Inspection on 09/10/07 for Caldene Rest Home

This inspection was carried out on 9th October 2007.

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

Caldene Rest Home 18/05/06

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 Caldene Rest Home 27 Beeches Road West Bromwich West Midlands B70 6QE Lead Inspector Mr Jon Potts Unannounced Inspection 9th October 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Caldene Rest Home DS0000066350.V343780.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. Caldene Rest Home DS0000066350.V343780.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Caldene Rest Home Address 27 Beeches Road West Bromwich West Midlands B70 6QE 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) 0121 500 5664 Richmond Court Nursing Home Ltd Vacant post Care Home 27 Category(ies) of Dementia - over 65 years of age (27), Old age, registration, with number not falling within any other category (27), of places Physical disability (1) Caldene Rest Home DS0000066350.V343780.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th May 2006 Brief Description of the Service: Caldene comprises of a traditional property that has a large extension (exceeding the size of the original property) built on. This means the majority of the property is built for purpose as a care home and offers a number of communal areas with some well-proportioned bedrooms. There is a range of adaptations available as would be necessary for the care of older people. The building is currently undergoing extensive refurbishment so as to improve the environment available to the residents. The home is sited close to the centre of West Bromwich and is easy to reach by public transport or car, as transport links and main roads are close by. The majority of the accommodation offered is for long term stays although the home has offered short term and emergency care when requested. The home is owned by a well established company that has a number of other nursing and care homes in Sandwell. The home is currently managed by the Registered manager from a sister home sited within a minutes walk from Caldene. The home is supported by a number of senior carers and care assistants as well as ancillary staff (i.e. domestics). The current range of charges for accommodation is not detailed within the homes statement of purpose or any of the contracts seen. Caldene Rest Home DS0000066350.V343780.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection focused primarily on the homes performance against key national minimum standards and was carried out over one day. Evidence was drawn from a variety of sources but involved tracking the care of a number of residents, which included discussion with some of these residents. All care records relating to these residents were examined as well as a number of other records including those pertaining to staff and management. The inspector also had discussion with staff on duty, and the manager currently responsible for the service. There was pre inspection information used that included an annual quality assurance assessment and a number of questionnaires completed by residents and relatives. The staff and especially residents are to be thanked for their assistance with this inspection. What the service does well: What has improved since the last inspection? There is evidence of much improvement and the home has addressed all the requirements from the last report. The home has: • Better and clearer care plans for individual residents with more regular review and updates of the same; • Better monitoring of residents health with regular weights taken and access to dental services. Caldene Rest Home DS0000066350.V343780.R01.S.doc Version 5.2 Page 6 • • • • • • Better training for staff including the provision of accredited medication training for seniors, adult protection, first aid and moving and handling for all staff; On going refurbishment that is improving the facilities available to residents; Better recording and record keeping in respect of staff records, resident’s inventories and monies in safekeeping. Better supervision of and support for staff on a group and one to one basis. Regular residents meetings: Improve systems for self-assessment of the service provided to residents. 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. Caldene Rest Home DS0000066350.V343780.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 Caldene Rest Home DS0000066350.V343780.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents have the information needed to choose whether Caldene is suitable for their needs in written format and through pre admission visits. They have their needs assessed and contracts, which clearly tell them about the service they will receive but not the fees. EVIDENCE: Caldene has a Statement of Purpose that is specific to the home, and the resident group they cater for. It clearly sets out the objectives and philosophy of the service and is supported by a Service User’s Guide that details what the prospective individual can expect and gives a clear account of the specialist services provided, quality of the accommodation, qualifications and experience of staff, how to make a complaint. There is reference within the guide to the CSCI inspection reports although there were no comments from residents as to Caldene Rest Home DS0000066350.V343780.R01.S.doc Version 5.2 Page 9 their experiences of life at the home. Nor was there any information as to the fees charged for the service. It was however apparent that all residents had access to the service users guide, with copies seen to be available in each bedroom in a wall mounted document holder. Some residents spoken to were aware of these. The homes statement of purpose was readily available within the homes office. The service users guide is currently available in larger print than the statement of purpose although not currently in any other format. Consideration as to how this maybe best presented to assist understanding for residents with dementia should be considered with use of such as photographs, pictorial presentations ands such like. There have been no recent admissions to the home. Evidence as to how admissions would be managed was therefore drawn from discussion with the manager, the homes procedures and comments from questionnaires received from residents and their representatives. The manager stated that admissions are not made to the home until a full needs assessment has been undertaken, this carried out by a manager and where possible a member of staff. Where the assessment has been undertaken through care management arrangements the service would insist on receiving a summary of the assessment and a copy of the care plan. The manager stated that admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident, with the management considering the application together with other staff involved in the assessment. There was evidence in resident’s files that the home confirms it ability to meet resident’s needs prior to admission. Existing residents were seen to have copies of a Statement of Terms and Conditions/Contract; this sets out in detail what is included in the fee (although not the fee itself), the role and responsibility of the provider, and the rights and obligations of the individual. This is clear, jargon free, easy to understand and gives a very clear understanding of what residents can expect, although again consideration could be given to the format it is presented in dependent on the individuals cognitive abilities. Responses to CSCI questionnaires indicated that 100 had received a contract and 80 stated they had enough information before moving in to make an informed decision. 20 of the respondents did however state that they had moved to Caldene prior to the current provider taking control. Caldene Rest Home DS0000066350.V343780.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health and personal care, which a resident receives, is broadly based on the care plan that is in place. There has been much improvement in respect of care planning and it is evident that these are far more accurate than at previous inspections. With no exceptions residents received the health care that they need and the principals of respect, dignity and privacy are put into practice. EVIDENCE: Based on viewing three residents care plans in depth it was apparent that their personal healthcare needs, this including specialist health, nursing and dietary requirements are clearly recorded; this giving a comprehensive overview of their individual health needs. Reviews of these and all individual resident’s risk assessments in respect of on going health and individual safety were seen to be reviewed every month this to assist with identifying changes in health requirements. The Statement of Purpose details the specialist treatments the Caldene Rest Home DS0000066350.V343780.R01.S.doc Version 5.2 Page 11 home can deliver with a commitment to person centred planning, and reference to the skills and ability of the staff group. There has clearly been a management focus on auditing care plans to ensure they have a person centred focus with an emphasis on identifying the individual’s personal preferences and choices in respect of their personal care. This has been supported by the introduction of a key worker scheme with staff heavily involved in the review of care plans based on their knowledge of residents (as opposed to just management completing these). The accuracy of some of the plans in terms of residents stated preference (confirmed in discussion with, or through observation by the inspector) suggests that residents are involved in the care planning process although documentation could be improved to make this more explicit (i.e. detailing the level of residents involvement on review). There were some instances where there was scope for improving the involvement of one resident in respect of methods of communication, these to be in accordance with their level of understanding and ability. Use of alternative methods of communication may assist such as pictorial images (photographs, picture enhanced communication etc), so as to translate such as their care plan to them in meaningful terms so that they can understand and if in agreement sign the plan to say so. There was however evidence in other care plans that the methods of communication with service users had been explored in greater depth. Responses from questionnaires to CSCI indicated that 80 of residents felt that staff provided appropriate care and support. This was supported by comments made to us by the residents, and observations within the home on the day of the inspection with evidence to show that residents are encouraged to be independent where possible (this also underlined in care plans). Residents who use services have access to healthcare and remedial services and staff ensure that they have regular appointments. The health care needs of residents are usually managed by visits from local health care services. People who use services have the aids and equipment they need and these are well maintained to support both people who use services and staff in daily living. Residents confirmed that they receive the medical support they needed. The home has an efficient medication policy supported by procedures and practice guidance, which staff have easy access to, with those administering medication now having had access to accredited training in this area. The majority of medication records are fully completed, contain required entries, and are signed by appropriate staff, although there was one exception relating to a supposed error in booking medication in where there was one tablet more than records indicated was the case. The manager responded to this matter quickly and there was no evidence to suggest in this instance there was any direct risk to a resident. Caldene Rest Home DS0000066350.V343780.R01.S.doc Version 5.2 Page 12 There is only on resident currently who wishes, or is able to manage some their own medication and they were seen to be given the support they need to do so. Thought has been given to providing safe but sensitive facilities for keeping medication in these instances with residents having access to lockable areas in their bedrooms. The home has policies and procedures in respect of the handing of controlled medication, but at present does not carry any such medication within the home. The aims and objectives of the home reinforce the importance of treating individuals with respect and dignity and discussion with staff and residents clearly indicated that the former understand how to provide this in practice, with the latter confirming the outcomes for them were positive in this respect. Caldene Rest Home DS0000066350.V343780.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 & 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents are able to choose their life style and keep in contact with family and friends. Social, cultural and recreational activities meet more able resident’s expectations although the availability of stimulation provided for more frail residents is lacking. Residents receive a healthy, varied diet according to their assessed needs and choice. EVIDENCE: Resident’s individual plans clearly show residents preferences in respect of their daily routines throughout the day and discussion with residents indicated that they are able to choose what they do and have flexibility in terms of planning their own time, and based on observation, discussion with residents, staff and manager these are followed. More able residents are clearly able to pursue their chosen daily activities although the provision of stimulation for more dependent residents is not seemingly so well provided for. Whilst the home has an activities file the last entry within this was on the 7th September indicating that either recording Caldene Rest Home DS0000066350.V343780.R01.S.doc Version 5.2 Page 14 needs to be better or the availability of suitable activities needs to be better or both. There was statement within the homes Annual Quality assurance assessment (AQAA) that they service recognised they needed to improve the provision of dementia related activities with more structured diversion therapies. Comment from resident’s questionnaires received by the CSCI indicated that whilst 40 stated there was sufficient activity the other 60 stated that this was only sometimes or usually the case with comment from relatives also indicating stimulation could be improved. Community opportunities for some residents were however found to be positive with attendance at culturally appropriate venues. The home actively encourages the residents to have involvement with their relatives and representatives this reflected by the homes policies and procedures and an open visiting policy. Relatives are involved with residents on-going care through reviews and contact with the home. It was noted that whilst there is clearly a focus of ensuring residents choices are clearly identified by the home and these are agreed; the signature of two care plans was by relatives. Where this is clearly the choice of the resident, as was seemingly the case, this is permissible although the home needs to ensure that this choice is explicit with due consideration given to the implications of new legislation in respect of mental capacity. The home was seen to have a varied menu and there was evidence that they are providing ample choice including the provision of West Indian cuisine. The recording of when this choice was offered was not always recorded however, although its availability was confirmed by one of the residents. Resident’s individual meal preferences were seen to be clearly documented in their records. The range of meals available are balanced and nutritional, with sight of those available on the day evidencing that good size portions are available as well as seconds been offered by staff. Where residents need assistance this is provided with adapted cutlery available provided where residents needs and wishes dictate. Caldene Rest Home DS0000066350.V343780.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): 16 & 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents have easy access to the homes complaints procedure. There are systems in place to protect residents from abuse and residents feel safe at the home. EVIDENCE: The service has a complaints procedure that is clearly written and easy to understand although is only available in written format. It is however freely available around the home (within the service users guide which is available in all the residents bedrooms). Residents spoken to stated that they understand how to make a complaint and also stated that staff listen to, and act upon what they say. Of note was comment from one relative who stated that the way the home dealt with concerns had improved of late. Discussion with staff in respect of understanding how dissatisfaction from residents may manifest itself where communication maybe limited evidenced that all those spoken to have a clear idea of what signs to look for, and also understood what action they should take where this was needed. The home also has monthly meetings with residents where concerns and any suggestions can be raised and discussed. Caldene Rest Home DS0000066350.V343780.R01.S.doc Version 5.2 Page 16 The home keeps a record of complaints that includes details of any investigation and any actions taken, although there have been no formal complaints received over the last 12-month period. Unless there are exceptional circumstances the service always responds within the agreed timescale. The homes policies and procedures for Safeguarding Adults as well as those for the relevant local authority are available and give clear specific guidance to those using them. Staff working at the service know when incidents need external input and who to refer the incident to. The home understands the procedures for Safeguarding Adults and will always attend meetings or provide information to external agencies when requested. There are a low number of referrals made as a result of lack of incidents, rather than a lack of understanding about when incidents should be reported. The manager and provider understand how outcomes from any referral should be managed. Training of staff in the area of protection is regularly arranged by the Home. Caldene Rest Home DS0000066350.V343780.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): 19 & 26 Quality in this outcome area is Adequate (but it should be noted that refurbishment of the home is yet to be completed) This judgement has been made using available evidence including a visit to this service. The physical design, layout and décor of the home has improved and work is continuing to further improve the environment. It is envisaged that on completion of these works Caldene will provide a living environment that enables residents to live in pleasant, safe, well-maintained and comfortable environment, which allows privacy and independence EVIDENCE: Caldene is currently part way through an extensive refurbishment and as such parts of the home (the ground floor) are not currently available to the residents due to health and safety concerns. Sufficient work has however been completed to show that the physical environment of the home provides for the requirements of the small number of residents that currently live there. The Caldene Rest Home DS0000066350.V343780.R01.S.doc Version 5.2 Page 18 parts of the home that the residents currently use is appropriate for the their particular lifestyle and needs and is homely, clean, safe, comfortable and well maintained. There was evidence that the provider has in some ways invested in works to improve the environment beyond usual expectations, examples including fitting of windows in doors to allow more light through and allow sight of others behind the door, roof lights on the top floor to let in natural light and additional windows in external walls to allow better light/ventilation. Whilst there is still much work to be completed, it can be seen from completed areas that the home is much lighter and far better decorated than when last inspected. Due to on –going works on the ground floor the homes kitchen area was closed at the time of the inspection, this to allow all the requirements from the last environmental services inspection to be fully addressed. As a temporary measure meals are been brought into the home from the providers other home (sited also next door). Whilst there were no immediate concerns as to how this was been managed the manager was advised to consult with environmental health to confirm these arrangements and to ask for advice as to any potential hazards this arrangement may present. The home is well lit, clean and tidy and smells fresh and there was evidence seen that there is regular cleaning by ancillary staff (this observed by us and confirmed by residents). The management has a robust infection control policy and have been known to seek advice from external specialists where needed. Discussion with staff evidenced that they were well aware of steps to be taken to prevent the spread of infection, this confirming that they had received training as detailed in the homes staff records. Caldene Rest Home DS0000066350.V343780.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 &30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Well trained staff are available in sufficient numbers to fulfil the needs of the current dependency and numbers of residents at the home. The homes recruitment procedures fully protect vulnerable residents. EVIDENCE: Based on sight of the homes staffing rotas, observation of the staff available on the day of the inspection and comments from residents the home has sufficient staff available to meet the needs of the residents currently accommodated. There is a diverse staff group in terms of age and culture and whilst the majority are female, male residents have been asked in regard to their preferences as to the gender of their carer and this currently presents no issues. The service has an established and robust recruitment procedure that has the needs of people who use the service at its core. The recruitment of good quality carers is seen as a priority and essential for the provision of a good service to residents. Whilst no new staff have been recruited recently, some staff have been transferred to Caldene from the provider’s other homes. Audit of selected staff files showed that redeployed staff are taken through an induction process as would any new staff member, this so as to familiarise Caldene Rest Home DS0000066350.V343780.R01.S.doc Version 5.2 Page 20 them with their new working environment, and the residents. Staff recruitment records were found to be complete and in good order. The employer demonstrates through the recruitment process that they are proactive and show a good understanding of equality and diversity in respect of employment. Based on the homes training plan, the provider was seen to ensure that all staff within its organisation receives relevant training that is targeted and focused on improving outcomes for people who use services. The training provided is usually from external providers although some in house training is delivered with use of such as videos and management support meaning this training can be small scale and individualised if necessary in order to promote the delivery of person centred services. There are some areas of training where input is needed although discussion with the manager and staff evidenced that this was identified and some staff had commenced the same (accredited dementia care training). It was also agreed awareness of the mental capacity act for staff would be useful. The home has achieved in excess of 50 qualified staff in respect of National Vocational qualification in care at level 2. The manager was seen to support staff in respect of their development and training through regular supervision and appraisal, this confirmed by the staff spoken to as well as through sight of documented records. Supervision is used as a base to discuss any issues as well as familiarise staff with the organisation’s priorities, procedures and ethos. This is built on through the manager holding regular staff meetings were staff can discuss these matters as a group and share experience and knowledge. These meetings are documented and available to staff. Comments from residents as to the staff were positive in respect of the service they provided to them and discussion with the staff evidence that they were knowledgeable as to the areas of practice/procedure discussed. Caldene Rest Home DS0000066350.V343780.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): 31,33,35,37 & 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The management and administration of the home has much improved and is stable despite the lack of a substantive manager. There are effective quality assurance systems that with use of comment from residents and appropriate others help management identify any potential shortcomings within the service. EVIDENCE: The home is currently managed by the registered manager of Richmond Court, a home owned by the same provider and sited on the same road with only one building between them. The manager is experienced and competent to run the service but the management of the two homes has only recently been Caldene Rest Home DS0000066350.V343780.R01.S.doc Version 5.2 Page 22 determined to be unacceptable as at this stage Caldene and Richmond Ct are separate entities both holding individual registration with CSCI, and the potential complexity of the two services would demand a ‘deputy’ to be sited in each location; these deputies would then be envisaged to be fulfilling what is essentially the registered managers post. At present the low occupancy level, and as a result the smaller staff group do not present excessive demands on the current manager as maybe the case when the service is at full capacity. In discussion the manager was able to demonstrate a clear understanding of Caldene’s and the organisation’s key principles and focus of the service, based the provider’s ethos. He was also aware of national developments that influenced the running of a care home. Staff were positive about the support that he provided to them and spoke of him having a clear knowledge of individual issues in respect of day to day resident care, this through his maintaining regular contact with residents. There was clear evidence that the home has systems in place to measure its performance against base line minimum standards, this assisting the formulation of the AQAA self assessment where there are clear statements as to how the home did well and needed to improve, this found to be in accord with our findings during the course of the inspection process. Evidence is drawn from consultation with residents and stakeholders through the use of annual questionnaires that are analysed and summarised in an easy to read graph. More frequent consultation with residents and staff is through monthly meetings. The home has facilities for the safekeeping of resident’s monies and records in relation to these were found to be accurate based on the amounts kept. Records are well documented and showed a clear audit trail. The manager is the only key holder although there are regular checks on the monies by the homes provider or their representative. Resident’s individual property in the home is also protected by the completion and maintenance of inventories that are kept in their individual files. Protection of resident’s financial affairs is backed up by the homes policies and procedures The home was seen to have a clear health and safety policy with staff spoken to having a good awareness of it, training also supporting them to put it into practice. Staff are trained in mandatory health and safety topics to allow them to put theory into practice. Where issues are identified in respect of health and safety requirements and legislation the provider has a good record of addressing these, and closely monitors its own practice. Records are generally of a good standard and are routinely completed although consideration needs to be given to the presentation of such as key policies, contracts, care plans (where appropriate) in alternative formats. The manager ensures risk assessments are completed although there are some areas where these could be more comprehensive. Caldene Rest Home DS0000066350.V343780.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 2 2 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 4 2 2 Caldene Rest Home DS0000066350.V343780.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP12 Regulation 16(2) n Requirement The registered provider must improve the level of stimulation available to more dependent residents through the provision of activities appropriate to their wishes, needs and abilities. Timescale for action 30/11/07 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. Refer to Standard OP1 OP7 Good Practice Recommendations The homes statement of purpose, service user guide and contract should include the range of fees for residency. The registered provider should ensure that wherever necessary communication plans are formulated for all residents where there are difficulties due to a residents needs and understanding The registered provider should ensure that where relatives/representatives act on a resident’s behalf (i.e. signing care plans) that it is clear this is the resident’s choice where possible and that the implications of the mental capacity act are fully considered. The registered provider should recruit a substantive DS0000066350.V343780.R01.S.doc Version 5.2 Page 25 3. OP17 4. OP31 Caldene Rest Home 5. 6. OP37 OP38 manager for the home. The provider should consider the formulation of key documents including policies, service users guide and care plans (where appropriate) in alternative formats The provider should seek the advice of Environmental Services in respect of the current arrangements for transferring meals from Richmond Court to Caldene. Caldene Rest Home DS0000066350.V343780.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Halesowen Local Office West Point Mucklow Office Park Mucklow Hill Halesowen B62 8DA 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 Caldene Rest Home DS0000066350.V343780.R01.S.doc Version 5.2 Page 27 - 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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