Inspection on 17/03/08 for Ayresome Court

This inspection was carried out on 17th March 2008.

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

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Turret Villa Retirement Home

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Mendip House

Beaconsfield Court Care Home

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

CARE HOMES FOR OLDER PEOPLE Ayresome Court Green Lane Yarm Stockton-on-Tees TS15 9EH Lead Inspector Katherine Acheson Key Unannounced Inspection 17th March 2008 09:40 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 Ayresome Court DS0000071021.V360363.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. Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ayresome Court Address Green Lane Yarm Stockton-on-Tees TS15 9EH 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) 01642 7888280 01642 7888287 ayresomecourt@bondcare.co.uk Southern Cross BC OpCo Ltd Mrs Pamela Ann Jackson Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43), Physical disability (5) of places Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 43 2. Physical Disability, Code PD, maximum number of places 5 The maximum number of service users who can be accommodated is: 43 Date of last inspection Brief Description of the Service: Ayresome Court is registered to provide personal and nursing care to fortythree older people. The home is situated on the outskirts of Yarm and is close to shops and a pub. Ayresome Court is a purpose built facility. There are two lounges, a dining room and a hairdressing room. All bedrooms are single in nature and all have ensuite facilities, which comprise of a toilet and hand washbasin. All bedrooms meet with size requirements of National Minimum Standards. Gardens and grounds to the front and rear of the property are accessible to people that use the service and well maintained. The cost of care at the time of the inspection visit ranged from £467.50 to £568.50 per week. Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars. This means that people who use this service experience good quality outcomes. This announced key inspection was carried out on 17th March 2008 and lasted for eight hours in total. An expert by experience also spent some time at the home. An expert by experience is a person who, because of their shared experience of using services or ways of communication visits a service with an Inspector to help them to get a picture of what it is like to live in or use the service. The expert by experience spoke to ten people that use the service; three care assistants and three sets of relatives. The manager was not present at the time of the inspection, however the homes deputy manager and operations manager were present. The reason for the inspection was to see how good a job the home does in meeting the National Minimum Standards set by the government for Care Homes. Numerous records including care plans, complaints and staff recruitment and training records were examined. The Inspector spoke at length to one person that uses the service and in general to others. The Inspector also spoke to two care staff, the laundry assistant, the deputy manager of the home and the operations manager. The Inspector walked around the home with the deputy manager. Before the inspection twenty surveys for people who use the service and twenty surveys for relatives were sent to the home for the manager to distribute accordingly. Surveys requested feedback on the service and staff provided. We did not receive any surveys from people who use the service but we did receive nine surveys from relatives. Comments received can be read within the report. The manager completed and returned an Annual Quality Assurance Assessment, (AQAA). The AQAA is the services self-assessment of how they think they are meeting national minimum standards. This information was received before the inspection and was used as part of the inspection process. The details of any issues identified at this inspection requiring action are to be found at the back of this report. Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Care plans for acute medical problems need to be updated each time the person has received treatment to ensure that all staff are up to date on planned care, deteriorations or improvements made. Skirting in bathrooms needs to be replaced or repaired so that it can be easily cleaned and as such ensure that bathrooms are hygienic. Records must be available within the home to confirm that Criminal Record Bureau checks are carried out on staff. All new staff who are not qualified to NVQ level 2 in care must complete a skills for care induction programme. Water temperatures of baths, and showers should be taken on a weekly basis as recommended by the Health and Safety Executive. Ayresome Court DS0000071021.V360363.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. Ayresome Court DS0000071021.V360363.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 Ayresome Court DS0000071021.V360363.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): Standards assessed 3 and 6 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Assessments of people who are to use the service are carried out to ensure that the home can meet their needs. EVIDENCE: The deputy manager said that before going into the home people who are to use the service are assessed by a social worker or health care professional to determine if they need nursing or personal care. Staff at the home then carry out their own pre-admission assessment either visiting the person in their own home or at hospital to ensure that the needs can be met at Ayresome Court. Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 10 If people are self-funding then an assessment is usually only carried out by experienced staff working at the home. The deputy manager said that people who are to use the service and relatives are encouraged to visit and spend some time to ensure that it is the right place for them. One person that uses the service who spoke to the expert by experience said, “I had been very ill and couldn’t manage. My family looked at four homes then found this one. I was pleased when I came to see it. It was just what I wanted as long as there was a room with a view on to the front, and there was!” The home does not provide intermediate care and as such standard 6 does not apply. Ayresome Court DS0000071021.V360363.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): Standards assessed 7, 8, 9 and 10 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a good standard of care, people using the service are happy and care received is based on their individual needs. Procedures are in place to ensure good management of medication to ensure safety of people using the service. EVIDENCE: Two plans of care were looked at during this visit both of which contained detailed information about the person using the service and the help they needed. One plan of care looked at was that of a person with complex nursing and care needs. This plan of care included likes and dislikes of the person and included clear evidence of choice. Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 12 Both people that use the service had been asked if they preferred care to be given by a male or female staff and this was clearly recorded. Information was also recorded on how to promote privacy and dignity. The home is in the process of changing over to new care plan documentation and as such there was a mixture of old care plan documentation and new on file. The operations manager said that all information for people that use the service is to be transferred onto the new documentation within the next couple of months. In general care plans were updated on a monthly basis or more often if required, however a care plan for one person that needed a dressing applying was not updated as often as it should be. This was pointed out to the operations manager who said that she had already spotted this in an audit and that she is taking steps to address it. Files of people who use the service included healthcare visits and appointments. The records showed the regularity of visits for treatment from: doctors and district nurses, opticians, dentists and other healthcare specialists. People who use the service confirmed that their dignity and privacy was respected. One person said, “They knock at the door before entering and say who they are”. The expert by experience spent some time talking to staff a comment made by the expert included, “I spoke to members of staff who were getting people into the dining area. They had to use a special lift to get some people from the easy chairs to the wheelchairs. They did it well and told me that they had been trained to do the lifting and use the machine”. People who use the service, relatives spoken to during the inspection by the expert and Inspector, and surveys received said, “The care staff make every effort to ensure that my mother is able to maintain her dignity, independence and privacy within a secure and supportive environment” “Ayresome Court looks after the welfare of my mum and the rest of the family. The staff are like a family to us and if we can’t care for her at home there is no better place. They are a great support” “The staff on the whole are pleasant and will respond if asked for anything” “The staff are very nice” Surveys asked relatives how they thought the service could improve. Comments received in a number of surveys included having a member of staff Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 13 in the lounge at all times. The deputy manager said that this had already been pointed out and as such the home now allocates a member of staff during the day and evening to be in the lounge area. This member of staff is to chat with people that use the service and inform other care staff if someone needs assistance. Another area pointed out as needing improvement is the alarm call system. Some relatives that completed the surveys felt that when someone called for help the alarm call was not answered quickly enough and that it was too loud. The deputy manager said that she is in the process of monitoring the call alarm system to see how quickly calls were answered. She said that it can appear that the call alarm can go on for some time but this could be one person after another calling for help, not the same person. The deputy manager said that she would speak to the people that use the service and relatives regarding the call alarm at the next meeting at the home in April 2008. During the inspection arrangements for receiving, storing, administering, recording and disposing of medication were observed and examined. The ordering and returning of unused medication was good and records were well written. Nurses are responsible for giving out medication to people that use the service. A medication audit of one person who uses the service was carried out. Medication administration charts had been completed correctly and the stock balance of medication belonging to the person was correct, matching up with medication ordered, received, administered and remaining in the home. Medicines were stored appropriately. Appropriate records and storage are in place for controlled drugs. Ayresome Court DS0000071021.V360363.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): Standards assessed 12, 13, 14 and 15 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Appropriate and enjoyable activities do take place at the home and people are able to exercise choice and control. Visitors are encouraged and made to feel welcome at anytime. Food provided is enjoyed by people who use the service and provides them with a wholesome balanced diet. EVIDENCE: The home employs a diversional therapist to plan, arrange and take part in activities for people who use the service. The diversional therapist works twenty hours a week over four days (Monday to Thursday). The deputy manager said that hours worked are flexible and can change depending on activities planned. Activities taking place include, cards, dominoes, flower arranging and bingo. On a morning the diversional therapist reads to a number of people that use the service, this can be reading from a book or a newspaper. Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 15 The home is visited by the Library bus, which provides a large selection of books for those people that use the service. Large print books and audiotapes are also available for the visually impaired. The deputy manager spoke of recent entertainment provided at the home. This included a jazz group and a ladies harmony group. People that use the service said that they enjoyed the singing and organ playing of a relative who visits on a regular basis. A St Bernard P.A.T dog visits the home. A P.A.T (pets as therapy) dog is a pet that has a friendly temperament that has been approved to visit a service e.g. a care home and spend time with the people that live there. People that use the service are encouraged to join in activities and mix with others. Some people choose not to join in activities, one person was observed to be reading the newspaper in a seating are in the corridor whilst another was knitting. A hairdresser visits the home on a Tuesday. One survey received from a relative commented that on the day the hairdresser comes in the diversional therapist is unable to do activities as she spends time assisting those people that use the service visiting the hairdresser. The deputy manager and operations manager said that they would look to change this so that activities can take place. People that use the service and relatives said that the home has its own minibus, however it has been broken for sometime. The deputy manager said that the company that owns and operates Ayresome Court also has a minibus, which is shared between a number of homes and that trips out are to be planned over the coming months. People living at the home said that they had been out with relatives and one person regularly uses dial a ride. Visits from relatives and friends are welcome at any time. Relatives are able to spend time and enjoy a meal at the home. People who use the service are encouraged and supported to practice their religion. Ministers from the local Church of England and Methodist church visit on a two weekly basis. A representative from the local Roman Catholic Church visits every Sunday to give those who want it communion. The lunchtime of people that use the service was observed. The inspection day was also St Patrick’s Day. The homes dining room was decorated beautifully. People that use the service, kitchen staff and the diversional therapist had been involved in making decorations for the dining room. Tables were set with green tablecloths and napkins and Guinness bottles filled with daffodils were used as table centres. The lunchtime menu of the day had also Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 16 been themed to the day, the choices being mince and dumplings or bacon chop, cabbage and mashed potato. One person who uses the service who was spoken to during the inspection said, “We helped to make the decorations and had great fun”. People who use the service and surveys received in general spoke positively about the food provided. Comments made included, “The food is really nice and plenty of it” “I enjoy all of the food” “The food is lovely” “The food could be a bit more adventurous” Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 16 and 18 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were confident their complaints would be listened to, taken seriously and acted upon. Adult protection procedures are in place, which helps to protect residents from abuse. EVIDENCE: The home has a complaint procedure, which informs people who use the service and relatives of their right to complain, timescales for action and who to contact. The home keeps a record of complaints. There have been thirteen complaints made in the last twelve months, three of which have been since November 2007 when there was a change in ownership. The home has an adult protection policy that details action that staff should take if abuse is suspected. The Manager said that staff receive adult protection training on induction and on a regular basis thereafter. The deputy manager and care staff spoken to during the visit were able to inform the Inspector of procedures that should be followed if abuse is suspected. There has been one adult protection referral within the last twelve months. This was dealt with appropriately by the home. Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 18 People who use the service said that they felt safe and said that they are able to raise any concerns they may have with care staff or the manager of the home. Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 19 and 26 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of the environment within this home is good providing the people who live there with and attractive, homely and comfortable place to live. Redecoration and replacing the carpets on the first floor corridor will further enhance this. EVIDENCE: The home is a modern, two storey, purpose built facility. It is situated on the outskirts of Yarm and is close to shops and a pub. There are two lounges, a dining room and a hairdressing room. All bedrooms are single in nature and all have ensuite facilities, which comprise of a toilet and hand washbasin. Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 20 Gardens and grounds to the front and rear of the property are accessible to people that use the service and are well maintained. The Inspector walked around the home with the deputy manager. The home in general is well maintained. Lounge areas are pleasant and homely and furniture provided is of a good standard. The first floor corridor is in need of re-decoration and the carpet needs to be replaced as it is worn and marked. The deputy manager said that the first floor corridor is to be re-decorated and the carpet replaced in the next few months. A number of bedrooms were visited, these were observed to be very personal, with residents having their own furniture such as tables and chairs as well as more personal items. The deputy manager said that there is a rolling programme in place for re-decoration of bedrooms. The deputy manager said that radiator guards in the home environment are to be renewed and will be more decorative than the wire guards that currently cover most of the radiators in the home environment. The home has a policy in respect of control of infection. Staff spoken to during the inspection said that there was always a plentiful supply of protective clothing. A number of bathrooms were looked at during the visit. In some of the bathrooms the skirting around the walls had come away from the wall and as such did not make surfaces readily cleanable. The deputy manager said that this had been reported to the estates department who are going to organise a repair. On the day of the inspection the home was clean and odour free. Appropriate laundry facilities are in place. A discussion took place with the Laundry Assistant during the walk round who was able to demonstrate knowledge in respect of hygiene requirements and procedures to follow to prevent the spread of inspection. Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 27, 28, 29 and 30 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management of the home spoke of a robust recruitment process, however, evidence was not available to confirm that appropriate Criminal Record Bureau checks are carried out on staff before they start work to help to ensure the safety of people that use the service. Staff do receive a rolling programme of mandatory training, however not all staff who need to have completed an induction programme, which could impact on care given. EVIDENCE: At the time of the inspection there were thirty-nine people living at the home. The homes duty rota showed that there are six care assistants on duty on a morning; five in an afternoon and five in an evening and three care assistants on night duty. In addition there are two trained nurses on duty during the day and one at night. Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 22 The operations manager said that the manager of the home, who is also nurse, is supernumerary and as such works in addition to the staff numbers above. The duty rota at Ayresome Court did not identify working hours for the manager. People who use the service who were spoken to during the visits and surveys received felt that there was sufficient staff on duty. The AQAA detailed that over 80 of care staff working at the home have achieved a minimum qualification of NVQ level 2 in care. The files of two newly appointed staff were looked at during the visit. Files examined contained the majority of the required information, a photograph of the staff member, proof of identity and two references. The operations manager spoke of a robust recruitment procedure and said that appropriate criminal record bureau checks are carried out on staff before they start working at the home. She said that a check of the POVA (Protection of vulnerable Adults) list is undertaken to ensure that staff are safe to work with adults and then an enhanced criminal record bureau check is carried out. The operations manager said that it is usual practice that staff do not start work until the home are in receipt of a satisfactory POVA check and Criminal Record bureau check. She said that in the event of needing a care staff member quickly then the staff member would start working at the home following a POVA check and be supervised until a satisfactory Criminal Record Bureau Check was received. At the time of the visit the operations manager was unable to locate evidence to confirm that Criminal Record Bureau Checks had been carried out. The Inspector was informed that all checks had been destroyed. People who use the service and surveys received in general spoke highly of the staff team, comments made included, “Care staff do a good job, they work hard and care for us well” and “The staff seem to enjoy their work and take pride in it. They offer support and advice to relatives and carers as well as people that use the service” Staff files looked at during the visit did not contain evidence to confirm that staff had undertaken induction. The deputy manager said that care staff had been given their induction booklet and must have it at home. The operations manager spoke of an in depth induction programme that care staff working at the home follow and that meets with the required standard of skills for care. The operations manager said that she would do an audit of staff files to look at who needed to undertake induction. A training matrix was available and showed that staff last received fire training in December 2007 with others sessions planned for the year a head. Moving and handling training took place in May 2007 and adult protection training on Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 23 August and September 2007. The operations manager spoke of a new training programme that is to be introduced this year. Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 24 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): Standards assessed 31, 33, 35 and 38 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home in general is well run, health and safety is promoted. Quality assurance systems are in place to ensure that the home is run in the best interest of people who use the service. EVIDENCE: The Manager is a Registered Nurse who has worked in the nursing and social care environment for many years. The Manager is appropriately qualified and experienced to run the home. The operations manager said that the home have quality assurance systems in place. Surveys are sent out to people that use the service and relatives on a Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 25 yearly basis to see if they are happy with the home. She said that surveys were last sent out in September 2007. Regular meetings are held with people that use the service and relatives. Minutes from meetings are displayed for all to read. The home looks after small amounts of money belonging to some people who use the service. Appropriate records of transactions are kept. A sample of health and safety records were examined and were found to be in order. Records were examined to confirm that fire alarms, gas boilers, and fire extinguishers had been serviced within the last year. On average there are weekly tests of the fire alarm system some of which involve staff to help to ensure that they would know what to do if there was a fire at the home. Records were available to confirm that water temperatures are taken on average monthly. A discussion took place with the manager in respect of the Health and Safety Guidance to monitor water temperatures weekly. Ayresome Court DS0000071021.V360363.R01.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 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 27 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. 1 Standard OP8 Regulation 14, 15 Requirement The Registered Person must ensure that care plans in respect of acute medical problems are updated and evaluated following prescribed treatment. This will help to ensure that appropriate people are aware that the prescribed treatment has taken place and deteriorations and improvements are noted. The Registered Person must ensure that the skirting in bathroom areas are repaired/replaced to ensure that surfaces are readily cleanable and as such ensure bathroom areas are hygienic. The Registered Person must ensure that evidence is available to confirm that Criminal Record Bureau checks have been carried out on staff to help to ensure the safety of people that use the service All new staff who are not qualified to NVQ Level 2 must complete the Skills for Care Induction programme. Timescale for action 17/03/08 2 OP21 13, 23 30/04/08 3 OP29 19 17/03/08 4 OP30 18 30/06/08 Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 28 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 2 3 Refer to Standard OP19 OP27 OP38 Good Practice Recommendations The Registered Person should decorate and replace the carpet on the first floor corridor to enhance the home environment. The homes duty rota should include the Managers daily input and scheduled working hours The Registered Person should give consideration to the Health and Safety Executive Guidelines to monitor bath and shower water temperatures weekly Ayresome Court DS0000071021.V360363.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Ayresome Court DS0000071021.V360363.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. 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