residents in the home at the time of inspection. Two wings, Sandpiper and Dunlin, were not in use at the time of inspection. A total of seven care plans were looked at. The care plans were based on good assessment and review. All care plans were reviewed monthly and gave information about the care needs of each individual. Each care plan was personalised and reflected the needs of each individual. The daily records Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 12 need more social and emotional content as this will assist in identifying triggers and patterns. The care plans are based on what the person cannot do and they need to be further developed to consider the person’s abilities and how they can be maintained. Staff also need to ensure that information about the person’s preferences and lifestyle are recorded as they learn about them. Some plans lacked information about the person and one lifestyle profile was restricted to a solitary entry that stated ‘likes animals’. Staff said they are much happier with the care plans. They have all now been changed over to the new format and it is much easier for staff to find information. They gave an example of continuous review that included relatives when a resident was at the end of her life. They also spoke about it being important to look at all the person’s needs and not just their physical ones. All staff, except the new starters, had completed care planning training A daily diary/record is used to alert staff to any changes or issues within the care plans. This was discussed with Mrs Bull and as described this will not breach confidentiality but staff need to be mindful of this and ensure no personal information is recorded in this record. GP and collaborative care visits were recorded in date order. There was good information about each visit, including immediate treatment and any proposed follow up treatment or review. The medication arrangements were looked at and discussed. Mrs Bull described the current robust practices in place to monitor medication storage, administration and recording. Staff have completed the Boots up date training and are administering insulin under supervision of the nurses. No residents were self-medicating on the dementia units. The medication room on the dementia units was looked at. It contains two locked trolleys, one for each of the units, and these were attached to the wall and kept locked when not in use. There was also a locked refrigerator in the room. A medicine destruction kit was kept in a locked cupboard and full details of all destroyed medicines were kept. Medication Administration Records were locked at and these had been completed properly. Interaction between staff and residents was observed throughout the day. There was good, appropriate use of touch, good use of eye contact and age appropriate communication. People were spoken to respectfully and all personal care was provided in private. Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are involved in daytime activities of their own choice and according to their needs and capabilities. Some residents are listened to and consulted on daily life in the service. People enjoy the food provided and the choices available. The dining experience for some people is not good enough. EVIDENCE: Residents were seen and spoken to throughout the home and observations were made, especially where communication was difficult. The opportunity was taken to sit with staff and residents in Avocet lounge. Mrs Bull explained that there is a word of the day across the dementia units to help staff trigger conversation and discussion and the word for the day of inspection was ‘hot supper’. Residents were talking about what they like for supper and the conversation developed across other subjects. Residents and staff alike were enjoying this. Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 14 One resident said he had moved into the home from hospital and described the staff as kind and helpful. He said there was always a choice menu and he can have what he likes to eat. He said his daughter visited him at the home. He said he doesn’t want to take part in activities any more although he used to do. Another resident said that staff are very caring. He likes to be independent but rings the bell if he needs help and doesn’t have to wait long. He said meals were very good and they have a choice of main course and pudding. There was also a wide choice at breakfast. Two other residents said they enjoyed the food, that staff were lovely and that this was a very good home. Another resident said he was the chair of the residents committee. He said he brings up things at the meetings and action is taken. This resident provided a copy of a letter written to staff. The letter was full of praise for the staff and he said the letter would be given to all staff and he was sending a copy to the newspaper. Residents said the new manager has made a lot of changes and all for the better. She sorts things out quickly and they felt they could talk to her. Residents spoke about various activities and mentioned trips out to Hemsby, the butterfly park and Sheringham museum. Some spoke about liking to play games such as chess and draughts, crib and scrabble. Very few visitors were seen at the home on the day of inspection and it was assumed this was due to the very wet weather. It was not therefore possible to obtain the views of visitors on this occasion. Lunchtime was observed on Lapwing unit. The unit had five residents needing to be supported by staff. Residents were either brought to the dining room or had their meal in the lounge or their bedroom. The meal was served when most residents were sitting at the table but because there were insufficient staff to support them all together residents had to sit at table and wait for assistance. The mealtimes on Lapwing have still not been resolved and there needs to be more thought given to how an enjoyable experience for all residents can be achieved. A member of staff was seen supporting a resident with his meal in a ground floor unit. This was done in a calm, quiet and kind manner. A requirement has been made. Biscuits, fruit and hot and cold drinks were available on each unit and residents could help themselves. The pureed elements of the meal were separate and clearly distinguishable. The main part, chicken pie, did not look appetising as it was very wet, however residents said it was tasty and they enjoyed their meal. Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 15 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. The service has a complaints procedure that is clearly written and easy to understand. All complaints made and the actions taken are fully recorded. Staff know and understand the procedures about safeguarding people and receive training about this. EVIDENCE: The complaints records were looked at and showed that the incidence of complaints received at this service is continuing to reduce. The service had received five complaints during October, November and December. The complaints records showed robust procedures and good recording of all concerns and complaints. The service complies with the company complaints procedure. The procedure is displayed in the entrance hall but was partially obscured by a plant. This was to be moved to ensure that people can clearly see the procedure. Evidence was seen that staff receive training about safeguarding adults. The home has an abuse policy and also a whistle blowing policy. Staff said they were aware of these and would follow the policies if they needed to. Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 16 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, 20, 21, 22, 24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides an environment that meets the needs of people living there. Arrangements are in place to ensure repairs are carried out quickly and effectively. All areas of the home are decorated and maintained to a good standard. Efforts are made to make personal and communal spaces as domestic as possible. The home is well lit, clean and tidy. Odour problems are dealt with effectively. EVIDENCE: A tour of the premises was completed. On the first floor, only Avocet and Lapwing units were in use. All areas were clean and tidy and the odour problems with one room were being addressed by daily deep cleaning. Arrangements were in place to replace the carpet with an easy clean surface so that the problem could be fully resolved. An odour problem was also identified in Curlew unit on the ground floor and this was also being resolved with new, Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 17 easy clean flooring being installed. The requirement made at the last inspection has been met. All store cupboard doors were locked. The bathrooms and toilets were very clean. Soap, deodorant and shampoo were found in the shower unit of one of the bathrooms on the first floor and were removed immediately it was pointed out. All other bathrooms were clear of cleaning substances. The kitchenettes were kept locked and the cupboards containing cleaning liquids were also locked. The bedrooms looked attractive with matching décor and soft furnishings. The rooms contained varying degrees of personalisation dependent on the wishes of the resident. Efforts have been made to make the communal areas look domestic in style. More signage is needed on the first floor to help people find their way about. On the ground floor, work was in progress to move the smoking area to a more appropriate place. The room to be used has now been tiled and the heat detector and extractor were due to be fitted the day after inspection. This will allow residents from the first floor to have unimpeded access to the garden without needing to go through a smoky environment. The new room was regarded as temporary as the space will not be large enough once more people are living at the home. This will eventually be replaced with a conservatory. The requirement made at the last inspection has been met. One of the fire doors to the kitchen had been badly damaged the week before inspection by the delivery service. Confirmation was received that a new door was on order and will be fitted very soon. The laundry was looked at and was in an orderly state. The laundry person said all the equipment was working well. She spoke about the limited space and said ways to increase the laundry space had been considered. The daily, weekly and monthly maintenance diaries were seen. These records cover all aspects of the maintenance of the internal and external environments and had only been introduced at the beginning of January. These will provide a comprehensive record of maintenance once fully up and running. There were some teething problems evident as the maintenance staff get to grips with the new records. For example, the week 3 fire alarm checks were not recorded as completed although the fire records showed this was done. Maintenance records showed a bi-monthly check of hot water temperatures in every room and also checks on window restrictors and bed rails. There was evidence of the annual routine electrical checks taking place in 2007. There was a gas safety call out dated 27/12/07 as there was no hot water and the report states boiler 3 was not wired and needs rectifying. There was no evidence of follow-up action. The requirement made at the last inspection has been met. Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. Sufficient staff are employed to meet the needs of people for the most part although there are some periods when more staff need to be available, for example at mealtimes. Staff receive training that reflects the needs of people living at the home. The recruitment process needs to be improved so that checks are made and references are obtained in all cases. EVIDENCE: Staff rotas for the period of inspection were provided for each unit. These showed that the service employs sufficient staff on each shift to ensure people’s needs are met appropriately. However, on the day of inspection, training taking place meant that staff were away from their units and there was evidence this caused some difficulties for the staff remaining, particularly during lunchtime. Records showed that 20 care staff were currently working towards National Vocational Qualification (NVQ) 2, and 3 towards NVQ3. A total of 31 of the current care staff workforce have completed NVQ. The NVQ assessor was present at the time of inspection and was speaking with 5 new NVQ starters during the morning. There was good evidence that the service is working to fully comply with NVQ standards in the future. Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 19 Four staff files were looked at in detail, including three recently appointed staff. For the most part, good practice was seen with, for example, fully completed application forms, health declarations and the use of interview records. However, all applicants need to have a minimum of two written references that are followed up if elements of the information received raise questions or concerns. It is also good practice to ensure two people conduct all interviews. The service also needs to make sure that each staff file contains evidence that Criminal Records Bureau and Protection of Vulnerable Adults checks have been completed. Robust practice and recording will help to ensure people working at the home have been subject to all the required checks to help safeguard people who use the service. A requirement has been made about this. Copies of the training matrix, monthly statutory training record and training calendar for January and February were provided. These showed that staff are receiving training in matters that are relevant to their role. They show that the service is committed to having a well-trained and competent work force. Four staff were spoken to in private. Two recently appointed staff described their duties and responsibilities and also gave good information about the training and support they receive. The member of staff responsible for staff training was spoken to and said she is a manual handling trainer and organises and presents this to all staff. She also organises all other training at the home. She said Ms Bull does abuse awareness and dementia workshops and Ms Woods also does some training. The service also has a training facility called an EL Box which was described as a mix of workshops, video and questionnaires. The requirement made at the last inspection has been met. Staff said they found their work ‘satisfying’ and feel ‘well supported’. They said there was time to talk with residents. Both Ms Woods and Mrs Bull were described as ‘approachable’. Two staff who have worked at the home for a longer period spoke about the improvements over the last six months. They said they had worked hard to improve practice at the home. They said there is now better training and everyone has a better understanding of their own roles and responsibilities. They gave examples of how choices were met. They spoke about receiving supervision monthly and said Ms Woods listens and takes action. Examples of this were given that improved the provision of food to the units. The requirement made at the last inspection has been met. Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 20 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, 36 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The relief manager is competent and experienced. The service regularly seeks the views of residents, relatives and other interested parties and acts on their responses. The practices followed regarding residents’ personal allowances are robust. Staff receive regular formal supervision. The service closely monitors health and safety practice and follows relevant regulations. EVIDENCE: Shirley Woods, the recently appointed manager, was on the premises during the morning and there was also another manager, Linda Sumner, who was working at the home to cover Ms’ Woods holiday absence. However, since the inspection, CSCI has been advised that Ms Woods has resigned. The service Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 21 provider is actively looking to appoint another manager as soon as possible and Ms Sumner will continue to work at the home until this is achieved. Ms Sumner is a manager already registered with CSCI in another part of the country. A requirement has been made about this. The overview of the responses to the Quality Assurance questionnaires was seen. This was conducted in July 2007 and 13 relatives responded. The responses were mostly positive with the majority of answers showing either good or average scoring. The comments received had a mix of both positive and negative opinion. The requirement made at the last inspection has been met. The residents’ personal allowances were checked against money held. The money was correct against the records. There was evidence that money is checked at least monthly and the records notated accordingly. Two signatures were used for all audits and transactions and there were full expenditure details in place. Invoices and receipts were also in place. Mrs Bull confirmed she is doing staff supervision of the team leaders and supports the team leaders to do formal supervision of carers. Mrs Woods provides her formal supervision. Other staff spoken to confirmed they are receiving supervision. Supervision records were seen in staff files in sealed envelopes. The requirement made at the last inspection has been met. Health and safety records were looked at. The fire book showed that fire alarms are tested weekly using a different call point. Extinguishers had inspection labels showing the supplier last checked them in September 2007. This complied with records in the fire book. Certificates of servicing for the emergency lighting and fire doors were also seen. The requirement made at the last inspection has been met. Accident records were looked at and cross-referred to care plans. All had been completed in full and a monthly accident analysis was seen. Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 22 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 X 3 X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 3 X 3 Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 23 Yes 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. 1. Standard OP3 Regulation 14(1)(a) Requirement Staff at the home must complete a full assessment of a person’s needs before they move into the home so that there can be confidence all needs will be met. This requirement was set on 2/4/07 & will be assessed when admission resume at this service. Timescale for action 01/04/08 2. OP15 18(1)(a) 3 OP28 18(1)(a) 4 OP29 19 Staff need to be available in 01/04/08 sufficient numbers at mealtimes so that people do not have to wait to be assisted to eat. This will ensure that people can enjoy a good dining experience. The service needs to continue to 01/07/08 work towards achieving 50 NVQ trained staff. This will help to ensure that people are cared for by staff who are suitably qualified. All staff must be subject to a 01/04/08 recruitment process that includes all relevant references and checks. This will help to ensure that people are protected by a robust procedure. Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 24 5 OP31 8 The home needs to appoint an experienced and competent person to manage the home as soon as possible. This will ensure that staff feel supported and people using the service will know there is a competent person managing the home. 01/05/08 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 Care plans need to consider the skills and abilities of people as well as their difficulties so that staff can support people to retain their skills for as long as possible. Staff need to record information about the person’s preferences and lifestyle as they learn it. This will mean that staff can support people to live as they prefer and enjoy good experiences. Daily records need to include more information about the social and emotional aspects of the person’s day. This will help staff to understand what is important to the person and also the things they do not like. Staff must take care that information written in the daily diary/record does not refer to personal matters about named residents. This will ensure that people can be confident their confidentiality is not compromised. Care needs to be taken to ensure that meals look appealing. This will enhance the dining experience for people. Staff need to ensure that shampoo, soap and other bath time items are not left in bathrooms. This will ensure that people are not at risk of accidentally ingesting these liquids. 2 OP7 3. OP7 4 OP7 5 6 OP15 OP19 Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 25 7 OP19 Signage throughout the home needs to be improved so that people can find their way about independently. Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Amberley Hall Care Home DS0000065153.V358194.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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