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Inspection on 14/06/07 for Arden Court Care Centre

Also see our care home review for Arden Court Care Centre for more information

This inspection was carried out on 14th June 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 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

Arden Court provides a comfortable environment for people to live in. The manager of the service demonstrated a thorough knowledge of the needs and wishes of people living at the home and had a clear understanding of the changing needs of people accessing residential services for care and nursing facilities. The service provides a varied and nutritious menu.Residents spoke positively about the support they received from the staff team.

What has improved since the last inspection?

Improvements had been made in the quality of what staff write on care plans, however, further development is still required. A permanent activities co-ordinator has now been employed and residents spoke positively about recent activities that have recently been made available. There had been improvements in the odour management throughout the building. Improvements had been made to the way complaints received by the home were recorded.

What the care home could do better:

Improvements must be made to the homes care planning process to ensure that the format in use can record all of peoples needs and wishes. Failure to record precise information may result in a person not receiving the care and support they need. All care and support delivered to residents must be documented in a manner that is understandable to ensure that people are able to read and respond to the records. Failure to do so may result in people not receiving the care and support they require. Risks assessments relating to individuals need to demonstrate that all the needs of the individual have been considered. Failure to do so may result in a person being put at unnecessary risk from harm. Improvements must be made to ensure that residents receive their medication at the time it is prescribed at. Medication Administration Records must be completed in full to ensure that all medication is accounted for and to demonstrate a detailed up to date record of what medication a person has actually taken. All residents need to have the opportunity to lock their bedroom doors to give the opportunity for privacy and the security of their personal effects. Staff must receive regular updated training for all aspects in their role to ensure that they are able to meet the needs of residents. Staff who do not receive regular up to date training for their role may put themselves and others at risk of harm by inappropriate care practices.

CARE HOMES FOR OLDER PEOPLE Arden Court Care Centre 76 Half Edge Lane Eccles Manchester M30 9BA Lead Inspector Adele Berriman Unannounced Inspection 14th June 2007 10:00 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 Arden Court Care Centre DS0000006693.V335464.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. Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Arden Court Care Centre Address 76 Half Edge Lane Eccles Manchester M30 9BA 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) 0161 707 9330 0161 707 9698 ardencourt@ashbourne.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited vacant post Care Home 47 Category(ies) of Old age, not falling within any other category registration, with number (44), Physical disability (3) of places Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 47 service users who require nursing or personal care may be accommodated. Three named service users are under 65 years of age and require care by reason of physical disability. If any of these service users leave or reach the age of 65 years the category will revert to OP. 5th January 2007 Date of last inspection Brief Description of the Service: Arden Court is a care home providing nursing and personal care for up to 47 older people. The registered owners are Ashbourne Eton Ltd. The single room accommodation is provided on two floors with communal day areas on both floors. Access to the first and second floors is by a passenger lift. Entry to the building is via steps or an access ramp and a manned reception is provided. The grounds include a large garden area with some car parking to the rear and side of the building. The home is on a main bus route, is close to the motorway network and a train station is five minutes away in Eccles town centre. Fees for the home are between £364.41 and £488.00 per week. Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by the Commission for Social Care Inspection (the Commission) in relation to Arden Court, prior to this visit. This information included a pre-inspection questionnaire completed by the manager of the service. Six service user survey forms were completed by residents and returned to the Commission. During the course of the visit, time was spent speaking to six residents, a relative of a resident, two staff and the manager of the home. The visit commenced at approx 11am and finished at approximately 6.45pm. Throughout the visit observations were made of care practices and a selection of records, policies and procedures were assessed. A tour of some areas of the building also took place. During the visit the key National Minimum Standards for Older People were assessed. Information from the six completed service users survey forms stated that all six people felt that staff listened and acted on what they said. Two people said that they always got the care and support they needed, three people said they usually did and one person said that they sometimes did. One person said that staff were always available when needed, three people said that they usually were and one person said that they sometimes were. One person said that they always received the medical support they needed, three people said that they usually received the medical support they need and two people said that they sometimes did. Two people said that they always liked the meals at the home and four people said that they usually did. All six people said that they knew how to make a complaint. What the service does well: Arden Court provides a comfortable environment for people to live in. The manager of the service demonstrated a thorough knowledge of the needs and wishes of people living at the home and had a clear understanding of the changing needs of people accessing residential services for care and nursing facilities. The service provides a varied and nutritious menu. Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 6 Residents spoke positively about the support they received from the staff team. What has improved since the last inspection? What they could do better: Improvements must be made to the homes care planning process to ensure that the format in use can record all of peoples needs and wishes. Failure to record precise information may result in a person not receiving the care and support they need. All care and support delivered to residents must be documented in a manner that is understandable to ensure that people are able to read and respond to the records. Failure to do so may result in people not receiving the care and support they require. Risks assessments relating to individuals need to demonstrate that all the needs of the individual have been considered. Failure to do so may result in a person being put at unnecessary risk from harm. Improvements must be made to ensure that residents receive their medication at the time it is prescribed at. Medication Administration Records must be completed in full to ensure that all medication is accounted for and to demonstrate a detailed up to date record of what medication a person has actually taken. All residents need to have the opportunity to lock their bedroom doors to give the opportunity for privacy and the security of their personal effects. Staff must receive regular updated training for all aspects in their role to ensure that they are able to meet the needs of residents. Staff who do not receive regular up to date training for their role may put themselves and others at risk of harm by inappropriate care practices. Arden Court Care Centre DS0000006693.V335464.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. Arden Court Care Centre DS0000006693.V335464.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 Arden Court Care Centre DS0000006693.V335464.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): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs were assessed prior to moving into the home to ensure their needs can be met. EVIDENCE: Resident’s needs were assessed before they moved into the home to ensure that the home had the facilities to be able to meet the individuals’ needs. The assessment was documented on a set pro-forma that contained tick boxes to demonstrate people’s needs and wishes. However, although the assessment format had the opportunity for the assessor to document the person’s physical, care and nursing needs there was little opportunity to document any needs specific to the individual’s lifestyle. This was discussed with the manager of the service who demonstrated on a recent assessment that she had carried out that she had written further notes on the persons needs. Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 10 Copies of the pre admission assessments were stored on resident’s files and information gained during the visit was transferred to the individuals’ care plan. Arden Court does not provide intermediate care facilities. Arden Court Care Centre DS0000006693.V335464.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. The care plan format did not use a person centred approach and did not fully reflect the resident’s needs; some medication practices have the potential to place residents at risk of harm. EVIDENCE: Each resident had a care plans and a sample of these were assessed. People’s assessments and care plans were documented on a pre printed format and needs were assessed via tick boxes and scoring. For example, the format for the dependency assessment with regards to continence uses a scoring system from 0=has full control of bladder to 4 = catheterised/urostomy. The set format for the care plans gave little opportunity for people’s specific needs that are individual to them to be recorded. There was an opportunity on one part of the care plan to record people’s individuality, for example, preference of Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 12 hair, does the person wear perfume etc, however, this section on many peoples care plans had not been completed. On occasions, the pre printed assessment and care plan format did not give staff opportunity to fully record peoples needs, for example, one dependency assessment stated a score of 4 = catheterised/urostomy, however, the resident had neither of these needs. The inspector was informed that staff had added a score 2 for occasionally incontinent by day and another score of 2 for occasionally incontinent by night together to demonstrate that the person was incontinent over the 24 hour period. However, the score of 4 on the assessment plan did not demonstrate to staff the actual needs of the person. Failure to record individual’s specific needs may result in them not receiving the care and support they require. Several care plans demonstrated that people with pressure areas were receiving the appropriate care. There was evidence of people having the use of appropriate pressure relieving mattresses, changes of positions during the day and regular visit from the Primary Care Trust’s Tissue Viability Nurse. Records also demonstrated that regular visits were made to the home by G.P’s. All five residents spoken to during the visit said that they were able to access their GP if they wished and they felt that their health needs were being looked after. Care plans contained individual risk assessments for individuals. These included risk assessments for falls, pressure areas and the use of bed rails. The majority of the assessments contained detailed information and records demonstrated that these assessments were reviewed on a regular basis. One care plan demonstrated that the resident had epilepsy. However, their risk assessment for the use of bed rails did not demonstrate this condition. Failure to not consider all known risks when assessing a situation may result in a person coming to unnecessary harm. There was evidence on some care plans that meetings had taken place to review the needs and wishes of people’s care. These reviews were documented on a set format and demonstrated that resident’s families had been invited to attend these reviews. One review demonstrated that the resident’s family had requested a wheelchair on their relative’s behalf. Further records demonstrated that the manager of the home had actioned this request promptly. Staff maintained regular records of what care and support had been delivered throughout the day and night. However, the inspector was unable to read some of the records due to the handwriting style in which they were written. The manager stated that this was a concern that she was in the process of addressing the situation. The content of the majority of records was informative and gave clear information about the individuals needs being met. However, some records were written in an impersonal manner and gave no information, for example, “she was assisted with turning and pad change”, Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 13 “she slept for most of the night” and “no change.” These statements give no indication of care and support people have been offered or received. Throughout the visit staff were observed knocking on people’s doors before they entered and addressing people in a respectful manner. On arrival at the home a member of staff informed the inspector that they had completed administering the breakfast medication at 11am and that this was due to a member of staff being late and also having to contact the next of kin of a resident. The administration of the teatime medication was completed at 6.55pm. It is essential that residents receive their medication at the time prescribed. All medication was stored in a locked secure environment. A sample of six Medication Administration Records (MAR) were looked at, of these, three were completed appropriately. However, three of the records did not contain all the information required. For example, one record had gaps where the signature should have been and no explanation had been recorded. Another record stated that fucidin cream was to be applied three times a day. There were some signatures to demonstrate that the cream had been applied and some boxes had not been signed. One record for a resident had been handwritten and contained the name of the medication and the dosage, however, there was no record of when the medication was commenced or the amount of medication that was received. Controlled drugs were stored appropriately and the amount of medication held corresponded with the record book. Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 14 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. This judgement has been made using available evidence including a visit to this service. Residents can be assured of a balanced and nutritious diet. Different activities provided suited the needs of most residents. Bedroom door locks would help to ensure residents expectations around privacy in bedrooms is better respected. EVIDENCE: An activities co-ordinator is employed at the home for thirty hours each week over a five-day period. A plan of activities is displayed in the foyer of the home along with recent photographs of resident enjoying different activities and enjoying the garden. Four residents told the inspector that they enjoyed the activities in the home. One person said that they’d really enjoyed a trip to the Lowry Theatre and another person said that she’d been out shopping for some clothing the previous day to Salford Precinct. Three people stated on their service user survey form that there were always activities arranged by the home that they can take part in; two people said that there usually was. One person stated that there was sometimes activities arranged by the home that they could take part in as they “struggle to do Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 15 them.” Another person wrote that the activities co-ordinator gets them involved. During the visit preparations were underway for an event scheduled for the following day in aid of Elder Abuse Awareness day and also to celebrate a residents 100th birthday. Several visitors were seen entering and leaving the building throughout the day. One visitor who was visiting his wife said that he was always made very welcome by the staff. All five residents spoken to during the visit said that visitors were welcome at any time. All residents who spoke to the inspector during the visit said that they opened all their mail themselves and that they had a choice as to whether they took part in activities around the home. Several of the bedrooms around the home did not have locks on them. One resident stated that she would like a lock on her room to prevent any other resident entering her room whilst she was not there during the day and when she was in bed at night. Residents should be given the opportunity to secure their private space and personal effects at all times. The manager stated that plans were in place to ensure that the home would meet the requirements of the No Smoking Legislation that comes into force on the 1st July 2007. These plans included new signage within the building and a dedicated ‘smokers’ lounge for residents only. Since the last inspection the ‘Nutmeg’ menu system has been introduced into the home. The system provides a facility to produce nutritionally balanced menus. A selection of menus was seen to provide a choice of a hot or cold breakfast and a choice of cooked meals for lunch and the evening meals. The menus demonstrated that mid morning and mid afternoon biscuits and fruit were offered and a sandwich selection for supper. Residents spoke positively about the food served at the home with three people saying that the food was “very good” and one person saying “very good in the main”. During the visit one resident said that they preferred a fried egg with for their breakfast and this was not always available. The resident said that she knew that poached or scrambled eggs were always available but as they made her toast “soggy” she preferred a fried egg. This information was passed to the manager who said that she would address the situation. Two people indicated on their survey that they always like the meals at the home and four people said that they usually do. One person wrote regarding the food in the home “I am always satisfied.” Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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. Residents are comfortable in using the home’s complaints procedure. People living and working at the home would benefit from having more information available relating to local safe guarding adults procedures. EVIDENCE: The home had a complaints procedure that was displayed. A register was in place to record any complaints received by the home. Information recorded included a reference number, the date the complaint was received, who recorded the details of the complaint, a brief detail of any action taken, the date it was resolved and the home managers signature. Information on the register was up to date. Information supplied in the pre inspection questionnaire stated that the service had received four complaints in the last six months all of which had been substantiated and had been responded to within twenty-eight days. All residents spoken to during the visit said that they felt comfortable in raising any complaint they had with the care manager or the home manager. Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 17 All residents who completed the service user survey forms stated that they knew how to make a complaint. One person stated that they would speak to the manager of they were not happy or “if only bits they ask the carers.” A copy of Salford Social Services joint agency Safeguarding Adults policy and procedures was available at the home along with the organisations own policy on adult protection. However, the policy relating to adult protection did not refer to Salford Social Services Safeguarding Adults procedures. Discussion took place with the manager regarding the need for the in-house policy on adult protection to refer people to Salford’s procedures to ensure that everybody is aware of what action to take if any acts of abuse are suspected or take place. The manager said that she would ensure that this information was made available to staff. During discussion the manager demonstrated a good awareness of adult protection issues. However, training records demonstrated that only two members of staff had received adult protection awareness training. It is essential that the managers and staff receive awareness in adult protection procedures to ensure that they are aware of what action to take in the event of a concern. Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that the premises are safe and the environment was well maintained externally and internally. One area of the home had an offensive smell that if further addressed, could improve residents experience in the home. EVIDENCE: The building was accessible to all by way of a ramped entrance at the front of the building and an internal passenger lift that enable people to access both floors. There is an ongoing programme of redecoration and a ‘handy person’ is employed to carry out regular maintenance and equipment testing. Communal areas were furnished with furniture to meet the needs of residents. Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 19 Several bedrooms were visited on the day of the visit and people’s personal effects were present in their rooms. One resident had taken the opportunity to install a microwave and a small fridge in their room for their convenience. Appropriate laundry facilities are available within the home. The home was clean and tidy. However, a small area on the first floor of the building was extremely odorous. Staff stated that they were continually trying to address the situation. The area smelt strongly of urine. Five people stated in their service user survey forms that the home was always fresh and clean and one person said it was usually fresh and clean. The home has a procedure for the disposal of clinical waste. Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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. Staff were deployed in sufficient numbers to meet the needs of the residents, however, staff training in relation to health and safety and adult protection must be updated at regular intervals to ensure the health and wellbeing of all residents. EVIDENCE: At the time of the visit there were was a nurse and three carers on duty on the first floor and a nurse and two carers on duty on the ground floor of the home to meet the needs of the residents. Staff confirmed that these were the ‘usual’ number of staff on duty. Waking night staff were available throughout the night to meet residents needs. All six residents who responded to the survey stated that staff listen and act on what they said. Positive interaction was observed between staff and residents. Staff were seen to address residents in a respectful manner and demonstrated a good knowledge of residents needs and wishes. Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 21 The service has a procedure for the recruitment of staff. Six staff files were assessed and the contents demonstrated that appropriate POVA (Protection Of Vulnerable Adults) and CRB (Criminal Records Bureau) checks had been carried out on employees. Records also demonstrated that two written references had also been sought prior to the staff member commencing employment. Some staff files contained evidence that the member of staff had been through an induction process at the beginning of their employment. Some, but not all files contained training certificates for pressure prevention, moving and handling and health and safety. A training matrix for the staff team dated 25.05.07 demonstrated that the majority of staff had received training in fire safety, food hygiene, and moving and handling. However, the matrix also demonstrated that only five staff members had received training in C.O.S.H.H (Control of Substances Hazardous to Health), only eight staff had received training on Healthy and Safety and only two staff had received training in Abuse and POVA. The matrix demonstrated that only one staff member had received training in infection control and the information supplied stated that no staff had received first aid training. It is essential that all staff receive regular updated training relevant to their role to ensure that peoples needs are met at all times with safe practice. Information supplied by the service prior to the inspection demonstrated that approximately 33 of the care staff team had completed a National Vocational Qualification level 2 or above. Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 22 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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents need to be assured that the person who is responsible for running the home has been assessed as being fit to be in charge by the Commission. The health and safety of residents, visitors and staff at the home is promoted by the organisations policies and procedures. EVIDENCE: The current manager of the home had been in post for approximately seven months and was in the process of submitting her application to register as manager with the Commission. The last inspection of the service required that such an application be made and this matter is still outstanding. Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 23 During the visit the manager demonstrated a detailed knowledge of her role and the changing needs of people accessing residential care. The organisation had a corporate procedure for the improvement and monitoring of peoples views on the service. Several questionnaires had been completed and the manager confirmed that she was going to evaluate the information and produce an action plan from the responses. Minutes were available from recent residents meetings held in the home. The home has a non-interest bearing account system in which residents personal money is banked. All transactions are documented and receipts kept on file. The balances on these accounts are randomly checked on a regular basis. A representative of the organisation (the responsible individual) makes monthly visits to the home, and reports of these visits are regularly sent to the Commission. These reports demonstrate that regular random checks are carried out on the accounts of peoples personal finances managed by the home. Corporate policies and procedures relating to health and safety were available in the home and the manager demonstrated that these policies were updated on a regular basis. However, these policies and procedures were stored in the managers’ office, which was locked at times and not always accessible to staff. The manager stated that she would relocate the policies to make them accessible at all times. Staff at the home maintained a record of accidents. These records were stored appropriately. A recording system was in place for the monitoring of hot water temperatures, fire detection equipment etc to minimise any risks of harm to people. Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 24 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 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 25 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. Standard OP7 Regulation 15 (1) Requirement Residents needs and wishes must be fully documented to ensure that staff are aware of what care and support the individual requires at all times. All care and support offered/delivered to residents must be recorded so that it is readable using appropriate language. All residents should receive their medication at the time it was prescribed. A full record of all residents prescribed medication must be kept to ensure that a full audit trail of the medication is available at all times. All Medication Administration Records must be completed appropriately at all times. Locks must be provided on bedrooms doors for those residents who wish to have them in order to promote privacy for the individual and to secure personal effects. DS0000006693.V335464.R01.S.doc Timescale for action 27/07/07 2. OP9 13 (2) 20/07/07 3. OP14 12 (4) (a) 03/08/07 Arden Court Care Centre Version 5.2 Page 26 4. OP18 18 (c) (i) 5. OP30 18 (c) (i) 6. OP31 9 All staff must have training in 03/08/07 the local safeguarding adults procedures to ensure all residents are properly protected from abuse. All residents must have all their 03/08/07 care and nursing needs met by staff who receive regular up to date training in their role. So that residents are assured 27/07/07 that the person who is responsible for running the home has been assessed as being fit to be in charge by the Commission; an application must be submitted for the registration of manager. This requirement is outstanding since 14.12.06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations It is strongly recommended that the services pre admission assessment format be revised to ensure that all of the unique needs of the person can be identified and documented. It is strongly recommended that all policies and procedures are stored in a place that is accessible to all staff at all times. It is strongly recommended that all risk assessments relating to individual residents should demonstrate that all identified factors relating to the individual have been considered 2. 3. OP38 OP7 Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 27 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 Arden Court Care Centre DS0000006693.V335464.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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