Inspection on 05/06/07 for Butterhill House

This inspection was carried out on 5th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Butterhill House 03/05/06

Butterhill House 12/12/05

Butterhill House 13/06/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Butterhill House Near Coppenhall Stafford ST18 9BU Lead Inspector Keith Jones Key Unannounced Inspection 5 June 2007 09:00 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 Butterhill House DS0000062760.V335258.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. Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Butterhill House Address Near Coppenhall Stafford ST18 9BU 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) 01785 780380 01785 780339 Mrs Shivvajkunver Jadeja Vacant Care Home 28 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (28), of places Physical disability over 65 years of age (9) Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 Day care place. Date of last inspection 3rd May 2006 Brief Description of the Service: Butterhill House is a twenty-eight bedded care home for elderly people situated in the Coppenhall area of Stafford. The Home is located off a country lane, leading to Butterhill farm, in peaceful open countryside of outstanding beauty. The Home stands in extensive mature grounds with attractive patio areas and mature gardens. The front aspect patio area overlooks a large lawn with an ornamental pool at the far end guarded with attractive wrought iron railings. There is limited parking on a circular gravel forecourt. Resident’s accommodation is located on the ground and first floor of the home offering both shared and single bedrooms, with a variety of en-suite facilities. Bathrooms and toilets are appropriately sited around the home, and offer a range of assisted facilities. The Home has three lounge areas for individuals to move around in as they wish. There is a large orangery that is used as a dining room, and for social events; this area is light, elegant and spacious. Secluded quiet rear walled patio areas have been created that are attractive and tranquil to sit in, with a raised garden overlooking pastureland. Rear ground floor bedrooms open onto this area and could have tables and chairs outside if resident wished. The local Primary Care Team visit the home as required, and are always available for advice. Limited local amenities are to be found in Hyde Lea Village over a mile distant, and there is no public transport in the area. Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was conducted with the Registered Provider of care and senior care staff. The last inspection report was discussed, and it was noted that requirements and recommendations made have been, or are in the process of being attended to. The tour of the home was carried out in a relaxed, courteous and professional manner; everyone concerned expressed confidence in the atmosphere. All the service users approached were complimentary of the care, service and attention they received from a willing, attentive care team. There were 22 residents in on the day of inspection, 6 of which required care for dementia. Three service users were case tracked, confirming the establishment of a satisfactorily run home, very comfortable and ‘homely’. Everyone appeared comfortable and at ease with their surroundings. Information gained from the pre-inspection questionnaire identified that current fees charged are £350 to £450 per week. A sample review of the administration confirmed solid practice and effective management. A feedback session was offered at the end of the inspection with open discussion involving the Registered Provider. The Inspector thanked all concerned for their contribution to a pleasing and constructive inspection. What the service does well: Butterhill House offers a genuine commitment to care with an open and personable approach, which reflects the homeliness of a confident relationship between carer and resident. Emphasis goes into involving the residents and their families in the process of care, ensuring a highly personal approach to meeting individual needs. Throughout the entire inspection a sense of homeliness, and familiar confidence pervaded into all aspects of daily activity expressed by those people met. Meals are of a good standard with a sensitive catering approach to meeting needs. The establishment of accountability towards effective assessment, care planning and review of resident’s needs are meaningful in formulating a satisfactory standard of care. This highly personable attitude and approach to care is appreciated and welcome by residents and visitors alike. The management demonstrate a professional approach in maintaining an environment conducive to residential care of the elderly. There is a constant Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 6 appraisal and review process of facilities and services by a high profile Provider, to maintain that environment. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Butterhill House DS0000062760.V335258.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 Butterhill House DS0000062760.V335258.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): 1,2,3,4,and 5 The quality in this outcome area is good. The Statement of Purpose has been, and continues to be reviewed, in addressing the major issues and reflecting changes. The Home ensures that the admission process is a recognition of a joint understanding that residents are aware, and that staff are able to meet expectations, to realise a comfortable transition. Prospective service users and their relatives are able to visit and assess the quality, facilities and suitability of Butterhill at any reasonable time, to meet with staff and management. The Home ensures that prospective residents have the necessary information to enable an informed choice to be made. All residents have contracts of terms and conditions of residence at the home a copy of which is on resident’s files. EVIDENCE: Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 9 The Statement of Purpose, and Service User’s guide represent a satisfactory description of the home’s aims and objectives, philosophy of care and terms and conditions. It offers residents, and their relatives the opportunity to make an informed choice about where to live. A readily available stock of up to date documents would be helpful. It is stated in the Statement of Purpose that independence, privacy and dignity are encouraged, with the full involvement of family in all matters concerning the well being of service users. The Statement of Purpose also indicates the terms and conditions, which are discussed with service users and relatives prior to admission. A pre-admission assessment, carried out by the Provider/Care Manager or deputy, appreciated any special needs of the individual, including cultural, social or personal needs, which are fully discussed and documented. This assessment initiates the process of care, each individual having a plan of care based on personal needs and a daily living process. The Home demonstrated through case tracking, that the assessor explained this information in respect of each individual to ensure a clear understanding is established. The assessor also makes a judgement as to the suitability of each prospective service user using the same criteria. At all times the family is kept fully informed of the situation, as was observed, offering prospective residents, and their relatives, the opportunity to make an informed choice about where to live. Butterhill House DS0000062760.V335258.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): 7,8,9,10 and 11 The quality in this outcome area is good. The service users’ assessment provides the base, from which care planning is formulated. It is recognised that this reflects an individual profile of needs, discussed fully with family. The home has access to GPs that visits the Home frequently, and the majority of service users are registered within 48 hours. The Service User Guide, admission assessment and care plans are geared to engender a sense of individuality and privacy. The inspector observed the free, courteous interaction between service users and staff based on a level of confidence of essential mutual trust and respect. The medication systems were found to be generally well organised, secure and efficient. Controlled drugs were safely stored and accurately recorded. EVIDENCE: Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 11 There was evidence to show that a review of the care process has produced a satisfactory standard of meeting care needs. The pre-admission assessment represents the foundation for an informative care planning process. Three residents’ care files were tracked and demonstrated a system of detailed information on the individual, their life style and needs, events and contacts, procedures and actions measured on a daily basis and reviewed monthly. Risk screening on an individual basis was seen to be effective. The policy of the home is to maintain service users own GP support wherever practical; otherwise residents are registered with the local surgery. District nursing services are also received, and the Home has an established, and positive professional rapport. On the day of inspection a visiting District Nurse was able to speak freely on her considered improved standards of care, hygiene and staff training. Discussions with service users confirmed their acceptance and confidence in the overall standard of care and service given. “ Everybody really kind”, ”I saw the nurse last week, it was really nice” were some of the comments offered by residents. There was evidence that suitable equipment was deployed effectively. Carers were seen to interact with residents with purpose and compassion. Activities are a key element in the socialisation approach to care, with visitors encouraged to be involved in a partnership style with care staff. Resources are available to appoint a co-ordinator for 10 hours a week to facilitate and engender a socialisation programme. Several residents indicated a degree of boredom, measured with “but not too much”. The facilities and bedrooms were presented to facilitate privacy for the individual, which included medical examinations and personal care procedures, being performed in private. Double bedrooms need the advantages of a privacy screen/curtain. The administration of medicines generally adhered to procedures to maximise protection to service users. The storage in a metal medicine trolley, within the orangery is considered to be too inconsistent and warm, and was advised to be re-sited in the manager’s office. The supporting documentation, although in place, needs a review to remove surplus and outdated information. The controlled drug management would be improved with the provision of a wallbolted metal cabinet situated in the office. A controlled drug register was examined and found to be in order. The Care Manager was advised to close off records of CDA when a resident leaves or discontinues the drug. The MAR sheets were found to be administered effectively. There were no residents selfmedicating at the time of inspection. Each service user has the opportunity of their own lockable facility in their bedrooms on request. Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 12 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 The quality in this outcome area is good This judgement is based on discussions with service users, staff and examination of records in relation to social activities undertaken and general observations during to course of the inspection. The home had a relaxed and welcoming atmosphere where people were encouraged to continue with their individualised lifestyle. Those who wish to bring in personal possessions are encouraged to do so. During the course of the inspection staff were observed to interact with the service users in a positive and polite manner. The Home operated a four-week menu providing a varied, nutritional and well balanced diet; service users had a choice of meals and were also offered alternative choice. Special diets were accommodated with the staff making every effort to engage with service users to discuss personal preferences. Staff were seen to offer discreet assistance to those who required it at lunchtime, when a very attractive and delicious luncheon was presented. Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 13 EVIDENCE: Discussions with residents and staff identified a relaxed atmosphere in which the residents’ needs were respected. A routine exists to establish a framework for managing the home, not as a regime for residents to comply with, but for a point of familiarity. Several residents expressed their appreciation for the freedom they enjoyed, with the security that there are routine events to the day they could relate to. The Home has attempted to appoint a part time activity staff member, for ten hours a week, without success as yet. Organised activities took place in the afternoon and included bingo, exercises, games, beauty and hairdressing sessions with occasional trips to the theatre and community events in Coppenhall village. The home provided an Anglican service on a regular basis. Those service users’ rooms inspected showed a significant influence of personalisation in the inclusion of belongings, some furniture and general décor. During the course of the inspection staff were observed to interact with the service users in a positive and polite manner. The standards of catering offered a satisfactory service, to which service users spoken to were complimentary of all aspects of quality. A menu on a four weekly cycle offered a wholesome, varied and suitable choice. A very pleasant lunch was served during inspection, with choices available, served in dining rooms adjacent to the lounge areas. Three meals were provided daily, with hot and cold beverages and snacks available throughout the day. Care staff take up catering duties in the absence of the cook. These duties do not adversely affect care staffing levels. Residents that were interviewed confirmed that that the quantity and quality food provided was good. Individual preferences were recorded in assessment and conveyed to the catering staff, whom met with, and discussed their requirements. It was confirmed that the cook knew each service user, and some of the relatives. Diversity was discussed with the care member of staff cooking on the day, who indicated an awareness in meeting individual needs. Staff were seen to offer discreet assistance to those who required it. The choice of dining room, lounge or bedroom was at the discretion of service users. Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 14 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, 17 and 18 The quality in this outcome area is good. The home had a meaningful complaints policy, clearly identifying the CSCI as a resource to approach with a complaint or grievance. Complaints had been received via the Commission since the last inspection, and had been dealt with effectively, with the management meeting regulation. Service users’ legal rights are protected by the systems in place. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. EVIDENCE: Service users’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care planning and policies in place i.e. the complaints procedure. The complaints policy was seen and records examined. There were few complaints, which would be better dealt with through a ‘record of concerns’, to record residents and families concerns in a meaningful and effective manner. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. The overall policy of openness and transparency was acknowledged. Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 15 All service users had received information on the procedure to complain, including reference to the CSCI. This process was evidenced on examination and case tracking as previously reported upon. Discussion with the Provider confirmed that there is satisfactory evidence of a protocol and response, to anyone reporting any form of abuse, to ensure effective handling of such an incident. The policy and procedure for handling issues of abuse was examined, and found to be in need of review to encompass recognition and procedural action. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, which would be enhanced with an annual training for all staff. All staff were suitably checked through CRB and POVA reports. Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 16 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): 19,20,21,23,24,25,26 The quality in this outcome area is adequate. This judgement was based on discussions with service users, staff and a tour of the premises. The home is well appointed to meet the needs of an elderly population of service users in providing a safe and comfortable environment. On inspection, bedrooms were highly personalised with most displaying service user’s own furniture, and with personal belongings. All communal areas are of a good standard, offering social as well as private reflection, as the mood takes. The overall environment was found to be safe for service user’s comfort within risk assessed limits. The domestic services in the home were seen to be of a good standard, with no evidence of unpleasant smells or unsightly debris anywhere throughout the inspection. EVIDENCE: Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 17 A tour of the Home verified that the premises were fit for purpose, clean warm and tidy, and being satisfactorily maintained. The surrounding garden areas and surrounding countryside, provide an outstanding vista for relaxation and recreation. Safety measures taken in the front lawn area render attractive, and safe areas for residents to take advantage of. A sheltered rear patio area has several areas in need of risk assessment, to ensure effective safety standards. Internal access was facilitated with suitable fittings of hand and grab rails, in adequate, well-lit and airy corridors. Wheelchair access was satisfactory throughout all areas of the home. On admission the Provider or Care Manager assesses each individual service users’ needs for equipment and necessary adaptations. Efforts had been made to provide a homely atmosphere and the décor in most areas of home was found to be of a high standard. The home provided three lounge areas that were pleasantly decorated, providing essential furnishings and items to provide comfortable areas where residents were able to interact with fellow residents, or to entertain their guests. The conservatory provided a superb dining area where service users could experience the views of the surrounding grounds, although it can get very warm and would benefit from an air conditioning unit or fans. Toilets and bathrooms were located on both floors and were in close proximity to bedrooms and communal areas. Bedrooms were well maintained to meet service user’s personal preferences. On inspection, most bedrooms were highly personalised, with some displaying service user’s own furniture, and most with personal belongings. Some of the original ‘white’ furniture is in need of renewal. It is the policy that on bedrooms becoming vacant that each room is reappraised for redecoration, as confirmed during the Inspection. Double bedrooms have no provisions for privacy, requiring overhead curtain screening. One bedroom had a damaged window fly screen. Service users spoken to expressed a sense of belonging and satisfaction in the quality and presentation of their living areas. Numerous floral displays greatly enhance the presentation. An effective call system is installed; care staff reacted readily to tests. The care manager expressed a willingness to meet any reasonable demand for special needs. A locked facility and lockable bedroom doors are made available on request, following suitable risk assessment. The evidence seen on inspection of service user’s rooms, and on discussion with the individual residents and family, assured that this standard was well met. Recent rain damage to the room given over to the hairdresser was noted. The kitchen was inspected, and found to present a well equipped and organised area. A recent Environmental Health inspection (September 2006) showed no major problems. All fridges and freezers were well maintained and Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 18 checked daily by the kitchen staff, although not recorded, as had been understood from advice given. A daily routine was agreed. The kitchen was clean and considered secure, although a cleaning schedule was not in place. It was agreed that evidence in a scheduled plan of cleaning would reflect the observed good standard. The laundry was poorly organised, although equipped to a good standard. Red Alginate linen bags should be made available to meet cross infection control procedures. The provision of suitable linen skips are required, with additional facility to accommodate infected waste material. COSHH notices regarding chemical handling in the areas that store chemicals should be openly displayed. The laundry area is cramped, requiring organising to ensure a smooth, and safe flow of items. Residents’ belongings were seen to be handled piecemeal in a confused process. It was advised that items should not be stored on toilet cistern lids. The Registered Provider is to provide the Inspector with a development plan for 2007/08, with consideration given to a risk assessment of the Home. Heating and ventilation were found to be satisfactory, and lighting was domestic in style. Aids, adaptations and equipment were available throughout the Home. Fire equipment was inspected and seen to be serviced and up to date, although alarm release on doors has been recommended by a recent Fire Inspection (04/07), all other matters raised have been attended to. The home presented a clean and pleasant, odour-free atmosphere, much to the credit of staff. Butterhill House DS0000062760.V335258.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): 27,28,29 and 30 The quality in this outcome area is adequate. The overall staffing coverage manages to maintain the expected levels each shift that was inspected, over a three-week period. Discussions with residents and visitors to the home also conveyed a very positive impression of staff conduct. However there is reliance upon care staff working in the laundry area and the kitchen, to cover for sickness, holidays and days off. The procedures for recruiting and appointing staff were seen to be inconsistent with various stages of the process not completed, in studying several staff files. Staff training was discussed and was found to need a review of the arrangements in regular training and supervision. Staff training records are to complement the effort placed into staff training. EVIDENCE: There were 22 service users in the home on the day of the inspection. Off-duties were provided and examined; staffing levels were seen to be satisfactory. The daily care staffing rota showed adequate balance between skills, experience and numbers to provide a good standard of care. Discussions Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 20 with staff also confirmed their commitment to providing a quality service and their awareness of the principles of good practice. The Registered Provider contributes a consistent presence in the absence of a Care Manager, helping in covering up to 5 shifts a week. The staffing establishments were examined and found to be satisfactory in meeting the staffing notice. An average coverage was seen to be: a.m – 1 Senior 3 carers p.m – 1 Senior 2 carers N.d - 1 Senior 1 carer Observations of staff on duty conveyed a very positive impression of their competence and care of the residents of Butterhill. Three members of staff were interviewed, who confirmed the appropriate staffing levels, conduct and training of staff. It was noted that there are several overseas care staff, who have been appointed to their position after suitable screening, including their ability to communicate effectively. Those spoken with on the day of inspection showed satisfactory standards, and an infectious enthusiasm for their work. Several staff files were examined which showed an inconsistency of general application of procedure in appointing staff. The procedures for recruiting and appointing staff were seen to be inconsistent with various stages of the process not completed. Several staff had insufficient evidence of clearance with references, letters of appointment, and contracts, although thorough checks are made of CRB and POVA records. The management is advised to review the procedures of appointing and maintaining staff. Staff training was discussed and was found to need a review of the arrangements in regular training and supervision. 5 staff have NVQ level II, and 4 with a suitable First Aid Certificate. Induction was seen to be consistent, whilst training records identified the lack of a training programme to meet compulsory requirements for fire safety, health and safety, and hygiene issues. It was noted that staff training is to be organised through a consultancy, commencing in the next few weeks. The Home has an involvement with Stafford College BTec course, and has an arrangement of deploying volunteers. There was evidence to show that a formal supervision process (referred to as appraisal) is in use, although requiring signed and dated ownership. The Provider emphasised the heavy commitment made by senior staff in offering on-duty practical supervision. A process to cascade the responsibilities throughout the workforce was advised. Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 21 Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 22 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): 31,32,33,34,35,36,37 and 38 The quality in this outcome area is good. This judgement was based on discussions with the Registered Provider, examination of the home policies and procedures, with regards to the effective management of the home, general observations during the process of the inspection, and discussions with service users and staff. There is a confidence apparent in the interaction of residents, staff and the Home’s management, that demonstrated a positive relationship that pervades throughout the Home. EVIDENCE: Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 23 The Registered Provider, Mrs Shivrajkunver Jadeja, has demonstrated evident competence in establishing a solid professional policy portfolio, that has been implemented over the past years to achieve a good standard of set aims and objectives. A qualified Social Working professional, with a relevant academic background. She is in the process of appointing a Care Manager who should be joining in July 2007. From March 2007 Mrs Jadeja has held the ‘acting’ Manager role, by a comprehensive leadership contribution, and direction of care services. This has necessitated a full shift involvement, including weekend work, fully committed to maintaining and improving the quality of the Home’s services. The inspector was impressed by the openness, professional and pleasing confidence in the observed interactions of staff, relatives and service users. The relationships were seen to be of mutual trust and respect. Appropriate risk assessments are in place for service users, through care planning and recording and general maintenance of the environment, are up to date and accurate. Health and safety notices can be seen throughout the home. The process would be enhanced with a room catalogue of risk assessment to update the present room based risk reports. The Home has an open door policy and a commitment to equal opportunities. An examination of administrative, monitoring, planning and care records showed an organised and professional attitude to effective record keeping. They were found to be well maintained, accurate and up to date, ensuring that the service users’ rights and best interests are safeguarded. The Provider offered evidence of safe working practices including: - accident management, abuse awareness, and COSHH management. It was noted that there is no formal first aid policy for the Home. The health and safety of service users and staff are promoted with safe storage of hazardous substances, regular electrical PAT and servicing of electrical and gas appliances, and regulation of the water system, each record examined, and found to be satisfactory. The accident book was seen and found to be in order for staff, service users and reporting arrangements to Riddor. The administration and management of the home is efficient, and sensitive to the needs of service users. Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 24 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 4 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 2 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 3 3 3 3 3 Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 25 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 OP32OP32 Regulation 8 Requirement The Care manager is registered with the CSCI. Timescale for action 01/09/07 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 OP29 Refer to Standard OP30 Good Practice Recommendations A training matrix was recommended to easily identify individual team member training needs, for 2007/08/09. A re-furbishment plan be drawn for 2007/08/09, with attention to old furniture renewal. You must demonstrate robust recruitment and selection procedures within the home, with regard to recording of interviews, letter of appointment and contracts. Establish a policy on the handling of abuse. OP1 Statement of Purpose and Service users Guide will need to be updated, and made freely available. 4 5 Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 26 6 7 8 9 10 OP38 OP38 OP9 OP26.5 Ensure curtain screens with overhead tracked rails for all double bedrooms. That a schedule of cleaning and fridge/freezer temperature recordings be established. Secure a suitable wall bolted container for Controlled Drugs. That the use of alginate bags for the handling of soiled/infected linen be implemented. That a reorganisation of the laundry provide a smoother flow of the process, and reinforce infection control procedures, with the provision of laundry skips. Butterhill House DS0000062760.V335258.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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