Inspection on 22/11/06 for Brendoncare Alton

This inspection was carried out on 22nd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Brendoncare Alton 28/11/08

Brendoncare Alton 14/10/05

Brendoncare Alton 16/05/05

Brendoncare Alton 02/08/04

Brendoncare Alton 07/05/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Brendoncare Alton Adams Way Alton Hampshire GU34 2UU Lead Inspector Marilyn Lewis Unannounced Inspection 22nd November 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brendoncare Alton DS0000012203.V316629.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. Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brendoncare Alton Address Adams Way Alton Hampshire GU34 2UU 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) 01420 549797 01420 549898 www.brendoncare.org.uk The Brendoncare Foundation Vivienne Cuff Care Home 75 Category(ies) of Dementia (30), Dementia - over 65 years of age registration, with number (30), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (30), Old age, not falling within any other category (45) Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users must be over 55 Date of last inspection 14th October 2005 Brief Description of the Service: Brendoncare Alton is a registered care home providing nursing and personal care for 45 service users in the older person category and 30 service users with mental health disorder. The home is owned by the Brendoncare Foundation and has two other homes in the Hampshire area. Accommodation is provided on two floors with passenger lifts that allows access to all floors. All bedrooms are single and have ensuite facilities. There is a variety of aids and assisted baths to meet the needs of service users. The home also benefits from large well maintained gardens that are enclosed and accessible to wheelchair users. The service is situated in Alton with some local amenities close by. The registered manager stated on the 22nd of November 2006 that the current fees for the home were from £693 to £798 for residency in the Elder Health Units and from £791 to 896 for the Mental Health Units. Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days, the 22nd of November and the 1st of December 2006. On the first day the inspector toured the home and met with twelve residents, three visiting relatives, a trained nurse, two carers, the team leader responsible for the care of residents on the mental health wings and the registered manager. Records seen included care needs assessments, care plans, medication records, complaints and residents finance records. On the second visit records were seen for staff training and recruitment and the inspector met with the activities coordinator and a number of other residents, visitors and staff. Information received from the home including the pre inspection questionnaire was used when inspecting the home and writing the report. Service users at the home wish to be known as residents and this has been reflected in the report. As part of this inspection, the quality of information given to people about the care home was looked at. People who use the services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the Service User Guide (sometimes called a brochure or prospectus), Statement of Terms and Conditions (also known as Contracts of Care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. What the service does well: The home looked clean and welcoming and residents said that they liked their rooms and the communal areas. The home provides prospective residents with clear information about life at the home and the prospective residents and their relatives are able to visit the home before making a decision about taking a place there. No one is admitted to the home without a care needs assessment to ensure the home can meet their care needs. Information from the assessments forms the basis for the individual care plans. Care plans seen provide good information on the care needs of the Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 6 resident and the actions required by staff to meet those needs. Two residents said that they were involved in the review of their care plans. The home has clear procedures in place for dealing with medicines and records seen had been completed appropriately. Residents said that they felt they were treated with respect and good interaction was seen between staff and residents during the visits. The home’s activities programme provides residents with a varied programme of activities. A resident said that they particularly enjoyed the quizzes and another said that they liked the sessions by visiting musicians. Many of the residents are frail and one of the home’s activities coordinators said that time was spent with them on a one to one basis for chats and reminiscence. During the visits to the home this was seen to take place. All the residents spoken with said that they enjoyed the food provided at the home. A choice of meals was offered and staff were seen to support residents who required assistance in a friendly and caring manner. Visiting relatives said that they were always made to feel welcome at the home. What has improved since the last inspection? Risks assessments were in place relating to falls and those seen indicated that these had been reviewed and updated to reflect the current needs of the residents. The home complaints records seen, gave details of any investigation that has taken place and the actions taken to resolve the issues. At the time of the last inspection visit fire doors were seen wedged open. On these visits no fire doors were seen wedged open. The registered manager said that new systems had been put in place for the kitchen doors where this had been a problem in the past and the doors were no longer wedged open. At the time of the last inspection staffing levels were not adequate to meet the assessed needs of the residents. Since then staffing levels have been reviewed and are flexible so that the needs of the residents can be met. Residents spoken with said that staff came quickly when they called for assistance. The registered manager said that an additional carer was being employed to work where needed. Staff spoken with said that they felt sufficient staff were on duty for each shift. Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 7 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. Brendoncare Alton DS0000012203.V316629.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 Brendoncare Alton DS0000012203.V316629.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): 1, 2, 3, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No one is admitted to the home without a care needs assessment to ensure the home can meet their care needs. Prospective residents are provided with clear information about life at the home, are given a written contract and are able with their relatives to visit the home before making a decision to live there. The home does not provide intermediate care. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place that provides clear information about life at the home. The documents included the organisational structure of the home, an example of a contract and the last inspection report. Two service users spoken with said that they had seen the Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 10 documents but that it was their relatives who had read them. A relative of another service user said that they had found the information helpful. Written contracts were seen for three of the service users being case tracked. The contracts stated what services were included in the fees and those available at additional cost, such as hairdressing. Five service users spoken with said that they did not get involved with the paying of fees as their relatives handled their finances. All said that they did not want to know about their contracts or any price rises in the cost of care provision. A visiting relative said that they were notified by letter if there were any changes to the fees. The registered manager said that a full care needs assessment was undertaken for all prospective residents. The assessments were carried out by the registered manager or the team leader responsible for the care of residents accommodated in the mental health units, depending on the needs identified during the application process. Assessments seen for ten service users indicated that all aspects care needs were assessed. A visiting relative said that they had been involved in the assessment for their relative and had visited the home before making a decision about them taking a place there. Three other residents also said that they had not visited the home but their relatives had. The registered manager said the home admitted people for respite care but did not provide intermediate care. Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is, good. This judgement has been made using available evidence including a visit to this service. Care plans provide good information on the care needs of the residents and the actions required by staff to meet those needs. Residents’ health care needs are met and they are protected by the home’s policies and procedures for dealing with medicines. Residents feel they are treated with respect. EVIDENCE: Care plans were seen for thirteen residents, eight who were accommodated on the nursing wing and five from the mental health wing. The care plans were detailed and included assessments for nutrition, mobility and communication. Risk assessments contained in the care plans included those for manual handling, falls, pressure areas, nutrition and challenging behaviour. The risk assessments seen had been reviewed regularly. Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 12 Two residents spoken with said that their care plans had been discussed and agreed with them. A staff member spoken with knew the assessed care needs of residents for whom she was the key worker. Records seen indicated that service users health care needs were being met. Visits from GPs and other health professionals including physiotherapists, speech and language therapists and a dentist were recorded in the service users’ files. The home has clear procedures for dealing with medication. Systems were in place for recording medicines brought into the home and for the disposal of unwanted medication. Records and medication storage were checked on one of the nursing wings and a mental health wing. Records seen had been completed appropriately. Checks made on medicines stored in the controlled drugs cupboard found that the amount of medication stored matched the records held. Staff spoken with said that they had received training in the safe handling of medicines and records seen confirmed this. Up to date information on medicines used at the home was readily available for staff. Medication records seen for one resident on the mental health wing indicated that medication was being given covertly but there was no indication that this had been discussed with the GP and pharmacist. On the second day of visits the team leader with responsibility for the mental health units said that the administration of the medicine by covert means had been discussed with the resident’s relatives and they had signed the consent form and it had also been discussed and agreed with the pharmacist and GP. Six residents spoken with said that the staff were very kind and caring and that they felt they were treated with respect at all times. During the visits staff were seen to knock on doors and wait before entering rooms and they spoke to the residents in a friendly, respectful manner. Two visiting relatives also commented on the caring attitude of staff. Brendoncare Alton DS0000012203.V316629.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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to exercise control over their lives, are provided with a varied programme of activities, are able to receive visitors as they wish and enjoy nourishing meals served in a relaxed atmosphere. EVIDENCE: The home employs two activities coordinators who are responsible for the programme of activities for residents. One of the coordinators provides activities for residents from the mental health units who attend the day centre and the other coordinator works alongside residents from the nursing wing. The residents’ interests and past hobbies are documented and records are kept of the activities that residents participate in. The coordinator for the nursing wing said that due to the frailty of the residents, the majority of the activities were based on one to one sessions with residents in their own rooms or in the small sitting areas on the wings. One resident said that they enjoyed quizzes and the word search sheets that they were given out for them to complete in their own time. The coordinator said that some residents just liked to chat and reminisce. Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 14 Activities for residents of the mental health units took place in a large room on the ground floor. The activities programme displayed in the room indicated that sessions included art and crafts and music. The registered manager said that she was working with the team leader on the mental health units and the coordinators, to provide a more structured programme of activities for those residents who stayed on the unit and did not go to the activities room. Entertainers visiting the home included musicians and people talking on topics of interest. Recently a gentleman had visited to give indoor golf lessons, which the coordinator said the residents who took part enjoyed and a further session has been booked. Notices were displayed around the home stating that a pantomime was due to take place in December and children from local schools were also visiting. Some residents were going to visit one of the local schools for Christmas lunch. One resident said that she was looking forward to the pantomime and that she enjoyed the visits by musicians. Ministers from local churches visit the home and a communion service is held every Friday for those who wish to attend. The home has recruited a number of volunteers who visit the home and are involved in the activities provided for the residents. One volunteer supports residents in art work, some give music sessions and others chat with residents on a one to one basis. Service users spoken with said that they were able to receive visitors as they wished and three visiting relatives said that they were always made to feel welcome by staff. Each unit of the home has it’s own dining room but there is also a ‘restaurant’ style dining room where residents and their friends and family can take meals together if they wish. During the visits to the home staff were observed encouraging residents to make their own decisions. Six residents spoken with said that they were able to choose when they got up and went to bed and whether they would like to spend time in their room or sit in one of the communal areas. During lunch on both visit days some residents ate their meals in the dining room while others chose to eat in their own rooms. All of the residents spoken with said that the food provided at the home was good. On the first visit to the home there was a choice of roast turkey or salmon, with roast potatoes, green beans and swede for lunch followed by peaches and cream, yoghurt or ice cream. The cook said that other alternatives were available such as salads and omelettes. A good supply of fresh fruit and vegetables were available and the cook said that fresh vegetables were used daily. The home was also providing special diets including diabetic, soft and gluten free. Homemade cakes and biscuits were provided on a daily basis. Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 15 Meals seen were well presented and residents said that they enjoyed them. Staff were observed on both visits to the home supporting residents who required assistance in a friendly and caring manner. Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel that any complaints will be taken seriously and acted upon quickly and they are protected by staff awareness of the prevention of abuse. EVIDENCE: The home has a policy and procedures in place for complaints. At the time of the last inspection the log of complaints kept did not give details of any investigations undertaken or the outcome. The registered manager has developed a new system where all the complaints are logged whether formal or informal and information is documented on the investigation, actions taken and the outcome. The registered manager said that she audited the log monthly to keep track of all complaints. Records seen indicated that all complaints were being taken seriously and acted upon quickly. Three residents spoken with said they knew the home had procedures for dealing with complaints and felt that any concerns raised would be acted upon promptly. Four other residents said that they were not interested in the complaint’s procedures and did not know if they had been given a copy of the document. They said that if they had any concerns they would speak to a member of staff or the registered manager and it would be dealt with. Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 17 A visiting relative spoken with said that a copy of the complaints procedure had been included in their relative’s information pack provided before they were admitted to the home. The relative said that they felt staff would act on any concerns raised. All residents and relatives spoken with said that they had not had any cause to make a complaint. Two staff members spoken were aware of the procedures for handling complaints and knew where the complaints log was kept. The home has policies and procedures in place for the prevention of abuse, including Hampshire County Councils Protection of Vulnerable Adults and one for whistle blowing. Three staff members spoken with were aware of the procedures to be followed should abuse be suspected. The staff members said they had attended training in abuse awareness and records seen confirmed this. Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a clean, safe and welcoming environment for all who live, work and visit there. EVIDENCE: On both visits the home looked clean and welcoming. Seating is provided in the reception area and a resident waiting there for relatives said that it was nice to sit there and ‘watch everyone coming and going’. The home is formed into five units, three for residents with nursing care needs and two for residents with mental health needs. Each unit accommodates fifteen residents and all units have a similar layout, with bedrooms, bathrooms Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 19 and toilet facilities, lounge area, dining room small kitchenette and staff office area. Stairs and lifts provide access to each floor. Large communal rooms and a library are also available for social activities and as previously mentioned there is a separate dining room for residents to take meals with their relatives. This dining room is also available for residents of the close care accommodation situated in the grounds of the home. Furnishings and fittings looked of good quality and were appropriate for the needs of the residents. Residents are accommodated in single rooms with en-suite facilities. Eight residents spoken with said that they liked their rooms with one saying that they had ‘all they needed’ and another commented on their appreciation of being able to bring personal items such as photographs and ornaments into the home with them. Rooms seen looked homely, clean and light. The home has sufficient bathroom and toilet facilities and all those seen on the visits looked clean and in good order. At the time of the last inspection a number of toiletries were found in one of the communal bathrooms. During these visits toiletries were not being kept in the bathrooms but in the resident’s own rooms, minimising the risk to resident’s health and safety. Specialist equipment such as hoists was provided as necessary and a staff member said that there was sufficient equipment available to fully support the residents. Protective equipment including disposable gloves and aprons were readily available for staff. The registered manager and the service manager have offices and there is also an office for the administration team. Staff also have a staff room. The laundry room is situated away from areas used by residents. The room looked clean and tidy. Staff working in the laundry room said that they had the equipment they required to do their jobs. Hand washing facilities were available. The home’s gardens are accessible to wheelchair users and looked well maintained. One resident said that they enjoyed sitting in the garden with visitors during the warm weather. During visits to the home no fire doors, including those of the kitchen, were seen wedged open as had been the case in the previous inspection visit. Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are flexible to ensure the needs of the residents are met. Records seen did not confirm that staff had received the training required to do their jobs and residents’ safety could be put at risk if staff are employed prior to security checks being completed. EVIDENCE: A requirement was issued at the last inspection for the number of staff on duty to be able to meet the needs of the residents at all times. The registered manager discussed the staffing levels with the inspector. Each of the five units accommodates fifteen residents. During the day one trained nurse and two carers are on duty for each of the three nursing wings and one trained nurse and three carers on the two mental health units although this reduces to two carers on duty in the afternoons. The team leader on the mental health unit said that staffing levels were sufficient as the rota was flexible and additional staff could be called in if needed. A staff member on one of the nursing wings also felt that sufficient staff were on duty. At night there is one nurse and four carers and on the nursing units and a trained nurse and three carers on the mental health units. Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 21 Three residents and two relatives said that staff came quickly when called. However a relative spoken with said that his relative had not yet been washed and made comfortable and it was 10.45am. He said he felt is was due to a shortage of staff. This was discussed with the trained nurse on the unit who said that the resident had been cared for and turned earlier in the morning but records seen did not confirm this. The registered manager said that staffing levels were flexible and were decided on a weekly basis depending on the level of needs of the residents. An additional carer was being put on duty to assist where needed. The registered manager also said that she would investigate the gentleman’s concerns about his relative’s care. Records seen indicated that twenty- two of the thirty eight care staff members held or are in the process of obtaining NVQ level 2 or above. Two staff members spoken with said that they were encouraged and supported by the registered manager and the team leader to undertake training to obtain qualifications. At the last inspection a requirement was made for records to be available for staff training and for each staff member to have a training and assessment profile. The registered manager has improved the record keeping and training profiles are in place for each staff member. However it was still difficult to ensure staff had received mandatory training as the records indicated training needs but did not confirm training had taken place and it was not clear as to whether the person had attended training in the subject such as moving and handling in the past and now required a refresher session or if they had not received any training at all. A programme of training sessions was available that indicated there was training available for staff but again this programme did not indicate which staff members were due to attend only that it was for trained nurses or care staff or all. This was discussed with the registered manager who said that the records would be further improved to give a clear picture of the training staff had received, training required and dates for training sessions to be attended. The registered manager must ensure that all staff receive the training required to do their jobs. Records were seen for nine staff members all of whom had started work with the home in 2006. Each file contained two written references and proof of identity, probationary period review and supervision notes. Four of the records seen indicated that staff had commenced employment at the home before a Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks had been completed. Police checks from their home country were contained in their files. The registered manager said that the four staff members who were from overseas, had not worked in the home but had been taking part in an induction programme in another building in the grounds of the home. The registered Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 22 manager agreed that to protect the safety of the residents staff would not commence employment with the home until at least a POVA First check had been completed and then would work under supervision until the CRB was through. Brendoncare Alton DS0000012203.V316629.R01.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): 31, 32, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the residents, whose financial interests are protected by the home’s policies for handling residents’ money. Staff at the home operate safe working practices but records for staff attendance at fire drills must be kept up to date to ensure the safety of the residents is protected. EVIDENCE: The home’s manager Vivienne Cuff is a trained nurse who registered with the commission as manager for the home in November 2005. Mrs Cuff has successfully completed the Registered Managers Award. Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 24 Staff spoken with said that Mrs Cuff provides good support and visiting relatives also said that they were able to discuss their relatives care needs with the registered manager. Four residents spoken with commented on being able to talk with the registered manager as they wished. It was evident during the visits to the home that there was a good rapport between the residents, staff and visitors and the registered manager. One to one meetings were being held so that residents and their relatives had the opportunity to give their opinions on the care provided. Questionnaires had been given to residents during September and October to gain their opinions on the care provided. Documents seen indicated that the information gained had been consolidated and the registered manager said that feed- back was given to staff, residents and relatives through meetings. The meeting for relatives was not successful as only one relative attended. The registered manager said that another meeting was due to be held at the end of December when it was hoped more would be able to attend. Two relatives spoken with said that communication with staff was good. A staff member said that staff meetings were held monthly for the trained nurses and carers. The registered manager said that, sometimes, additional meetings were held for the nurses and information from these meetings was fed back to the carers. Meetings for night staff were held every six to eight weeks. Records seen confirmed the meetings took place. The home does not hold any money for residents. A system is in place where payments for services such as hairdressing are made by the home and the resident is invoiced for payment. One bank account is held for residents’ money that has no charges and no interest payments. Individual records are kept for each resident. Records seen showed the amount of money paid into the account and any payments taken out. The system for handling finances is stated in the home’s Statement of Purpose and in the written contract. During the visits to the home substances hazardous to health such as cleaning fluids were stored securely. The kitchen looked clean and in good order with food stored appropriately. All staff working in the kitchen had received training in food hygiene and certificates were on display to confirm this. Health and Safety notices were displayed around the home. Staff were seen to follow safe working practices including the use of disposable aprons and gloves when needed, to reduce the risk of infection. Certificates were seen that confirmed the regular maintenance of specialist equipment such as hoists, the lifts and electrical appliances. Records seen confirmed that the home has a fire safety risk assessment in place and checks were made on fire safety equipment and certificates for the maintenance of the equipment were available. Records for fire drills did not indicate which staff members had been in attendance and it was therefore not Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 25 possible to confirm that all staff had attended fire drills. The registered manager said that she would change the systems to document the staff attending drills so that attendance for all staff could be confirmed. At the time of the last inspection visit some fire doors were seen wedged open. During these visits no fire doors were wedged open. Brendoncare Alton DS0000012203.V316629.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 3 3 3 x 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 3 3 3 3 3 3 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 3 3 x 3 x x 3 Brendoncare Alton DS0000012203.V316629.R01.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. 2. Standard OP30 OP29 Regulation 18 (c) 19 Schedule 2 Requirement Timescale for action 31/03/07 The registered person must ensure that staff receive the training required to do their jobs. The registered person must 01/01/07 ensure at least a POVA First check is completed before staff commence employment at the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Brendoncare Alton DS0000012203.V316629.R01.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 Brendoncare Alton DS0000012203.V316629.R01.S.doc Version 5.2 Page 29 - 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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