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Inspection on 11/09/06 for Amethyst House Care Centre

Also see our care home review for Amethyst House Care Centre for more information

This inspection was carried out on 11th September 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is well managed and service users know what they can expect from the service. Information about the service and assessments prior to admission ensure those who choose to live at the home can have their care needs met by staff that are trained. Staff knows the needs of the service users, as it is described in well-written care plans. Residents spoken to say staff were kind and knew how to care for them. Residents spoken to said they liked living at the home, although some said they would like to go out more. Residents said they would like more activities. Residents said they thought the food was very good with plenty of choice especially liked was the home cooked puddings and pastry. There is a robust complaints procedure, and the registered providers are proactive in their approach to dealing with concerns/complaints. Six complaints have been fully investigated since the last visit and resolved within appropriate timescales. Staff are carefully recruited to ensure the safety and protection of service users, and new staff receive a comprehensive induction programme to ensure they understand their roles and responsibilities.

What has improved since the last inspection?

The staff have worked hard to achieve NVQ awards in care and are commended for their efforts. They now meet to required 50% of staff with NVQ Level 2/3 qualifications. Service users financial records were checked and were found to accurate. All records checked included two signatures and receipts were checked against records. Staff meeting minutes were checked and they are read by staff who are not able to attend to ensure they are aware of the issues discussed, and kept up to date with information about the home.

What the care home could do better:

On the day of this visit the home did have some offensive odours, although there appeared to be sufficient domestic staff to keep the home clean. The inspector noticed that extractor fans in bathrooms and toilets were not working and it appeared that the corridor extractors had not worked for some time. This fact may contribute to the odours around the home and must be repaired or replaced by the registered providers. A partial tour of the home found that the bathroom on the first floor was not used, so the residents whose bedrooms were on the first floor had to have a bath downstairs. This is not acceptable and must be addressed by the registered providers. The bathroom/shower facilities downstairs were in poor condition and the flooring showed signs of wear. The areas are unwelcoming and must be refurbished within the timescales stated in this report. The bathroom scales (seated ground floor bathroom) were in poor repair and must be repaired or replaced to prevent cross infection. The inspector discussed risk assessments with regard to the use of cot sides. Although the assessments are comprehensive the registered manager should consider developing a care plan, which is agreed and signed by the service user or their relative that identifies how risk is minimised. The registered manager should ensure that quality assurance surveys are collated to form an action plan, identifying areas where improvement is needed. The registered manager should consider developing a survey specifically to gain the views of relatives, visitors and other stakeholders.Examination of care plans and discussion with residents indicated that activities are limited. The staff member designated with responsibility fororganising the activity programme is currently off sick. The registered manager should consider the appointment of a member of staff to specifically organise activities, until the regular staff member returns to work.

CARE HOMES FOR OLDER PEOPLE Amethyst House Care Centre Sheepbridge Lane Rossington Doncaster South Yorkshire DN11 0EZ Lead Inspector Valerie Hoyle Key Unannounced Inspection 09:00 11 and 12 September 2006 th th 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 Amethyst House Care Centre DS0000015849.V308496.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. Amethyst House Care Centre DS0000015849.V308496.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Amethyst House Care Centre Address Sheepbridge Lane Rossington Doncaster South Yorkshire DN11 0EZ 01302 866226 01302 865415 amethyst.house@ashbourne.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ashbourne Homes Limited Mrs Susan Seale Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Amethyst House Care Centre DS0000015849.V308496.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specific service user under/over the age of 65, named on variation dated 23rd August 2004, may reside at the home. 29th September 2005 Date of last inspection Brief Description of the Service: Amethyst House is a care home for older people providing personal and nursing care, registered for 39 service users. Southern Cross Healthcare owns the home and the registered manager is Susan Seale who is a registered nurse and has achieved the registered managers award. The accommodation is a converted older building with a new extension. The home is situated in the village of Rossington, near Doncaster. The home has well maintained gardens that are level, save and accessible to people who use wheelchairs or have mobility problems. Qualified nurses provide the necessary care to those with nursing needs, and trained care staff provides care to the residential service users. Information gained on the 11th September 2006 indicates the current fees range from £375 - £400 for residential care and up to £500 for nursing care. Additional charges include hairdressing (£4 - £15), newspapers and private chiropody (£7). The home provides information to service users and their relatives prior to admission into the home. Service Users Guides are available on request from the manager. The last published inspection report and the homes Statement of Purpose is available on request and a copy is available for visitors to read in the entrance hall. Amethyst House Care Centre DS0000015849.V308496.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 9.5 hours (over two days) where a partial inspection of the buildings was undertaken. The inspector examined four service users care plans and supporting documentation. Nine service users and five staff and two nurses were spoken to during the visit. The inspector was able to speak to one relative, to gain his/her views on how the home is run. Staff was observed interacting with residents (service users) in a positive supportive manner, enabling them to participate in daily living skills. Ten CSCI ‘Have your say’ surveys were sent to service users prior to this visit. Five were completed and returned. The information has been collated and their views are contained within this report. Occupancy remains high with 13 service users who are assessed as needing residential care and 25 who have nursing needs. The registered manager was present throughout this inspection and assisted with the inspection process. The registered manager completed and returned the pre-inspection questionnaire prior to this visit and information from this document is included in this report. What the service does well: The home is well managed and service users know what they can expect from the service. Information about the service and assessments prior to admission ensure those who choose to live at the home can have their care needs met by staff that are trained. Staff knows the needs of the service users, as it is described in well-written care plans. Residents spoken to say staff were kind and knew how to care for them. Residents spoken to said they liked living at the home, although some said they would like to go out more. Residents said they would like more activities. Residents said they thought the food was very good with plenty of choice especially liked was the home cooked puddings and pastry. There is a robust complaints procedure, and the registered providers are proactive in their approach to dealing with concerns/complaints. Six complaints have been fully investigated since the last visit and resolved within appropriate timescales. Staff are carefully recruited to ensure the safety and protection of service users, and new staff receive a comprehensive induction programme to ensure they understand their roles and responsibilities. Amethyst House Care Centre DS0000015849.V308496.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: On the day of this visit the home did have some offensive odours, although there appeared to be sufficient domestic staff to keep the home clean. The inspector noticed that extractor fans in bathrooms and toilets were not working and it appeared that the corridor extractors had not worked for some time. This fact may contribute to the odours around the home and must be repaired or replaced by the registered providers. A partial tour of the home found that the bathroom on the first floor was not used, so the residents whose bedrooms were on the first floor had to have a bath downstairs. This is not acceptable and must be addressed by the registered providers. The bathroom/shower facilities downstairs were in poor condition and the flooring showed signs of wear. The areas are unwelcoming and must be refurbished within the timescales stated in this report. The bathroom scales (seated ground floor bathroom) were in poor repair and must be repaired or replaced to prevent cross infection. The inspector discussed risk assessments with regard to the use of cot sides. Although the assessments are comprehensive the registered manager should consider developing a care plan, which is agreed and signed by the service user or their relative that identifies how risk is minimised. The registered manager should ensure that quality assurance surveys are collated to form an action plan, identifying areas where improvement is needed. The registered manager should consider developing a survey specifically to gain the views of relatives, visitors and other stakeholders. Examination of care plans and discussion with residents indicated that activities are limited. The staff member designated with responsibility for Amethyst House Care Centre DS0000015849.V308496.R01.S.doc Version 5.2 Page 7 organising the activity programme is currently off sick. The registered manager should consider the appointment of a member of staff to specifically organise activities, until the regular staff member returns to work. 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. Amethyst House Care Centre DS0000015849.V308496.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 Amethyst House Care Centre DS0000015849.V308496.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The registered manager undertakes an assessment of service users prior to them moving into the home, ensuring their needs can be met. EVIDENCE: Admissions are not made to the home until a full needs assessment has been undertaken. The manager was able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the statement of purpose. For people whom are self funding and without a social service assessment the assessment is always undertaken by a skilled and experienced member of staff. Evidence confirms that the assessment is conducted professionally and sensitively and has involved the family or representative of the resident. Amethyst House Care Centre DS0000015849.V308496.R01.S.doc Version 5.2 Page 10 Four assessment documents were examined and provided sufficient information to ensure care needs can be met by the staff at the home. The inspector was able to speak to one service user who had only lived at the home for a short period of time, and he/she said the home was very nice and staff were kind, although he/she would prefer to live in his/her own home but realised he/she could not manage anymore. Another service user who was staying at the home while her/his family was on holiday said she/he liked staying in her/his room and that was fine by staff. Amethyst House Care Centre DS0000015849.V308496.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 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. The judgement has been made using available evidence including a visit to this service, including examination of documents and discussion with staff and visitors to the home. The care plans provides staff with detailed information to ensure they can meet the needs of service users, although some important records need to be fully completed. Arrangements for dealing with service users health issues are adequately met by staff at the home, with support from health professionals. Medication policies and procedures are well managed and staff have the necessary skills to administer the medication to service users, ensuring their safety and protection. Amethyst House Care Centre DS0000015849.V308496.R01.S.doc Version 5.2 Page 12 EVIDENCE: Four care plans were examined during this visit, and included sufficient information to ensure staff understands the support needed by individuals. There is evidence that the care plan is regularly updated and reviewed. Risk assessments demonstrate service users are safe in the environment, whilst able to maintain their independence. The inspector discussed risk assessments with regard to the use of cot sides. Although the assessments are comprehensive the registered manager should consider developing a care plan, which is agreed and signed by the service user or their relative. Staff spoken to confirmed that they had a good understanding of the needs of service users, they said handovers also keep staff up-to-date with any changes to service users. The deputy manager said she had responsibility for transferring information onto new documentation, although the process was time consuming the plans were comprehensive. Records examined and discussion with the staff confirmed service users healthcare needs are met. The qualified nurses are able to carry out nursing requirements for those service users who fall into the nursing category. District nurses also attend the home to carry out injections, take bloods and attend to dressing for service users who are residential. There is evidence within the records that service users are able to access dieticians and speech therapists, the nurses have responsibility in dealing with infection control and continence assessments. The registered manager told the inspector that the nurses had recently attended courses on palliative, to develop new skills and knowledge. An audit of medication and records was examined and were found to be correct ensuring the health and safety of service users. Qualified nurses have responsibility for administering medications and the local pharmacist is contracted to undertake periodic checks to ensure the stock levels are maintained and procedures are followed. The registered manager told the inspector that there is a new supplier of medication who also has responsibility for the safe disposal of waste medicines. The inspector observed medication being administered to service users. The nurse ensured medication was administered with a drink and service users were encouraged to take their medication promptly. The senior carer was observed administering medication and she said she had received training to ensure she had the knowledge required to ensure service users were safe Throughout this visit staff were seen interacting with service users in a kind manner, they spent time talking to service users and were observed knocking on bedroom doors before entering. All service users were referred to by their first name and this was agreed in the care plans examined. Amethyst House Care Centre DS0000015849.V308496.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 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 adequate. The judgement has been made using available evidence including a visit to this service. Social activities are arranged by the home and service users are able to participate if they wish, although due to the sickness of the activity coordinator the frequency of activities have been affected. Mealtimes are well managed and the facilities promote a calm environment with dining areas to accommodate all service users. Service users are encouraged to make choices and control over their own lives. The home has clear visiting policies and procedures to ensure residents can maintain contact with their family and friends. Amethyst House Care Centre DS0000015849.V308496.R01.S.doc Version 5.2 Page 14 EVIDENCE: CSCI ‘Have your say’ surveys received and discussion with service users indicated that planned activities are infrequent. The registered manager said the staff member identified to organise social activities had been of sick, although care staff try to organise activities as part of their caring duties. Social activity care plans examined indicated that watching TV and talking to staff were the main activities recorded. The registered manager said trips to Cleethorpes and a barge trip had taken place recently and the local Church visits monthly. Ladies from the Church also calls and takes service users to the Sunday service. Local schools and scouts visit at festive times of the year. The registered manager should consider the appointment of a member of staff to specifically organise activities, until the regular staff member returns to work. Residents are actively encouraged to keep in contact with family and friends living in the community. Visitors are welcome at any time and facilities are available for them to have a drink or a meal with the resident. Service users can choose to entertain visitors in their own rooms or perhaps a lounge or garden areas. One visitor said she/he was always made to feel welcome and offered a drink. She/he said staff always kept her/him informed of any accidents or changes to their relatives care. The food in the home is of good quality, well presented and meets the dietary needs of residents. The cooks are experienced, and they consult with residents and tries to meet the preferences and suggested dishes when preparing the menu. The catering staff have been awarded a silver food hygiene award. Menus were examined and appear to be well balanced, including seasonal fruits and vegetables. Staff are trained to help those service users who need help when eating and are sensitive in their approach. Breakfast and lunch was observed during this visit. Residents sat chatting after finishing their meal while waiting for assistance from staff. Residents spoken to say the food was very nice with lots of home cooked food. CSCI surveys received confirmed that service users like the food provided, and there is sufficient choice. Amethyst House Care Centre DS0000015849.V308496.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service, and examination of documents. Service users and their relatives are provided information to enable them the raise concerns about the home and their care. Adult protection Policies, procedures are followed to ensure the protection of service users from abuse, and staff are kept up to date with regular refresher training EVIDENCE: The service has a complaints procedure that is up to date, very clearly written, and is easy to understand. It can be made available in a number of formats (on request) to enable anyone associated with the service to complain or make suggestions for improvement. The complaints procedure is widely distributed, and has a high profile within the service. Guests and others associated with the home demonstrate a good understanding of how to make a complaint and they are very clear of what can be expected to happen if a complaint is made. Unless there are exceptional circumstances the service always responds within the agreed timescale. Amethyst House Care Centre DS0000015849.V308496.R01.S.doc Version 5.2 Page 16 Six complaints have been investigated by the registered providers since the last inspection, and have been successfully resolved. The inspector was able to examine all investigation records and letters to the complainants. Two of the six complaints were initially made to CSCI before being passed to the registered manager to investigate. The inspector was able to examine documentation and discuss the complaint. The inspector is satisfied with the way the home has investigated all complaints. The policies and procedures regarding protection of guests are of a good quality and are regularly reviewed and updated. The service is clear when incidents need external input and who to refer the incident to. There are a low number of referrals made as a result of lack of incidents, rather than a lack of understanding when incidents should be reported. Examination of training records indicates staff receives training in the area of the protection of vulnerable adults. Amethyst House Care Centre DS0000015849.V308496.R01.S.doc Version 5.2 Page 17 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, 21, 22, 23 and 26 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service, including a partial tour of the building. The home requires some investment to bathing and bedroom facilities to ensure the environment is suitable for service users to spend their time. The home is generally kept clean, although some areas had offensive odours and needs attention EVIDENCE: A partial tour of the building found some areas to have offensive odours. The inspector noted that a number of the extractor fans around the home (corridors and bathrooms) were not working. The extractor fans must be repaired or replaced to ensure the home is free from odours. Amethyst House Care Centre DS0000015849.V308496.R01.S.doc Version 5.2 Page 18 The inspector noted that the home only has two functioning bathrooms, as the bathroom on the first floor is not used. This bathroom must be refurbished to ensure service users whose bedrooms are located upstairs, are given a choice to use a bathroom close to where they sleep. The bathrooms on the ground floor are used by all residents although the shower facility is in need of a thorough clean and possible re-grouting. The flooring in bathrooms and some of the toilets are badly stained and need thorough cleaning or replacing. The chair scales located in the downstairs bathroom are in poor repair and must be repaired or replaced. A number of bedrooms were examined during the visit, highlighted that some furniture does not match and in poor repair. The registered providers should consider replacing some of the older bedroom furniture to enhance to areas for service users to spend their time Amethyst House Care Centre DS0000015849.V308496.R01.S.doc Version 5.2 Page 19 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. The judgement has been made using available evidence including a visit to this service, and interviews with staff. Staff have the skills and knowledge to fulfil their roles within the home, and a stable staff group ensures continuity of care by staff that knows the service users. Recruitment policies are followed ensuring the safety and protection of service users. EVIDENCE: Staff rotas were examined and there appeared sufficient to meet the needs of the service users. Staff spoken to said they liked working at the home and felt supported by the manager and the nurses. The staff at the home have achieved the required 50 NVQ level 2/3 and are commended for their efforts. The registered manager has demonstrated a continuing commitment to developing the workforce, and there is evidence of a training plan to ensure staff attend all statutory training. The deputy manager who also takes the lead for training and developing staff said the induction programme meets the ‘skills for care’ standards. The inspector was able to examine a completed document. Amethyst House Care Centre DS0000015849.V308496.R01.S.doc Version 5.2 Page 20 Discussion with the manager regarding the recruitment of staff demonstrates clear understanding of the procedures to ensure the safety and protection of service users. There is a stable staff group who have a clear understanding of the needs of service users. Six new staff have been employed at the home since the last inspection, and their recruitment files were examined and contained all the necessary employment checks including references and CRB checks. Examination of nurses PIN and qualifications confirmed that the nursing needs of service users are met The registered manager said the nurses continue to develop their own knowledge, by attending relevant training courses. Amethyst House Care Centre DS0000015849.V308496.R01.S.doc Version 5.2 Page 21 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. The judgement has been made using available evidence including a visit to this service, and interviews with staff. The registered manager is skilled and experienced to manage the home to ensure the safety and protection of the service users. The registered provider has developed methods to actively seek the views of service users, although the data needs to be collated to produce an action plan. Procedures are in place to ensure the financial interests of service users are safeguarded. Staff and service users follow health and safety procedures and records provide evidence of servicing of essential equipment. Amethyst House Care Centre DS0000015849.V308496.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager has the required nursing qualifications and experience and is competent to run the home. She works to continuously improve services and provide an increased quality of life for service users. The manager continues to work towards the Registered Managers Award and she is hoping to finish the course shortly. The organisation has introduced a management development programme that commences in September. The course consists of 9 modules covering all aspects of managing the home. There is a strong ethos of being open and transparent in all areas of running of the home. Residents/relatives meetings are used to gain the views of service users, including suggestions for menus and activity programme. Quality surveys are used twice a year to formally gain the views of residents and the registered manager collates the data. The last residents quality surveys was undertaken in February 2006 although the results had not formed an action plan to identify areas of improvement. The registered manager should consider developing a survey specifically for relatives and visitors to the home, to ensure their views are gained about the service. The registered providers undertakes a monthly quality audit at the home and the reports are available for inspection. Accident reports are analysed by the manager to ensure risk assessments are developed where required. Maintenance and service records examined were up to date and current to the services provided. The manager has the required Health and Safety policies and procedures and displays the relevant notices. Fire safety procedures are in place and service records were examined and were current, ensuring the safety of service users. Service users are able to manage their own finances, although most prefer the manager to assist with dealing with their personal allowances. A number of service users pocket money records were checked and these were accurate. Amethyst House Care Centre DS0000015849.V308496.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 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 2 X 2 2 3 X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Amethyst House Care Centre DS0000015849.V308496.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 2. 3. Standard OP19 OP21 OP21 Regulation 13 (3) 12 (3) 13 (3) 13 (3) Requirement The registered manager must ensure the extractor fans are working effectively The registered provider must ensure that the bathing facilities are suitable and fit for use The registered provider must ensure toilet and bathroom floorings are clear and free from stains to prevent the risk of cross infection The registered provider must ensure that the seated scales are replaced to minimise the risk of cross infection. The registered manager must ensure the home is clean and free from offensive odours Timescale for action 01/12/06 01/12/06 01/12/06 4. OP22 13 (3) 01/11/06 5. OP26 13 (3) 01/11/06 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 Amethyst House Care Centre DS0000015849.V308496.R01.S.doc Version 5.2 Page 25 1. OP7 2. OP12 The inspector discussed risk assessments with regard to the use of cot sides. Although the assessments are comprehensive the registered manager should consider developing a care plan which is agreed and signed by the service user or their relative that identifies how risk is minimised The registered manager should consider the appointment of a member of staff to specifically organise activities, until the regular staff member returns to work. The registered providers should consider replacing some of the older bedroom furniture to enhance to areas for service users to spend their time The registered manager must complete the registered manager award. The registered manager should ensure that quality assurance surveys are collated to form an action plan, identifying areas where improvement is needed. The registered manager should consider developing a survey specifically to gain the views of relatives, visitors and other stakeholders. 3. OP22 4. 5. OP31 OP33 Amethyst House Care Centre DS0000015849.V308496.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Amethyst House Care Centre DS0000015849.V308496.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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