Inspection on 11/10/07 for Autumn House

This inspection was carried out on 11th October 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

Autumn House 23/09/08

Autumn House 30/11/06

Autumn House 27/04/06

Autumn House 19/10/05

Autumn House 29/04/05

Autumn House 18/11/04

Autumn House 12/05/04

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

CARE HOMES FOR OLDER PEOPLE Autumn House 21 - 27 Avenue Road Sandown Isle Of Wight PO36 8BN Lead Inspector Mark Sims Unannounced Inspection 11th October 2007 11:30 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 Autumn House DS0000012463.V348433.R02.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. Autumn House DS0000012463.V348433.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Autumn House Address 21 - 27 Avenue Road Sandown Isle Of Wight PO36 8BN 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) 01983 402125 Mrs Janet Holmes Post vacant Care Home 44 Category(ies) of Dementia - over 65 years of age (31), Old age, registration, with number not falling within any other category (44), of places Physical disability over 65 years of age (3) Autumn House DS0000012463.V348433.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. From time to time the service can admit people over 60 years in categories DE and PD. One service user in the MD(E) category will continue to be accommodated. 30th November 2006 Date of last inspection Brief Description of the Service: Autumn House is a large period property situated in a busy part of Sandown. The property has been extended in recent years and provides accommodation on the ground and first floors for up to 44 older people and is registered to provide care for up to 31 older people with dementia. The first floor can be accessed via a passenger lift and the addition of ramps, during the extension, has improved access for those residents who are not fully mobile. There is limited parking in the street and staff park in the courtyard area of the building, which restricts off road parking for visitors. There is a small area of garden to the rear of the property, with a terraced seating area. The fee’s for accommodation charged by the home range from £380 to £453. Autumn House DS0000012463.V348433.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a ‘Key Inspection’, which forms part of regulatory function of the Commission for Social Care Inspection; and measures the service against core National Minimum Standards. The fieldwork visit, the actual visit to the site of the home, was conducted over five and half hours, where in addition to any paperwork that required reviewing the inspector met with service users and staff and undertook a tour of the premises to gauge its fitness for purpose, several issues outstanding from the last inspection were also considered during the fieldwork. The inspection process involves far more pre fieldwork visit activity, with the inspectors gathering information from a variety of professional sources, the Commission’s database, pre-inspection information provided by the service, an Annual Quality Assurance Assessment (AQQA) and linking with previous inspectors who have visited the home. What the service does well: Significant investment has been committed to the business since the last inspection, with additional bedrooms and communal facilities having been created. Amongst the newer services to be introduced into the home, as a consequence of the improvements being made, are an Aromatherapy Suite and a Reiki Healing room, both of which are free services paid for by the home. The variety and number of communal areas are also a benefit for people, with four lounges and two dining areas available for use throughout the day. It was apparent, given the migration between these amenities that the service users both enjoy and benefit from having so many communal areas, as this allows people who like to walk around to find somewhere to rest and relax at the end of their journey. Service users are also benefiting from the management’s efforts to improve the presentation of the home, with several of the existing bedrooms having been redecorated and refurbished bring the standard into line with the newly created bedrooms. A reception style entrance has been established within the front hallway with a desk, brochure documents, information leaflets, copies of surveys and complaints/comment forms and a signing in book all readily available for people’s use. Autumn House DS0000012463.V348433.R02.S.doc Version 5.2 Page 6 The acting manager has introduced a number of new systems into the home, which are aimed at improving the monitoring of the service and the skills, support and development of the staff. The proprietor has supported the improvements in monitoring and managing the service through the purchasing of a computerised care services programme, which contains many features and functions including care planning, accident and incident recording; and an auditing and collation of information tool. What has improved since the last inspection? What they could do better: The new care planning system and computer technology that supports it is relatively new to the home and whilst in the long-term its functions and systems will be of use to the home and the staff team some initial difficulties are being experienced. The manager was, at the time of the fieldwork visit, unable to establish or furnish the Commission with details of how and when the monthly reviews of the care plans were taking place. The care plans also largely focused on the physical health care needs of the client’s and failed to consider or reflect the support required by people suffering from confusional or cognitive illnesses (Dementia, Alzheimer’s, etc). Review the home’s approach to managing medications to ensure secondary dispensing is not being carried out and revise the PRN protocols as discussed above. Autumn House DS0000012463.V348433.R02.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. Autumn House DS0000012463.V348433.R02.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 Autumn House DS0000012463.V348433.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 3 and 6: Prospective residents and their representatives have the information needed when choosing the home and have their needs assessed. EVIDENCE: The home does not provide an intermediate care service. The proprietor has made attempts to improve access to information for prospective residents and their relatives, through the creation/development of a reception area. On arriving at the home it was noticed that copies of the service’s brochure, the home’s last inspection report and a complaints/comments proforma were made available to people within this new facility. The proprietor who completed the Annual Quality Assurance Assessment Autumn House DS0000012463.V348433.R02.S.doc Version 5.2 Page 10 (AQAA) document in the absence of a permanent manager, makes a clear statement that: ‘We have a clear statement of purpose/service user guide which has just been reviewed. The guide is easy to read and laid out in clear format. This is given to every prospective client along with our terms & conditions (contract). We have a contract which states the room the client is occupying and the fee paid on admission. The contract is signed by the service user or their advocate after the first month. A copy is retained by the service user’. The indication, based on the receipt of six service user surveys, is that people do receive contracts as part of the admissions process, this was further confirmed by a relative who remarked ‘we signed a contract but have received no other formal assessment of his care needs’. Formal professional assessments of people’s care need are made to the home, copies of both care management assessments and discharge summaries, provided by the local hospital were seen on people’s files during the fieldwork visit. The acting manager also confirmed that she does visit each person prior to them being admitted to the home, although she prefers to use a more informal approach to assessment and has limited records of the assessment she undertakes, preferring to use this as an opportunity to supplement the information provided by the professionals. It has been suggested to the acting manager that she should consider formalising this process and maintain records of her visits, which include details of the information gathered. The overall indication is, however, that sufficient information, re the client’s needs, are made available to the manager before making a decision about the persons’ suitablity and the staff prior to the person arriving at the home. Autumn House DS0000012463.V348433.R02.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards 7, 8, 9 and 10: The health and personal care that people receive is based upon their individual needs and wishes, dignity and privacy issues are well managed, however improvements in the home’s medication management arrangements could be made. EVIDENCE: The provider has purchased and introduced a fully computerised care planning and social care management system, which does contain a variety of programmes, functions and tools, which should assist the staff and management with their roles. The plans produced are new to the staff and so far they have concentrated on people’s physical health care needs, with little attention given over to peoples emotional, psychological and social needs, although with time the manager believes this will improve. Autumn House DS0000012463.V348433.R02.S.doc Version 5.2 Page 12 The service users, due to their cognitive impairments, appear largely unaware of the care plans produced and maintained on their behalf, whilst their families acknowledge that plans or records are maintained but seem to feel isolated from the process, as evidenced by a statement included in the outcome area above. The acting manager, as with all the staff, is presently familiarising herself with the new system and was unable to recall how to generate a report, which recorded when the care plans had last been reviewed and updated. On reviewing some of the paperwork versions of the care plans it was not possible to identify when a plan was updated or reviewed, although some of the computerised entries did contain recent dates, which suggested that plans are updated when changes occur in a persons health states / circumstances, etc and not solely during the monthly reviews. In general the service users appear to have good access to health care support, with one client’s records documenting how they had recently been supported with their illness prior to being admitted to hospital, the records including information of consultant and nursing staff visits and changes in treatments, etc. Other service users records detailed when medical staff or health care staff had visited and contained copies of correspondence between the resident and clinical staff both pre and post clinic appointments. Information provided by the service users and their relatives indicate that people generally feel well supported when accessing health and medical care and that families, where necessary are kept informed of events effecting their next-of-kin’s wellbeing. Although some people felt the home were less forthcoming with details of events such as falls that people suffered and that since the previous manager had departed communications between the home and the families had tailed of slightly, although people acknowledged that this was most likely temporary, as the acting manager settled into the position. Medications were not being appropriately managed during the fieldwork visit, with staff observed dispensing medicines and handing them over to colleagues to administer. This technically is secondary dispensing, which is considered poor practice and does not adhere to current good practice guidance. However, the provider was quick to react to this information and before the fieldwork visit had concluded had implemented changes in the home’s medication process to eradicate this practice. Autumn House DS0000012463.V348433.R02.S.doc Version 5.2 Page 13 The management have also worked hard on developing PRN (as and when required protocols) including information on the client’s care plan, if they are prescribed a PRN medication and copying this advice to the medication records file. However, the protocols still require more attention if they are to achieve compliance with current best practice models, as they should include a description of the signs that indicate to the staff that that a particular PRN medicine needs to be given. The signs are different for different people and so should be individualized, ensuring that there is a common approach to the resident regarding this medicine by all members of staff. The protocol should also be drafted with the intention of setting out why the medication was prescribed, avoiding the situation of a multi-use medication being administered without the prescriber’s permission. Privacy and dignity appear well supported within the home, each bedroom door is fitted with a lock, which the occupant can choose to use if they wish, however they do need to be assessed to ensure they are able to manage the locks fitted, etc. In discussion with the provider it was stated that the home is shortly to introduce a new style of lock, which is operated by an electronic fob and which it is hoped will enable more people to keep their doors locked, whilst still ensuring they can enter if they wish. The provider has also created two treatment rooms where Reflexology and Reiki therapies can be carried out in solitude and privacy and communal areas were also noted to be fitted with appropriate locks. Autumn House DS0000012463.V348433.R02.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 12, 13, 14 and 15: People who use services are able to make choices about their life style and are supported to maintain their social, educational, cultural and recreational activities. Meals provide nourishment and variety, whilst the dining experience offers people the opportunity to socialise. EVIDENCE: As mentioned above the provider has introduced alternative therapies into the home, Reiki and Reflexology, which are free services to the residents, although the client’s General Practitioner has to be informed, as some therapies can conflict with contemporary treatments. The AQAA indicates that activities are made available on a day-to-day basis and that residents are kept informed of the events organised via a notice board. Autumn House DS0000012463.V348433.R02.S.doc Version 5.2 Page 15 During the tour of the premise the notice board was observed to be outside the small dining room adjacent to the lift and did contain a rundown of the forthcoming activities and events. The home also employs an activities co-ordinator, who splitting her role between care and the co-ordination of activities. During the fieldwork visit the co-ordinator was organising a trip out, which would appear to be a regular occurrence as one service user asking if they could go on the trip but informed they could not, as the trip was over subscribed and reminded that they had been on last weeks trip. Visiting arrangements also appear to be well managed and to meet the needs of the residents and their families, several groups of people were seen around the home during the visit and those spoken with felt the open visiting times suited their needs. Details of the home’s visiting arrangements are included within the ‘statement of purpose and service user guide’ documents, which according to the AQAA are provided to all clients or their relatives on entering the home. The new entrance reception provides an area for people to sign into the home and collect / digest information about the service prior to entering the main building. The choice of communal space and/or individual bedrooms provides the clients with a variety of location when entertaining families/visitors, should people wish to speak to the management in private, the recently completed building work has been designed to provided additional office space. The addition of the new extension has enabled the provider to increase the home’s dining space, with both a large and small dining room now available to the service users. The provider also has plans in place to refurbish the kitchen, which will improve storage and catering facilities. The home is currently operating a two weekly rotational menu, which has been based on the needs and wishes of the service users, as determined during residents meetings. Mealtimes appear well managed with sufficient staff available to support those service users who require assistance. People spoken with stated that they enjoyed the food provided at the home and the choice and variety of meal prepared. Autumn House DS0000012463.V348433.R02.S.doc Version 5.2 Page 16 The service user plans also contain ‘catering plans’, which document the support a person requires when eating and drinking, including utensils, etc, that they should be provided with to achieve independence when dining. Autumn House DS0000012463.V348433.R02.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 16 and 18: People who use the service are able to voice their concerns and have access to an effective complaints procedure and are protected from abuse. EVIDENCE: The dataset establishes the existence of the home’s complaints and concerns procedure, which was last updated in August 2007. The dataset also contains partial information about the home’s complaints activity over the last twelve months: No of complaints: 4. No of complaints substantiated: unspecified. No of complaints partially substantiated: unspecified. Percentage of complaints responded to within 28 days: 50 . No of complaints pending an outcome: unspecified. However, the indication is that complaints raised with the home are being appropriately handled, several complaints raised regarding the management of laundry within the home, prompting the provider to employ dedicated laundry staff. Autumn House DS0000012463.V348433.R02.S.doc Version 5.2 Page 18 Details of the home’s complaints process have been included within the ‘statement of purpose and service users guide’ documentation and a concerns and/or comments proforma is made available to people within the reception entrance should they require. The indication, from the relatives comment cards is that people are made fully aware of the home’s complaints process and will/have implemented it where necessary. The acting manager, previously held the post of training co-ordinator within the home, a role she continues to fulfil whilst overseeing the day-to-day operation of the home. During the visit the manager produced copies of the homes training matrix, which indicates that all staff have completed ‘safeguarding adults’ training and corroborated the information contained within the AQAA, which states that staff have undertaken ‘adult protection training’. The AQAA and Dataset also establish that policies for the protection of the service users are in place and have been reviewed / updated: ‘Safeguarding adults and the prevention of abuse’ and ‘Disclosure of abuse and bad practice’ both updated in August 2007. As mentioned within the summary the home has been the subject of several ‘safeguarding’ referrals and investigations, which lead to the previous manager resigning her position within the home. Following the ‘safeguarding’ investigation and the receipt of correspondents from us the home has made changes to the way service users finances are managed within the home, this is discussed within the management section of this report. Autumn House DS0000012463.V348433.R02.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 19 and 26: The physical design and layout of the home enables people who use the service to live in a comfortable environment, which promotes independent mobility and movement from room to room. EVIDENCE: The tour of the premise established that the communal areas of the home are in a good decorative condition and well furnished and equipped throughout. The service users and their relatives are continuously using the four lounges and two dining rooms during visits or generally throughout the day, people observed migrating between the different rooms during the fieldwork visit. Service users rooms were also being well maintained with several rooms within the older part of the home recently redecorated and refurbished to match the high standards achieved within the new extension. Autumn House DS0000012463.V348433.R02.S.doc Version 5.2 Page 20 The provider, as mentioned, has also created two alternative therapy suites, where people can receive treatments aimed at reducing tension and stress. In discussions with the provider, manager and maintenance co-ordinator it was stated that plans are in place for the complete refurbishment of the kitchen and alterations to the kitchen entrance/exit, which it is hoped will improve the delivery of meals to the service users tables. Plans are also in place to fit all bedroom doors with electronic locks, which are activated by a fob and therefore should enable more people to secure their bedrooms when they are not in the room. The lock is a one-way system and cannot be secured from in side the room, so alleviating the potential problem of people locking themselves within their bedrooms. Feedback from the service user surveys indicates that the home is considered to be clean and fresh. The AQAA and duty rosters establish that the home employs two domestic staff who work from 08:00 hrs to 14:00hrs daily. During the fieldwork visit only one domestic employee was observed working, although during conversation she explained that she would be working later, as her colleague had gone home early feeling unwell and she was completing her duties. In the past the home has received complaints about its laundry service, which was mentioned by several relatives via their surveys. In response to the complaints the provider has employed laundry staff, with one person working 07:00 hrs to 13:30 hrs and two further staff working 11:00 hrs to 17:00 hrs. Whilst mistakes are still occurring the manager and provider feel these have significantly reduced and the situation will improve further, as the new personnel become familiar with the role and the residents. The laundry was also re-sited and refitted during the recent extension of the home is fitted with large industrial washing machines and dryers, including a gas operated dryer. The manager, will need to ensure that staff are not tempted to short cut to the laundry via the kitchen, which it was observed is the quickest route to the laundry, although no one during the fieldwork visit was observed using this route. Autumn House DS0000012463.V348433.R02.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 27, 28, 29 and 30: Staff in the home are trained, skilled and provided in sufficient numbers to support the people who use the service and the management with the smooth running of the service. EVIDENCE: The acting manager previously held the position of training co-ordinator, which as mentioned is a role she wishes to continue with whilst overseeing the dayto-day operation of the home. During the visit the manager produced a training matrix, which she uses to record all of the training completed by staff and to monitor dates for the renewal and/or updating of knowledge/skills. The manager also produces for each staff member an individualised training portfolio/file, which also lists the training courses attended and completed. An annual training plan is also produced by the manager, which identifies when courses have been schedules, often with two or three sessions to enable all of the staff to attend. The provider, during the extension of the home included a training room within the plans and this was seen during the fieldwork visit. The room was noted to Autumn House DS0000012463.V348433.R02.S.doc Version 5.2 Page 22 contain a variety of learning materials, folders, videos/CD’s, booklets, etc, the manager explaining that she prefers to use a variety of training providers and educational presentations to ensure the staff are kept up to date. The manager has also introduced a number of monitoring tools to the training system, including a pre-attendance form, which establishes what the person hopes to gain from the training, an evaluation form, which reviews the course content and presentation and in house certificates. An in house induction is also used with all new staff prior to commencing the more detailed ‘Skills for Care’ induction programme. Information taken from the dataset and confirmed with the manager, indicates` that currently the home employs twenty-four care staff. Sixteen of the twenty-four care staff have completed a National Vocational Qualification (NVQ) at level 2 or above and this gives the home a percentage of 67 of its care staff possessing an NVQ at level 2 or above. The dataset establishes that a recruitment and selection strategy/procedure exists to support the management staff when employing new staff. It also indicates that all of the people who worked in the home over the last twelve months had undergone satisfactory pre-employment checks. On reviewing the files of several newly recruited staff all of the required checks were in place, Criminal Records Bureau (CRB) checks, Protection Of Vulnerable Adults (POVA) checks and two references. The files also contained completed application forms, health declarations, photographs of the employee, interview summaries, personal information and information used to support the CRB application process. Feedback taken from staff surveys indicate that people were happy with the recruitment and selection process and that they had undergone the required checks prior to commencing employment. Autumn House DS0000012463.V348433.R02.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 31, 33, 35 and 38: The management and administration of the home is based on openness and respect, and has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: The home does not presently have a Registered Manager, however an acting manager has been appointed and is to decide later this month whether or not she wishes to pursuit the permanent Registered Manager’s post. During the fieldwork visit the acting manager was found to be a very well organised and structured person, who has concentrated over the last few months on the introduction of several management tools, which are aimed at simplifying the task of running the home. Autumn House DS0000012463.V348433.R02.S.doc Version 5.2 Page 24 Process, such as, planned supervision (for staff), planned and scheduled resident and staff meetings, training plans / matrix and records, a review and updating of the home’s policies and procedures, three times a day room checks, which are intended to ensure people’s rooms remain clean and tidy, etc, and complaints/comment cards. The manager has also overseen the introduction of the new computerised care package and the creation of the new service user plans. Whilst some relatives have commented on the reduction in communication between the manager and the relatives of service users, people were quick to acknowledge that they felt this would be a temporary glitch, which would rectify itself as the manager became used to her role. Observations of the manager’s interactions with relatives and one excellent piece of communication skill displayed whilst supporting a client make a decision about going on the trip, suggests the manager has found her feet and is becoming accustomed to meeting and communicating with people. Another area of the service, which appears to have improved since the last inspection is the home’s quality auditing, which has been formalised and now includes and annual service user and relative survey, the results of which can be processed by the new computer database and evaluated. In addition to the questionnaires and/or surveys, the manager has also overseen the introduction of resident meetings with minutes for the last three meetings seen during the fieldwork visit and which addressed topics such as the delivery of care and the facilities. The manager, as mentioned, has also overseen a review of the home’s policies and procedures, scheduled formal supervision sessions for staff, scheduled staff meetings and introduced the room check system, which is designed to ensure people’s rooms are clean and their possessions safeguarded, as some clients due to their conditions can become disorientated and enter rooms that are not their own. As mentioned earlier within the report the home has been the subject of several safeguarding investigations, which have lead to changes in personnel and practice. One of the recommendations following such an investigation was that the home review the way it manages and safeguards individual client’s monies held on the premise, as some accounting irregularities were discovered. In order to comply with the recommendations of the investigation the home have introduced a tick (style) system, whereby the home purchases items or Autumn House DS0000012463.V348433.R02.S.doc Version 5.2 Page 25 pays for any treatments, services used by the client and then invoice the person or their representative accordingly. Receipts for all items purchased are retained by the home and each purchase is itemised on the invoice. Details of the new financial management system have yet to be included within either the home’s ‘statement of purpose or service users guide’, as the system is new. Should people wish not to participate in the new system each bedroom is fitted with a lockable draw, where small amounts of money and personal items could be safely maintained. A tour of the premise raised no immediate health and safety concerns and environmental risk assessments are, according to the manager, in place and available. However, the Commission would advice the manager to monitor staff accessing the laundry to ensure people are not tempted to short cut through the kitchen. The AQAA and dataset establishes that full health and safety policies/guidance documents are made available to the staff and that equipment is regularly maintained and serviced, gas, electrical installations, portable electrical appliances, hoists, baths, etc. Health and safety training is clearly made available to staff, with the training matrix providing evidencing of the health and safety training completed: moving and handling, infection control, first aid, fire safety, etc. Communal facilities were noted to contain both paper towels and liquid soaps and sluicing facilities on the ground floor contained infection control and COSSH information posters. Autumn House DS0000012463.V348433.R02.S.doc Version 5.2 Page 26 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Autumn House DS0000012463.V348433.R02.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 Requirement Timescale for action 26/11/07 2. OP9 Regulation The manager must ensure that 15 the service user plans include details/information of how people’s psychological, emotional and social care needs are to be meet. Regulation The manager must ensure that 26/11/07 13 any steps introduced to prevent secondary dispensing are maintained. 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 manager should review the home’s PRN protocols, to ensure they provide the staff with advice on the signs and symptoms, which would guide them to administer a PRN medication and how to monitor for the desired outcomes. Autumn House DS0000012463.V348433.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Autumn House DS0000012463.V348433.R02.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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