Inspection on 19/09/07 for Ascot Nursing Home

This inspection was carried out on 19th September 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

Ascot Nursing Home 02/05/06

Ascot Nursing Home 18/10/05

Ascot Nursing Home 04/05/05

Similar services:

21 High Street

Vale House

Chestnut Walk

The Old Vicarage

Cherwood House Care Centre

Ashley House

Fountain View

Wardington House Nursing Home

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Ascot Nursing Home Burleigh Road Ascot Berkshire SL5 7LD Lead Inspector Julie Willis Unannounced Inspection 19th September 2007 09:45 DS0000062218.V350258.R01.S.doc Version 5.2 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 DS0000062218.V350258.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 and Care Homes for Adults 18 – 65*. 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. DS0000062218.V350258.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ascot Nursing Home Address Burleigh Road Ascot Berkshire SL5 7LD 01344 620656 01344 621606 jillchuascot@aol.com 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) Ascot Nursing Home Limited Mrs Jill Chufungleung Care Home 72 Category(ies) of Dementia (15), Dementia - over 65 years of age registration, with number (29), Mental disorder, excluding learning of places disability or dementia (22), Mental Disorder, excluding learning disability or dementia - over 65 years of age (26) DS0000062218.V350258.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd May 2006 Brief Description of the Service: Ascot Nursing Home is an Edwardian House with a purpose-built extension set in its own grounds close to Ascot Village and Ascot Racecourse. The home is registered to provide nursing care for up to 72 people who have mental health needs, consisting of people who suffer from dementia or a mental disorder either in older age or under 65 years of age. The nursing home is divided into three units each function independently with unit offices, dining rooms, sitting rooms and distinctive staff teams. Unit one cares for residents of all ages who have been diagnosed as suffering from moderate to severe dementia. Unit two cares for older residents who have enduring mental health needs, and may need physical assistance. The Wrens unit cares for residents with enduring mental health needs who are generally able to maintain their own physical care with support and encouragement. The home has an appointed a Head of Care. The registered manager Mrs Jill Chufungleung is responsible for the overall management of the home. The cost of the service varies between £875 and £1100 per week depending on the level of support required. DS0000062218.V350258.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was a ‘Key Inspection’ and took place on Wednesday 19th September between 09:45 am and 5.10 pm. The inspection covered all the core standards for younger adults and older people. Prior to the visit a questionnaire was sent to the Manager along with survey and comment cards for residents, relatives and visiting professionals such as doctors and nurses. Any replies were used to help form judgements about the service. Consideration has also been given to other information that has been provided to the Commission since the last inspection. The inspector toured the building, examined records and met most of the residents and 5 relatives that were visiting at the time of the inspection. The inspector also spent time talking to staff and observing how care was being delivered to the residents. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals with various religious, racial or cultural needs. The inspector gave feedback about her findings to the homes Manager and ‘Head of Care’ at the end of inspection. There were no legal requirements made as a result of this inspection and only one recommendation. The Commission has received no information concerning complaints about the home since the last inspection. What the service does well: Ascot Nursing Home is well managed by an experienced, caring and enthusiastic manager supported by a competent and professional staff team. This is a specialist service, which meets the need of residents with enduring mental health needs and mental frailty. Staff at the home are highly skilled and well trained. Residents say that staff are “caring and kind” and there is a warm, welcoming and relaxed atmosphere throughout the home. There are enough staff on duty to meet the needs of residents. Written records are well kept and up-to-date. They provide staff with sufficient information to provide the right care. People living at the home are involved in decisions about their lives and play an active role in planning their care and DS0000062218.V350258.R01.S.doc Version 5.2 Page 6 deciding how their personal care and support is provided. Residents are able to make choices about their daily lives and are supported to develop life skills. The home enables people to take risks and helps them to remain as independent as possible. Effective risk assessment underpins all services that the home provides. The home has a team of six activity organisers who provide a range of interesting activities in which residents may participate. The ‘drop-in’ centre is particularly well used for people that require some ‘quiet time’ and the tuck shop is much appreciated. The provision of a minibus and full time driver has allowed residents the freedom to access the community more often and trips out to local venues are a popular pastime. The home and grounds are satisfactorily maintained and provide plenty of space for residents to enjoy in safety. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000062218.V350258.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) DS0000062218.V350258.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 (Adults 18 – 65) & Standard 3 (older People) Quality in this outcome is is good. All potential residents are fully assessed prior to their admission to the home to ensure that the service will be able to effectively meet their needs This judgement has been made using available evidence including a visit to this service. EVIDENCE: It is evident from discussion with management and examination of records that admissions are managed well and only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. All prospective residents are fully assessed prior to admission either at home or in hospital. DS0000062218.V350258.R01.S.doc Version 5.2 Page 9 The documentation for 8 people that use the service was examined and 3 residents were case tracked from pre-admission to date. The records evidenced that all necessary information about the users health and personal care needs were sought and recorded. Clinical tools were being used to assess the resident’s nutritional needs, communication needs and level of mobility. Manual handling risk assessments and ‘safe systems of work’ had been devised to reduce the likelihood of injury to residents and to staff. Tools to assess the residents risk of falls, continence needs and mental state were well developed. The inspector had the opportunity to meet all of the residents that were being case tracked. The relative of one of the residents was visiting at the time of inspection and spoke to the inspector at length. The relative confirmed that they had been provided with the opportunity to visit the home informally and been shown around by staff. The relative said, “ I was impressed by the calm relaxed atmosphere in the home”, “staff seemed to be warm and cheerful and appeared to be spending time with residents”. They went on to say, “ that they felt confident that the home was the right one” for their relative. DS0000062218.V350258.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 9 (Adults 18 – 65) and 7, 14, 33 (older People) Quality in this outcome area is excellent. People using this service are encouraged to make choices about their lives and to take everyday risks. The written records accurately reflect the individual needs, aspirations and lifestyle choices of people using the service. This judgement has been made using available evidence including a visit to this service. DS0000062218.V350258.R01.S.doc Version 5.2 Page 11 EVIDENCE: From examination of 8 care plans it was evident that the home encourages people to develop life skills and to enhance their level of independence if at all possible. The content of care plans evidenced that people are supported to take risks as part of their everyday life style and to experience new situations. Risk assessments were well developed and took into account the specialist needs of the individual balanced against their aspirations for independence, choice and normal living. Risks had been fully assessed and guidelines had been put in place to minimise the risk to people using the service. A number of the current residents regularly use public transport to visit local shops and other amenities and several residents go to visit relatives unsupported by staff. At the time of inspection one resident had been away from the home for three days and was keeping in touch with the home by phone to notify the staff of his whereabouts. The inspector was informed that this was part of his normal routine, had been agreed in a multi-agency meeting and was well documented. The inspector case tracked 3 peoples care. Records were up-to-date and accurate. It was clear that the staff had tried to involve residents in the care plan process from the outset and their input was clearly recorded in the care files. The home works in partnership with family members, other agencies and health professionals to benefit residents. Residents confirmed that they are encouraged to make choices and are supported in their decisions by the staff. One resident is currently undertaking a National Vocational Qualification to enhance her skills and knowledge. The resident told the inspector that they liked living at the home and felt well supported by staff. DS0000062218.V350258.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): DS0000062218.V350258.R01.S.doc Version 5.2 Page 13 Standards 12, 13, 15, 16, 17 (Adults 18 – 25) & Standards 10, 12, 13, 15 (Older People) Quality in this outcome area is excellent. People that use the service take part in activities that provide opportunity for personal, practical and emotional development and are encouraged to be part of the local community. People are provided with a menu that is nourishing, varied and meets their individual and cultural need. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are provided with the opportunity to engage in activities that are both stimulating and worthwhile. There was evidence that residents make good use of local community facilities including local restaurants, cinemas, sports centres, ice rinks and public houses. The home engages a team of 6 activity organisers managed by an activities co-ordinator. There is a programme of activities for each unit and a central ‘drop-in’ centre at the home where residents may spend quiet time, join groups or purchase small items from the on-site shop. Many residents in the dementia units experience one-to-one activities or musical therapy as a diversion and staff are constantly on-hand to provide the necessary supervision and support. The home also employs a dedicated minibus driver who is RMN (Registered Mental Nurse) qualified. His role is to take residents out on trips or visits to hospital and clinics. He is also available to take people on trips out to local beauty spots and other venues. Resident’s attendance at each session is well documented and their overall progress is monitored and forms part of their on-going care plan review. Several residents have participated in an annual holiday this year and several have spent long weekends with relatives and friends. Residents are positively encouraged to maintain their relationships. The home has recently started a ‘Sub-AQAA’ group where staff, relatives and residents look at how well the home is meeting residents need in all of the areas required by legislation. The group provides management with quality assurance feedback in all areas of practice on a regular basis. The home provides a nourishing menu, which meets the needs of its residents. The home offers a ‘healthy option’ at each mealtime to encourage good nutrition. Residents are provided with a wide choice and variety and are regularly consulted about the menus. Each lunchtime there are 5 alternatives and at suppertime 4 choices are offered. For those residents requiring support during mealtime’s staff provide assistance, which is discrete and sensitive, DS0000062218.V350258.R01.S.doc Version 5.2 Page 14 both to the resident they are helping and also to other residents living at the home. The mealtimes are a social time when residents can get together. All of the residents are encouraged to eat meals in the dining room. Comments made to the inspector about the service included “I am doing an NVQ 2, everyone is great here they are very helpful and I wouldn’t want to leave”. Another resident said, “The food is good, plenty of choice and its well cooked”. A relative said, “there is always something going on, the residents are visiting the circus soon” and “we are always made most welcome”. DS0000062218.V350258.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) Service users retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicines. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, 20 (Adults) & 8, 9, 10 (Older People) Quality in this outcome area is good. Sufficient information is in place to enable staff to effectively meet the health & personal care needs of residents. The system for the administration of medication is good with clear and comprehensive arrangements in place to ensure the safety of people using the service. This judgement has been made using available evidence including a visit to this service. DS0000062218.V350258.R01.S.doc Version 5.2 Page 16 EVIDENCE: The inspector case tracked three of the residents from their initial referral to the home by Social Services or mental health unit, to-date. There was evidence that the written records were detailed, comprehensive and well documented. Care was being delivered individually to each resident in a flexible consistent and reliable manner. Clinical tools were being used routinely to assess and monitor tissue viability, nutrition, dependency levels and mental state. Where a risk had been identified there were effective risk reduction measures in place and care plans gave clear guidelines to staff on how to reduce the risks identified. Risk assessments had been routinely undertaken on a range of risks including manual handling & safe systems of work, risk of falls, use of cot sides and bathing. In addition there were a range of risk assessments relating to the residents mental health and the need to encourage independence. These included the likelihood of a person absconding and any risks associated with verbal and/or physical aggression. From examination of documentation it is evident that the home reviews care plans monthly and any changes in residents need was well documented and was responded to appropriately. The plan is a working tool and staff are involved in writing the daily report and keeping the care plan up-to-date. Staff were observed to be polite and courteous to residents at all times. They were mindful of the need to encourage residents to remain as independent as possible by providing the appropriate level of support. It was evident that the staff team took a uniform approach to the behaviours of individual residents offering gentle persuasion and a range of diversionary tactics to reduce the likelihood of confrontation or challenges to the service. Staff are well trained in the care of people with mental health needs and are routinely given access to training in healthcare matters. To aid efficiency the home employs a dedicated trainer who offers regular courses on mental health issues, core skills and Mental Health Act training. Management confirmed that residents were provided with access to appropriate health and social care professionals when needed. The local GP visits regularly each Wednesday and in addition will visit when called. Screening and preventative treatments are offered routinely. There was evidence on file that users have regular chiropody treatments, hearing tests and sight tests. DS0000062218.V350258.R01.S.doc Version 5.2 Page 17 From examination of the medication administration system and discussion with staff it is clear that the home follows best practice guidance in relation to the storage, administration and disposal of drugs. The home operates a monitored dosage system and medication is delivered to the home on a monthly basis. Storage systems are effective and disposal systems using the ‘doom box’ system are safe. DS0000062218.V350258.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22, 23 (Adults) & 16,18 (older people). Quality in this outcome area is good. The home has a satisfactory complaints system. Residents feel their views are listened to and acted upon. Residents are protected from abuse and exploitation by staff that can demonstrate knowledge of the homes abuse of vulnerable adults and whistleblowing policies. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has a complaints procedure, which is clear and accessible to residents. Residents are provided with information on how to make a complaint to the home, the time scale for response and the stages and process of the Organisations complaint procedure. Examination of the complaint records indicated that there have been no complaints made to the home since 2006. The CSCI has not received any information about complaints about the service since the last inspection. DS0000062218.V350258.R01.S.doc Version 5.2 Page 19 Relatives and residents spoken to at the time of inspection confirmed that they felt confident that concerns would be taken seriously by the home and efforts would be made to remedy any problems in a timely fashion. They knew how to make a complaint, who they needed to report to and what to expect in terms of a response time. All said that they knew that the home would take steps immediately to resolve the issue and ensure that the matter was dealt with effectively. From examination of staff training records and from discussion with management and staff, it is evident that they receive training in the protection of vulnerable adults as part of their formal induction to the home. This learning is later consolidated when undertaking NVQ training in which it forms a core module. Staff interviewed were aware of the homes whistle-blowing policy and understood the importance of protecting the residents from abuse and exploitation at all times. DS0000062218.V350258.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 30 (Adults) & 19, 26 (Older people) Quality in this outcome area is adequate. Standards of hygiene in this home are good but the decor and furnishings are rather bland and institutional in design and could be improved to offer residents a more comfortable and homely place to live. This judgement has been made using available evidence including a visit to this service. DS0000062218.V350258.R01.S.doc Version 5.2 Page 21 EVIDENCE: The home is clean and hygienic throughout. Communal areas are spacious and airy and are well lit. There is however, a need to consider offering residents a more homely environment by improving the décor. It may benefit those residents with dementia if walls and doors were different colours rather than being painted in magnolia. This may help residents to negotiate around the home and enable them to locate the bathrooms, toilets or their own bedroom with more ease. There is an on-going programme of refurbishment and redecoration but there has been some deviation from the homes original 3-year plan. The home currently employs two full time handymen and uses contractors to carry out any larger projects or specialist works. All bedrooms are redecorated between occupants and residents may personalise their own room to their particular taste and preference. Most rooms are en-suite and there are many other toilets and bathrooms with aids and adaptations in the home. There are plans to have a qualified nurse in each unit who will take the lead in infection control matters. Information will be cascaded from the Manager and Head of Care who are currently undertaking a specialist MRSA course. Residents confirmed that the home is always clean, warm and comfortable and that they have the freedom to wander in the grounds and to spend time alone in their rooms or in any of the communal areas including the designated smoking room. DS0000062218.V350258.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34, 35 (Adults) & 27, 28, 29, 30 (Older People) Quality in this outcome area is good. The staff team were able to demonstrate that they have the necessary skills and experience to effectively meet the needs of residents in their care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents and relatives spoken with confirmed that the staff are “kind and caring”. One relative said “I have total confidence in the staff teams professional abilities, they are all kind, caring and approachable”. Rosters confirm that there are sufficient numbers of staff on duty at all times and that there retention in employment is high. There has been no reliance on DS0000062218.V350258.R01.S.doc Version 5.2 Page 23 agency staff to cover gaps in the roster, other than the temporary use of a kitchen porter during the summer holidays. The home employs staff of different ages, gender and ethnicity to reflect the resident mix at the home. There is awareness of the equality and diversity needs of the individual and the home is pro-active in translating this understanding into positive outcomes for people who use the service irrespective of race, ethnicity, age and sexuality. The home employs a dedicated Training Manager who oversees all training and development. Discussion with the Training Manager evidenced that much of the training is provided in-house including core skills, induction and specialist mental health training. Workers from oversees are routinely offered English Language lessons via Bracknell & Wokingham College if English is their second language. All staff are provided with the opportunity to gain external qualifications. Care staff are offered NVQ 2 & 3 in care and promoting independence. Housekeeping staff undertake a Level 1 or level 2 in support services for healthcare. Five of the senior staff are NVQ Assessors and the Training Manager is a qualified Assessor/Verifier. The home regularly sources external training and distance learning courses for the staff team. The home has achieved the ‘Investors in People Award’ and is constantly seeking to improve the recruitment, selection and training processes. A ‘personnel advisory company’ provides the home with specialist recruitment advice and support. The ‘sub AQAA’ group have a number of residents interested in being part of the recruitment panel for interviewing new staff. The management informed the inspector that there are plans to put this into operation within the next few months after providing residents with the necessary support and guidance. DS0000062218.V350258.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, 42 (Adults) & 31, 33, 35 38 (Older people) Quality in this outcome area is good. Service users benefit from living in a well run home, where there is evidence that their health welfare and safety is of primary importance. This judgement has been made using available evidence including a visit to this service. DS0000062218.V350258.R01.S.doc Version 5.2 Page 25 EVIDENCE: The Manager of the home - Jill Chu is well qualified with relevant nursing, managerial and teaching experience. She has run the home successfully for approximately 11 years and is well respected by her peers, senior management, staff, relatives and residents. The Manager has recently undertaken the Berkshire Care Associations leadership programme to further enhance her knowledge and skills and is currently undertaking a distancelearning course on the control of MRSA. The Manager is ably supported in her work role by her deputy, the newly appointed ‘Head of Care’ who is currently undertaking the Registered Managers Award and further distance learning courses to update her knowledge and skills. There is a registered nurse in charge of each unit and a team of nurses, carers and ancillary staff that provide on-going support to the residents on a daily basis. From discussion with staff there is evidence that the ethos of the home is open, inclusive and transparent. Staff confirm that they have the opportunity to express their opinions openly in staff meetings, supervision sessions and staff handovers. They say that they are provided with plenty of opportunity to express concerns, share information and to feel included and involved in the way the service is delivered and this is evidenced in the minutes of meetings. The manager of the home operates an ‘open door’ policy and actively encourages suggestions, comments and recommendations from residents, staff and relatives. Quality assurance feedback is constantly gleaned from residents and relatives meetings, the newly formed ‘sub AQAA’ group, staff meetings and formal questionnaire. The information is used to identify any gaps in service and to confirm that the home is effectively meeting its stated aims and objectives. Examination of a sample of the health & safety records indicated that they were up to date and in good order. Routine servicing and maintenance of equipment is undertaken at appropriate intervals to maintain the home as a safe and risk free environment for residents. All risks are effectively risk assessed and managed. Advice was given about ensuring there were up-todate records of hot water temperatures from outlets accessible to residents and the necessary records were supplied to the inspector by e-mail the day following the site visit. From examination of records and discussion with management it is clear that accidents and incidents are monitored to identify trends and reduce the likelihood of recurrence. DS0000062218.V350258.R01.S.doc Version 5.2 Page 26 Residents and relatives made the following comments about the qualities of the management and the running of the home. One user said, “I know that Jill and Emma will always listen to me” another said, “The managers are great they are always welcoming and kind”. A relative said, “I only recently moved my husband here. I am so pleased he moved when he did, he is a different man here because the staff take time to talk to him and encourage him to join in”, they went on to say, “This is a very good home”. DS0000062218.V350258.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 3 40 X 41 X 42 3 43 X 3 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X DS0000062218.V350258.R01.S.doc Version 5.2 Page 28 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA24 Good Practice Recommendations Consideration should be given to enhancing the quality of the environment for the residents with mental frailty by providing more interesting and stimulating surroundings. This could help residents to orient themselves in time and space more effectively. DS0000062218.V350258.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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. DS0000062218.V350258.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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