Inspection on 25/07/07 for Arbour Court

This inspection was carried out on 25th July 2007.

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

Arbour Court 24/04/09

Arbour Court 15/12/08

Arbour Court 29/04/08

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Sunny Bank (P.R.S.) Ltd

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Alfred House Residential Care Home

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Creative Support

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

CARE HOMES FOR OLDER PEOPLE Arbour Court Buxton Lane Marple Stockport Cheshire SK6 7QL Lead Inspector Mrs Fiona Bryan Unannounced Inspection 25th July 2007 09:05 25/07/07 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 Arbour Court DS0000069256.V344748.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. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Arbour Court Address Buxton Lane Marple Stockport Cheshire SK6 7QL 0161 4278599 0161 4271653 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) Barchester Healthcare Homes Ltd Mrs Susanne Sneddon Care Home 74 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Mental disorder, excluding learning of places disability or dementia (0), Mental Disorder, excluding learning disability or dementia - over 65 years of age (0) Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No service user may be received in the home who is less than 60 years old. Male/Female. The registered person may provide the following categories of service only:Care home with nursing - code N, to service users of the following gender:- Either. Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE Dementia over 65 years of age - Code DE (E) Mental disorder, excluding learning disability or dementia over 65 years - Code MD (E) Mental disorder, excluding learning disability or dementia - Code DE The maximum number of service users who can be accommodated is: 74 Date of last inspection N/A Brief Description of the Service: Arbour Court is a purpose built care home that provides 24 hour residential and nursing care and accommodation to 74 to service users over the age of 60 with dementia and/or mental health problems. The home is owned by Barchester Healthcare Homes Limited and is managed on a day-to-day basis by a registered nurse. The home is situated in Marple and is fairly close to Marple village. Local amenities, such as shops, library, cinema and swimming baths are close by. Arbour Court is built in pleasant surroundings with attractive garden areas that are partly secure and accessible to the residents. Car parking facilities are provided at the main entrance to the home. Accommodation is provided over two floors. On the ground floor the original building is divided into three smaller secure units, each accommodating ten service users. Each area has its own lounge/dining area. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 5 An extension to the building was completed in February 2007, which provides accommodation for up to 14 people. The extension can be accessed via a separate entrance or through the main building. All the bedrooms in this part of the home are on the ground floor. On the first floor of the extension an activities room is provided, which is well equipped with resources to enable residents to enjoy social activities and maintain life skills, such as baking. A pleasant courtyard garden enables residents to enjoy being outdoors and participate in gardening if they wish. The first floor is arranged in an open-plan design, allowing service users to walk around the whole floor, excluding the extension. All the bedrooms are spacious single rooms providing en-suite facilities. A choice of bathroom or shower is available on each floor. The home has its own hairdressing room and the hairdresser visits once a fortnight. A wide variety of adaptations and aids are provided to assist in the nursing of the residents. Fees for accommodation and care at the home range from £481 to £875 per week. Additional charges are also made for hairdressing and chiropody services, newspapers and personal toiletries. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection, which included a site visit, took place on Wednesday, 25th July 2007. The home was not told beforehand of the inspection visit. In order to obtain as much information as possible about how well the manager and staff looked after the people living there, we spoke to service users, staff, and visitors. A period of two hours was spent sitting in the first floor lounge, watching how staff dealt with and spoke to residents and getting a feel of what it would be like to live at the home and sit in the lounge most days. Four people were looked at in detail, looking at their experience of the home from their admission to the present day. A partial tour of the building was conducted and a selection of staff and care records was examined, including medication records, employment and training records and staff duty rotas. Before the inspection, comment cards were sent out to residents and relatives/ carers asking what they thought about the care at the home. Information from these has also been used in the report. We also sent the manager a form before the inspection for her to complete and tell us what she thought they did well, and what they need to improve on. The home has been classed as a new service following the addition of an extra 14 beds and the registration of a new owner (Barchester Healthcare Homes Limited). The registered manager has remained the same. What the service does well: The home has lots of space and residents can move around freely in a safe environment that is well designed with the needs of people with dementia in mind. The extension to the original building, the Ashwood Suite, has been thoughtfully developed and provides residents with lots of sensory stimulation. An activities room provides an area for residents to bake and maintain other life skills with the support of staff, and also offers lots of resources for residents to enjoy recreations, such as arts and crafts and games. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 7 Staff were seen to treat residents as individuals and spoke to them in a warm and relaxed manner. This made the atmosphere within the home pleasant and calm. Residents seemed to like the staff and many were chatty and at ease with them. One resident said, “Staff are very good, very kind, they all extremely caring” and “I couldn’t get better care”. Relatives commented on the professionalism of the staff and said that they felt the residents’ needs were well met at the home. One relative said “I feel (residents’) needs are being well met and I am impressed by all the staff – they are caring, cheerful always courteous and treat all residents with dignity”. Another visitor said she was “very satisfied” with the care her relative received. The meals seen on the day of the site visit looked appetising and tasty and residents seemed to enjoy them. Menus were interesting and varied. Staff helped those residents that needed help in a quiet and discreet way, without rushing them. The manager takes any complaints seriously and records showed that any complaints received had been properly investigated and acted upon. What has improved since the last inspection? What they could do better: Care plans and risk assessments were generally detailed and outlined people’s specific care needs. Staff do need to take care that assessments and plans are updated as soon as possible when there are changes to the residents’ condition to make sure that all the information is accurate. Although quite a lot of information was available about residents’ social histories, such as childhood memories, former occupations, family contacts and preferred interests and hobbies, this information had not always been used as well as it could be to plan for social activities that would be most suited to individual residents and staff could further develop this area. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 8 The application form and references for one member of staff who had transferred from another home within the company were missing. The manager must make sure that staff personnel files contain all the necessary information and documents to show that proper checks have been made about the suitability of staff to work at the home. 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. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. Detailed assessments are undertaken before people come into to the home so they can feel confident that their needs can be met. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Four residents were case tracked. Detailed assessments had been undertaken for all residents prior to their admission to the home. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 11 In most cases, attempts had been made to create a social profile for each resident, which provided information about their family, previous career and hobbies, interests and preferences. Some social profiles were more informative than others, depending on the degree of input from the residents’ families, as it was difficult for staff to obtain a lot of information from the resident themselves. Behavioural assessments had been undertaken for some residents to try to identify trigger factors for agitation, etc. Staff were very knowledgeable about the residents’ care needs and could describe their usual daily routines and preferences. Staff stated that they received a handover report at the beginning of each shift and used these occasions to discuss individuals’ changing care needs. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. Care needs for the majority of residents were well met, with evidence of good multi-disciplinary working taking place on a regular basis supporting people’s health. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Four people were case tracked. All had care plans that, in the main, addressed their needs. Risk assessments had been undertaken for risk of pressure sores, risk of falling, moving and handling and nutrition. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 13 However, staff need to make sure that risk assessments are accurate and that care plans are updated promptly to reflect increased risks identified through the assessments or treatment ordered by other healthcare professionals. For example, one resident had lost weight but this had not been taken into account when their risk assessment regarding pressure ulcers was reviewed so the score was inaccurate. The score stated on the care plan was also inaccurate. Also, one resident had been prescribed treatment for sore skin but this information had not been added to their care plan. Staff also need to make sure that actions stated as required in residents’ care plans are actually carried out in practice. For example, the care plan for one resident said that they needed to be weighed every week but the last recorded weight was 10th June 2007 when the resident had lost more weight. The care plan for this resident did not detail how their nutritional intake would be recorded, such as completing food intake charts, so the resident was at risk of losing more weight and this not being identified quickly. Records showed that residents had seen GP’s, podiatrists, and psychiatrists. A medicine review had been undertaken for one resident who had fallen several times. During the inspection a small number of residents were observed for two hours in the early afternoon. Many of the residents appeared to be in a generally positive state of being for large parts of the time, starting up small conversations with staff or other residents and taking an interest in their surroundings and the people around them. Two of the residents who were particularly observed spent a large part of the time asleep but staff said that they tended to become more alert later in the day and this was subsequently seen. Carers spoke to the residents in warm relaxed manner, kneeling down so they were at the right height for the residents to see them. Staff interactions were generally respectful, patient, caring and friendly. Only one resident appeared to be unhappy and ill at ease for the majority of the time the inspector spent sitting in the lounge. Although staff did try to comfort them for short periods, this appeared to have no effect and, for large periods of the time, the resident was left alone. This resident’s care plan could have been used better to help staff identify causes for their distress and monitor their well being more effectively, and the nurse spoken to about this resident did not really demonstrate that a great deal of thought had been given as to why the resident was so unhappy. A visitor to the home said that they were very satisfied with the care given to their relative and a resident spoken to said that staff were “very good, very kind, all extremely caring”. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 14 The manager had recently distributed a survey to relatives and had received a good response, which she was in the process of analysing. Comments noted in some of the surveys included “I am confident with the way (resident) is cared for, in the professional manner everyone has with each other and the patients. I have never heard a voice raised in anger or impatience – only laughter”, “Staff in general are very polite and will help as much as possible” and “I feel (resident’s) needs are being well met and I am impressed by all your staff – they are caring, cheerful always courteous and treat all residents with dignity”. The procedures for managing medicines within the home were generally satisfactory. The records for several people were examined and indicated that medicines had been administered correctly. Medicines were stored correctly. Medication administration details had been handwritten for one person. These transcribed details should have been checked and validated by an additional member of staff. Staff must also make sure that they always check the quantities of medicines that are received and sign the records accordingly. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. Staff are aware of the need to provide opportunities for social stimulation and interaction for people living at the home and, in the main, meet these needs well. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A full-time activities organiser and an activities assistant are employed. It was reported that recent employment of the activities assistant, who is qualified to drive the home’s minibus, has enabled some residents to visit their families at home, with a carer accompanying them. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 16 A new activities room has been provided in the extension to the home. Good resources are available for staff to use with the residents; the activities room provides a TV and DVD and some residents were seen enjoying the film “Oliver” on the afternoon of the site visit. A comfortable area with armchairs is provided for residents to relax and another area with tables and chairs gives room for residents to play board games or enjoy arts and crafts activities, such as painting and jewellery making. There are also facilities for residents to bake and practise kitchen skills if they wish. The environment of the home is very suitable for people with dementia and is further described later in this report. Residents have plenty of objects to look at, touch, pick up and talk about, which are stimulating and interesting; several residents spent time trying on a variety of hats that were available around the home and enjoyed walking around the units, which the staff allowed them to do unimpeded. Staff spent time with residents on a one-to-one basis, for example, showing residents photographs and talking about them and a trip out of the home had been arranged for the following day. The home has a Pat Dog that residents like to make a fuss of and pet. Of the four residents that were case tracked, only one had a care plan regarding their social care needs that had been completed. Although information about their past occupations, family and interests had been obtained for two of the other three residents (the other resident was quite new to the home), this information had not been used to create person-centred plans for how this aspect of their care could be developed. Examination of the menus showed that a varied and imaginative range of meals was offered and residents had a choice of dishes, including hot options, at each mealtime. Lunch on the day of the site visit was either chicken and coconut curry or baked fish with red pepper relish with dill rice or croquette potatoes, courgettes and sweetcorn. Dessert was bread and butter pudding or rhubarb fool. People who needed a soft diet were also offered the same options that had been suitably adapted for them. Carers were observed showing residents the different meals so they could see what they looked like and choose what they wanted. One resident did not like either of the two desserts on offer and was offered trifle instead. Carers helped those residents who needed help discreetly, in a relaxed way, without hurrying them. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. People feel that their views are listened to and residents are protected from abuse. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A complaints procedure is made available to residents and their representatives. Two residents and two relatives returned comments cards and said that they were aware of the complaints procedure. A record of complaints had been maintained, which showed that two complaints had been made, which had been dealt with and acted upon satisfactorily. Staff spoken to were aware of the home’s policy for dealing with complaints and were also able to describe the action they would take if they suspected abuse. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 18 All staff receive training in safeguarding adults and the home follows local authority procedures. An allegation was made by some members of staff regarding the practices of another member of staff and the manager had taken appropriate action to deal with this and had informed the relevant agencies. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22 and 26 Quality in this outcome area is excellent. The physical design and layout of the home enable residents to live in a safe, well-maintained and comfortable environment. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A partial tour of the home was conducted. The home was well maintained and furnished to a high standard. Although the décor had quite a “corporate” feel, a nice balance had been reached, in that, the overall ambience was still homely and provided a place that residents could relax and feel comfortable. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 20 A new 14 bedded unit, which has been called the Ashwood Suite, has been provided. The unit has a separate front entrance should visitors prefer to enter this way rather than going through the main home area. The unit has been sensitively designed to take into account the need for sensory stimulation within the environment. It was reported that ideas used in the design of this unit are to be carried through to the rest of the home, and it was apparent that this work had already started. Within the Ashwood suite the bedrooms are all on ground floor level and all offer en-suite shower facilities. An activity room with a kitchen for residents to do baking and practice life skills using a dishwasher, fridge, microwave and induction hob/cooker was provided that could accommodate three-four residents at a time with the activity organiser and a carer. A large lounge/dining area provided a range of comfortable seating and a servery kitchen area with facilities to keep food hot until it was served to the residents. Within the rest of the home the living and dining areas on both floors provided pleasant seating areas. The home was clean, tidy and had a calm and relaxed atmosphere. There were a variety of armchairs and settees for the residents and their visitors’ comfort. Throughout the home there were lots of tapestries on the wall and interesting objects for residents to look at, pick up, touch and talk about, such as hats, bags, soft toys, bottles, boxes and chests with different sized drawers and brightly coloured handles, plus old style telephones and other household objects that residents would remember from their younger days. These contributed to a stimulating, interesting and attractive environment for residents. A lovely courtyard garden with a water feature and raised flower-beds had been created and it was reported that one resident spent a lot of time there gardening. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. Staff are generally well trained and in sufficient numbers to meet the needs of the residents. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Most people said that there were usually enough staff working at the home and that very few agency staff were used which ensured that there was continuity of care for the residents. Examination of the staff duty rotas showed that numbers of staff were usually satisfactory to meet the needs of the people living at the home. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 22 Three staff personnel files were examined. Two contained all the information and documents needed to ensure that the necessary checks had been made before they started work at the home. One person had come to work at the home from another home within the company and their application form and references were missing from the file. The manager telephoned the home that the staff member had previously worked at but they were unable to find the required documents. This person had been recruited via a recruitment agency from overseas so the manager was asked to contact the agency to try to obtain copies of the required documents. The person had worked within the company for some time and had been given a good verbal report from the manager of the home where they had previously worked. Of 35 care staff, nine had successfully obtained NVQ level 2 and a further four had achieved an NVQ level 3 in dementia care. This equates to 37 of care staff being trained. Several care staff had completed training to be Assessors so that in-house training and assessment for NVQ’s could continue. Training records showed that staff had undertaken training in a variety of topics, such as health and safety, care planning, person-centred care, memory lane, safeguarding adults, an introduction to dementia care and communicating with people with dementia, dealing with challenging behaviour, wound care and infection control. Records showed that several new staff had received induction training in line with Skills For Care. Induction covered areas such as orientation, food safety, roles and responsibilities and health and safety and staff were asked to complete questionnaires afterwards to check their understanding of the information they received. In some of the records, although the trainer had signed to say that the training had been given, the candidate had not signed to say they had received it. Both parties should sign so that the records remain accurate. Comments seen from relatives who completed the home’s quality assurance survey confirmed that relatives felt the staff had the skills to properly care for the residents. Comments included “the whole team at Arbour Court are excellent” and “(staff) are professional and caring”. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. Systems are in place to create an open and inclusive atmosphere, which provides a positive home for people to live in. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The manager is registered with the CSCI and has nearly completed the Registered Manager’s Award. Other training, such as a leadership and development course in dementia care and a two-day course for managers in health and safety, have been arranged for later this year. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 24 The manager said that she has not arranged any relatives meetings for some time, as when they were last held the attendance was quite poor. In order to keep relatives up to date with developments in the home, a newsletter is produced and distributed quarterly. A quality assurance survey is undertaken annually and the manager had received 27 replies from questionnaires that had been sent out in June 2007. The manager was in the process of analysing the feedback. The regional operations manager from the company visits the home monthly and assesses how the home is performing. The manager said the company also employs a clinical development nurse who visits to help the manager identify areas for improvement. A clinical audit was undertaken in July 2007 and the record of this showed that staff were able to identify shortfalls and plan how they would be addressed. Staff do not deal directly with residents’ finances. Invoices are sent to the residents’ representatives for sundry expenses such as hairdressing and chiropody bills. Staff receive regular training and updates in health and safety topics and regular checks had been made of the building and equipment in respect of fire prevention and health and safety. Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 4 3 X 4 X X X 4 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13 Requirement The registered person must ensure that risk assessments and care plans are updated promptly to reflect any changes to a resident’s condition. This will ensure that staff receive the most up to date information on the care required. Timescale for action 07/09/07 Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 27 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 OP9 Good Practice Recommendations The registered person should ensure that where staff handwrite instructions about medicine administration on the residents’ records, the details are validated and countersigned by a second member of staff. The registered person should consider how staff can use the information they get about residents’ past histories, family contacts and interests to develop further individual social care plans for residents that meet their specific needs. The registered person should ensure that when staff are transferred from other homes within the company to work at Arbour Court, all the necessary documents and information are provided by the previous workplace. The registered person should consider holding relatives’ meetings as another means of gaining their views about how the home is running. 2 OP12 3 OP29 4 OP33 Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Arbour Court DS0000069256.V344748.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!