Inspection on 11/06/08 for Brenalwood Care Home

This inspection was carried out on 11th June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Brenalwood Care Home 20/06/07

Brenalwood Care Home 24/08/06

Brenalwood Care Home 14/12/05

Brenalwood Care Home 21/09/05

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Brenalwood Care Home Hall Lane Walton On Naze Essex CO14 8HN Lead Inspector Francesca Halliday Unannounced Inspection 11th June 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000062892.V366254.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. DS0000062892.V366254.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brenalwood Care Home Address Hall Lane Walton On Naze Essex CO14 8HN 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) 01255 675632 01255 850356 manager.brenalwood@regalcarehomes.com R.W. Care Homes Ltd Care Home 38 Category(ies) of Dementia - over 65 years of age (38) registration, with number of places DS0000062892.V366254.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 38 persons) 20th June 2007 Date of last inspection Brief Description of the Service: Brenalwood is a home providing care and accommodation for 38 individuals over the age of 65 who have dementia. The premises consists of a large detached property, offering accommodation on two floors, with a passenger lift to the first floor. There are three double rooms and thirty-two single rooms, all rooms offer en-suite facilities. The home has a large communal lounge with a dining area. The home is situated within walking distance of all the local amenities of Walton-on-the-Naze. Adequate parking spaces are provided to the side of the property. The weekly fee at the time of inspection in June 2008 ranged from £383 to £600. More up to date information about fees can be obtained directly from the home. Additional charges were made for private chiropody, toiletries, newspaper, telephone bills, some outings and hairdressing. DS0000062892.V366254.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 one star. This means that people who use this service experience adequate quality outcomes. This key inspection was carried out on 11th June 2008. The term resident is used throughout the report to refer to people who live in the home and the term “we” refers to the Commission for Social Care Inspection. The manager was present throughout the inspection. We spoke with five members of staff including the manager and we also had a chat with six residents. We spoke with two relatives who were visiting at the time of inspection. Five residents responded to our surveys (staff assisted the residents to complete the surveys) and three relatives and two staff also responded to our surveys. Information from the surveys has been included within the report where appropriate. We carried out a tour of the premises and sampled the records held in the home. We also looked at the annual quality assurance assessment (AQAA) completed by the manager. In October 2007 the home was taken over by a new company, Regal Care Homes Ltd. A new manager took up post in March 2008 but was not registered with us at the time of inspection. This is the first inspection we have carried out at the home since the change of ownership. What the service does well: What has improved since the last inspection? DS0000062892.V366254.R01.S.doc Version 5.2 Page 6 The new manager had moved the office from the first floor to a room on the ground floor off the hall. This improved her ability to monitor residents and staff and made her more accessible to visiting relatives and professionals. The care documentation had been improved and a number of forms had been introduced for staff to use for monitoring residents more closely when concerns were raised about their condition. 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. DS0000062892.V366254.R01.S.doc Version 5.2 Page 7 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 DS0000062892.V366254.R01.S.doc Version 5.2 Page 8 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): Standard 1, 3, 5 (standard 6 not applicable) Quality in this outcome area is good. Prospective residents can be confident that their needs will be assessed before making a decision to move into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information about the service was available in a Statement of Purpose and a Service User’s Guide. The home had also produced the user guide in a pictorial form, which was more accessible for potential residents with dementia. This was very good practice. Prospective residents and their families or representatives were encouraged to visit the home prior to making a decision about admission. A month’s trial period was offered to all new residents before they decided whether to move into the home permanently. Some residents who were surveyed said that their families had chosen the home and one said “I liked it (the home) when I came to view”. The DS0000062892.V366254.R01.S.doc Version 5.2 Page 9 assessment form used previously was much more comprehensive than the one brought in by Regal Care and this was the one that staff used. The manager said that she usually carried out the assessments with the deputy manager but that occasionally she carried them out with another home within the company, to ensure that the most appropriate placement was offered. We sampled two pre-admission assessments and they demonstrated a good assessment process. DS0000062892.V366254.R01.S.doc Version 5.2 Page 10 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 7, 8, 9, 10 Quality in this outcome area is adequate. Residents receive good care and are treated with respect and dignity but some improvements in medicines management are needed to ensure residents’ safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken with and surveyed told us that they were happy with the standard of care in the home and with the support they received from the care staff. A resident who was surveyed described the staff as “always very positive, friendly and helpful”. One resident told us that the staff were “very kind and patient”. A relative who was surveyed told us “staff are always around to assist Mum when she needs it. This we can see on our visits”. Another relative told us “They seem to take care of all Mum’s needs and she seems to eat better now in the home”. They also told us that they had been informed about their mother’s fall. A letter from a relative praised the standards of care in the home saying “she received as much care and attention as if she had been in a hospice”. Staff told us that communication within the DS0000062892.V366254.R01.S.doc Version 5.2 Page 11 home was good and that they were regularly updated about residents’ changing needs. A relative described staff as “extremely approachable”. We looked at a sample of four care records. Staff had put considerable efforts into updating the care records and introducing new documentation since the last inspection and told us that they liked the new format. The care records were very lengthy and some of the care plans would have benefited from being condensed. However, there was a summary of each resident’s care needs that would be useful for a new member of staff. There was considerable reliance on the standard care plans and it was sometimes difficult to establish what parts of the care plans were personal to the individual resident. Some care needs identified in discussion with residents and staff, for example a resident’s problems with eating and the assistance that they required, were not covered by the care plans. The daily care records we sampled contained a variable amount of detail. Residents’ likes and dislikes were documented. The mental health records and assessments we sampled contained insufficient detail to provide evidence that staff were systematically monitoring residents’ mental health, their responses to changes in medication or any periods of challenging behaviour. The home had a range of risk assessments including risk of residents developing of pressure ulcers and residents’ needs for moving and handling. Accidents were well recorded in the sample of records we looked at. There was a form, which staff completed, for monitoring residents at intervals for up to 48 hours following an accident. This is good practice. Residents’ weight was monitored on a regular basis and the weight chart prompted staff to take a number of actions if weight loss was identified. These included informing the resident’s GP, contacting a dietician and providing additional pressure relieving equipment. This is good practice. Staff said that if they were concerned about weight loss or a resident’s poor appetite they would monitor the food and drink they consumed and complete a food diary. A relative told us that the resident they visited had “improved no end in the short time they had been in the home”. Staff told us that they had good support from local GPs and district nurses. There was a record of GP and district nurses’ visits. A resident told us that staff “call the doctor if I feel unwell”. The home had a physiotherapy session once a month for half a day to assist residents with their mobility. The home had a visiting dentist, chiropodist and optician. Staff who responded to our survey confirmed that staff tried to preserve residents’ dignity and treat them as individuals, they said “Every resident is an individual and their needs are reviewed on a regular basis in an effort to meet their specific individual needs”. Another told us “I respect their dignity, their opinions and treat them with the utmost care. It’s their home and we all respect that”. A relative told us “Staff always respond to them (residents) as individuals and take great care to know and understand their various needs DS0000062892.V366254.R01.S.doc Version 5.2 Page 12 and their background”. Another relative who wrote a letter of thanks to the home said “I was especially comforted to know that she was being looked after with dignity and consideration”. During the inspection we observed residents being treated with respect. The medicine cupboard was very well organised and the medicine administration records we sampled were well completed. Staff had created pigeonholes for residents’ monthly medication so that fewer medicines were stored on the trolley. Staff told us that the home did not use homely remedies. They also confirmed that covert or hidden medication was rarely used and only if this had been agreed by the residents’ GP and their next of kin. Some prescription only medicines, which should have been kept locked up when not in use, were found in residents’ rooms. This could pose a potential risk to residents with dementia. The manager confirmed that a risk assessment was being introduced for assessing residents with dementia who might be at risk if lotions, liquids and creams were not stored appropriately. The home had introduced a form to record the support given to and/or the diversionary tactics used with residents who presented with challenging behaviour, to ensure that sedatives or anti-psychotics medication were only given as a last resort. This is very good practice. Some medicines that had a short shelf life once opened did not have a date of opening on them. This might result in medicines being given to residents beyond the time that they were safe to be used. There was no system for recording the application of topical creams or ointments and residents’ response to treatment. It was not always possible to correctly audit the medicines that were not stored in monitored dosage systems, as the amount recorded as brought forward did not include the medicines that were unused the previous month. It was therefore not possible to assess whether residents had received all their prescribed medicines. Staff were not recording the receipt of controlled drugs (CD) with the name of the pharmacist and two staff were not always signing when CDs were received or returned to the pharmacy. One CD had been recorded as administered on the medicine administration record but not in the CD register. Staff who administered medicines confirmed that they had received medication training and an assessment of competence before administering medication. The records provided evidence that senior staff had received medication training, however, one member of staff had not received any training since 2005. DS0000062892.V366254.R01.S.doc Version 5.2 Page 13 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 12, 13, 14, 15 Quality in this outcome area is good. Residents can expect a range of activities and to be offered a nutritious and varied diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One resident surveyed considered that there were “sometimes” activities that they could take part in. Another was aware of the activities but chose not to join in and said that they did “like to go out for a walk with a carer”. One resident told us about the entertainment that was going to be held in the afternoon and said that the home “could do with more entertainment” and added “there’s not always things to do”. The activities coordinator worked part time between activities and care duties. They usually had four days each week on activities depending on the amount of care hours needed. There were no activities on the days that the activity coordinator was not covering the role. The activity coordinator said that there were a range of activities and also 1:1 sessions with residents and there was evidence of this from the records. The activities included physical activities such as ball games or skittles and quizzes or reminiscence sessions suitable for people with dementia. Six of the DS0000062892.V366254.R01.S.doc Version 5.2 Page 14 residents attended the church next door to the home and had a cup of tea while they were there. The manager said that the local vicar also visited the home on request. Residents had occasional visits to the beach, which was a short walk away. The activities coordinator said that they were planning to do some gardening with residents and to purchase some musical instruments for the residents to join in with music sessions. They were also hoping to organise some sessions with the theme of the Olympic games. There was a visiting library and books were borrowed that reflected residents particular interests and hobbies. The activity coordinator was planning to expand the activities for residents with more advanced dementia, such as sessions with objects that stimulated the senses with different textures and smells. This is to be commended, as residents with advanced dementia are often not included sufficiently in care homes’ activity sessions. The home was also due to hold a social event for residents and relatives. Visiting to the home was not restricted. Relatives we spoke with said that they were always made to feel very welcome and were able to keep in good contact with the resident they visited. A relative who was surveyed said, “when I telephone the home I am able to speak to Mum”. Staff told us how they encouraged residents to retain their independence and encouraged them to make choices about what they wanted to eat and which clothes they wanted to wear. This was observed at lunchtime when residents were asked about the choices they wanted at the time. Residents who were surveyed said that they enjoyed the food and said that there was plenty of choice. One resident described the food as “very good”. A relative told us that it was “excellent”. The day’s pictorial menu was on display in the lounge/dining room. A letter from a relative described staff’s “patience when feeding the more disabled, who were never rushed”. During the inspection we saw staff assisting some residents and prompting others to eat in a supportive and appropriate manner. The home catered for a range of diets. The meal we saw looked well cooked and nutritious. DS0000062892.V366254.R01.S.doc Version 5.2 Page 15 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 16, 18 Quality in this outcome area is good. Residents can be confident that their concerns are addressed and they are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints policy, which was on display in the home. Relatives who responded to our surveys told us that they knew who to speak to and how to make a complaint if they had any concerns. One relative told us “Senior staff are always approachable to talk to, also I have the name of Mum’s social worker”. One relative responding to our survey said that staff “always” responded appropriately if they raised concerns and two relatives said that staff “usually” responded appropriately when they raised concerns. Staff told us that they knew how to respond to any concerns raised with them. The complaints register demonstrated that appropriate action had been taken to any resolve complaints raised. One relative said that they had raised a concern on a number of occasions but that it was now resolved. The manager said that she had introduced a system for documenting concerns with actions taken to address them, in order that any minor concerns could be dealt with promptly before they turned into complaints. The home had a policy on safeguarding adult and the prevention of abuse. A number of staff had received safeguarding training in September 2007 and further training was booked for the majority of the remaining staff at the end DS0000062892.V366254.R01.S.doc Version 5.2 Page 16 of June 2008. We asked a member of staff about the different types of abuse that could occur and the actions to take if abuse was suspected and found that they had a very good understanding of safeguarding issues and how to protect vulnerable residents. DS0000062892.V366254.R01.S.doc Version 5.2 Page 17 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 19, 21, 25, 26 Quality in this outcome area is adequate. Residents live in a clean and comfortable home but hazards in the environment potentially put them at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager said that they were planning to personalise residents’ bedroom doors to make it easier for residents to identify their own room. One relative who was surveyed said “there is no small quiet area to go”. Another relative told us that the home “definitely requires at least one quiet area for so many people”. The manager stated in the annual quality assurance assessment (AQAA) that there was a plan to provide a quiet lounge/activities room in the next twelve months. The carpet in the entrance hall was worn and torn causing a potential trip hazard. However, this was being replaced as well as carpets/flooring in the lounge and dining area, in two corridors, in ten bedrooms and in the laundry. DS0000062892.V366254.R01.S.doc Version 5.2 Page 18 The home had two showers and three bathrooms. However, two of the bathrooms were out of action despite this having been identified as a requirement (to have them in working order) in the last two inspection reports. Following the inspection the manager confirmed that a new hoist had been ordered and would be delivered and fitted within a week of the inspection. She also said that the other bath that was out of action would be assessed in order to establish whether the hoist could be repaired. A number of the radiators did not have radiator guards or had loose pads in place that could easily be removed. These radiators were a potential hazard to residents. The manager said that new radiator guards were on order. We tested the temperature of the water in a number of residents’ rooms during the inspection. Some rooms were within safe limits of 43c or below but one was found to be 50c and another was found to be at 69.2. The temperature of water outlets used by residents was not being monitored to ensure that it was maintained within safe limits. The person responsible for maintenance disabled these taps immediately during the inspection. The manager said that there was a problem with the water systems in one part of the home that was overriding the thermostatically controlled valves and that a new water tank was on order. However, the problem with the water temperatures and the unguarded radiators was not identified in the annual quality assurance assessment as areas that needed to be addressed and improved. A system to monitor the temperatures was put in place during the inspection. The manager also confirmed that the home would in future flush through all water outlets in vacant rooms and unused baths or showers to reduce the risk of Legionella. The manager also confirmed that the loose handrails we saw in residents’ en-suites were being replaced and new raised toilet seats were on order. The majority of residents’ bedrooms had a lockable drawer for valuables, money or medicines. We found two windows on the first floor that were without window restrictors. The manager said that this would be fixed immediately following the inspection. A number of residents’ en-suites did not have toilet paper, paper hand towels or liquid soap for staff use. The manager said that this would be addressed following the inspection. Protective aprons and gloves were available for staff use. The majority of the linen in the home was sent to an outside laundry. Staff mainly carried out the laundry of residents’ clothing. The home was due to have two new washing machines with a sluice facility and new drying machines delivered. They also had red dissolvable bags for the handling of soiled linen. Residents’ clothes were well laundered. DS0000062892.V366254.R01.S.doc Version 5.2 Page 19 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 27, 28, 29, 30 Quality in this outcome area is adequate. Residents are supported by an adequate number of well recruited staff but the lack of training in some areas means that their safety cannot be assured. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels were 5 carers from 08.00 to 14.00, four from 14.00 to 20.00 and three from 20.00 to 08.00. There was an additional carer from 07.00 to 08.00 and from 20.00 to 21.00. The manager and deputy were generally supernumerary to these numbers from Monday to Friday. The home had domestic staff who also covered the laundry duties. The person responsible for maintenance covered Brenalwood for half of the week and another care home owned by Regal Care for the other half of the week. The home had one cook on duty from 08.30 to 17.30 on three days each week and one on from 08.30 to 15.00 on four days each week. The manager said that the cook prepared the supper before they went off duty on the days they left at 15.00. There was also a kitchen assistant from 07.00 to 15.00 every day. This meant that care staff were carrying out kitchen duties in the evenings. One relative who responded to our survey commented that there were “less staff to see to residents later in the day”. There were 33 residents in the home at the time of inspection and their dependency was generally high. According to the annual quality assurance assessment over half the residents needed the assistance of DS0000062892.V366254.R01.S.doc Version 5.2 Page 20 two carers. There were adequate levels for the number and dependency of residents during the day until 17.00 but less staff available in the evenings to attend to residents’ needs. We looked at three staff files. All demonstrated that good recruitment procedures had been followed. Staff had checks with the criminal records bureau (CRB) and with the protection of vulnerable adults (POVA) list. Two references had been obtained and identification was held on file. The manager confirmed that staff who had a clear POVA list check, but their CRB had not been returned, would always work under supervision. Four carers had completed National Vocational Training (NVQ) at level 2 or 3 and five staff were working towards NVQ level 2 and five were working towards NVQ level 3. The home had an induction that met Skills for Care standards, as well as an induction to the home. The manager said that all staff had a period of three to five days supernumerary depending on their role and experience, when they worked with other staff as part of their induction programme. Three senior staff had received training in the Mental Capacity Act and its relevance to the support of residents with dementia. The home had a resident with Parkinson’s disease but staff had not had any training in relation to the specific care needs of people with this disease. Some of the staff had not received dementia care training and training in how to manager challenging behaviour but the manager confirmed that further training was planned. Only two members of staff had received first aid training; this would not enable the home to have a member of staff with a first aid certificate on duty at all times. The majority of staff were booked for infection control training following the inspection. A number of staff needed training in health and safety and in the Control of Substances Hazardous to Health (COSHH). Care staff had received limited care related training apart from during their NVQ training. Two residents had pressure sores. The manager said in the annual quality assurance assessment that the number of pressure sores in the home had reduced but only two staff had received training in the prevention of pressure sores. The home had residents with diabetes but only one member of staff had training in the management on the care of residents with diabetes. A training session on the promotion of continence was due shortly after the inspection. DS0000062892.V366254.R01.S.doc Version 5.2 Page 21 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 31, 33, 35, 36, 38 Quality in this outcome area is adequate. Residents generally live in a well managed home but potential risks to their health and safety are not always identified and addressed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager had completed the Registered Manager’s award and the National Vocational Qualification at level 4. She is an experienced manager having managed another home for six years and has completed a dementia course. The home also has a deputy manager and a head of care. The manager and deputy were on call alternate weeks. DS0000062892.V366254.R01.S.doc Version 5.2 Page 22 Regal Care carried out visits in line with Regulation 26, as part of the quality assurance process in the home. The manager had a good range of audits, which she confirmed were carried out on a regular basis. These included audits on care documentation, medication, health and safety and the environment. However, a number of health and safety issues in the home had not been identified or action taken to address them until they were discussed with the manager during the inspection. There were surveys for residents in an easily readable format with pictures and the manager said that surveys of relatives were due to be carried out. There was a suggestion box in the entrance hall. The visitors’ log also had a section encouraging visitors to comment on whether they were satisfied with the service in the home during their visit and if they were not satisfied whether they reported it. The annual quality assurance assessment completed by the manager demonstrated that she had an understanding of quality assurance and the need to constantly review and improve standards. We looked at the systems in place for handling residents’ personal monies. Receipts were available for all transactions and balances checked were correct. There was not a second signature recorded when money was received but the manager said that this would be done in future. Staff surveyed said that they received good support from colleagues and the management team. They also told us that they had regular supervision and the records confirmed this. The manager told us that staff responding to a survey carried out by Regal Care had said that good teamwork was the best thing about the home. There were systems in place for servicing and maintenance of equipment. The manager stated in the annual quality assurance assessment that the fire service were happy with standards in the home. DS0000062892.V366254.R01.S.doc Version 5.2 Page 23 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 4 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 X X X 1 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 DS0000062892.V366254.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation 14 Requirement Residents’ psychological health must be assessed on a regular basis in order that appropriate support and treatment can be given to them. Staff must ensure that medicines with a short shelf life when opened have a date on first use, so that medicines are not given to residents beyond the time that they are safe to use. Staff must ensure that medicines left over from the previous month are recorded on the medicine administration record, in order that a check can be made on whether residents have received all their prescribed medicines. Controlled drugs must be recorded in accordance with the Misuse of Drugs Act and associated Regulations. Risk assessments must be carried out and appropriate action taken to minimise the risk to residents from windows on the first floor without restrictors. DS0000062892.V366254.R01.S.doc Timescale for action 11/06/08 2. OP9 13(2) 11/06/08 3. OP19 13(4) 12/06/08 Version 5.2 Page 25 4. OP25 13(4) Risk assessments must be carried out and appropriate action taken to minimise the risk of residents being injured by hot radiators. 01/10/08 5. OP27 18 The home must ensure that 01/08/08 there are sufficient care hours on the evening shift to meet residents’ needs. Staff must be given the training 01/12/08 to enable them to care safely and appropriately for residents. This refers to first aid training for senior staff, training in health and safety, COSHH and care related training such as the prevention of pressure sores. 6. OP30 18(c) 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 Staff should develop a system for recording the application of residents’ creams and ointments and their response to treatment. Activities and 1:1 sessions should be available every day of the week and the activity coordinator’s sessions should be covered when they are not available, in order to improve the quality of life of residents living in the home. A separate quiet room should be developed for residents who wish to be away from the noise in the large lounge/dining room and the television. Staff should receive training in care of older people with DS0000062892.V366254.R01.S.doc Version 5.2 Page 26 2. OP12 3. OP19 4. OP30 Parkinson’s disease and diabetes in order that they have up to date knowledge on how to provide the best care to residents with these conditions. DS0000062892.V366254.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 DS0000062892.V366254.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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