Inspection on 20/06/07 for Calway House

This inspection was carried out on 20th 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

Calway House 27/09/06

Calway House 15/02/06

Calway House 20/09/05

Calway House 31/03/05

Calway House 24/08/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE Calway House Calway Road Taunton Somerset TA1 3EQ Lead Inspector Gail Richardson Unannounced Inspection 20th June 2007 09:40 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Calway House DS0000016059.V336312.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. Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Calway House Address Calway Road Taunton Somerset TA1 3EQ 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) 01823 333283 01823 347930 Somerset Care Limited Verity Anne Underhill Care Home 83 Category(ies) of Old age, not falling within any other category registration, with number (83) of places Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. A Registered Nurse (RGN) must be employed as `Clinical Lead` to support the Registered Manager for a minimum of 37 hours per week, as indicated in the Statement of Purpose. May provide personal care for 53 persons in OP category. Within this 53, may also provide personal care for 15 persons with dementia (over 65 years) in the Dementia Care Unit. May provide nursing care for 30 persons in category OP. May accommodate one person between the ages of 58-65 years who requires personal care only in MD category. This placement must be reviewed 6 monthly. Date of last inspection Brief Description of the Service: Calway House is a new purpose built home registered with the Commission for Social Care Inspection to accommodate up to 83 service users over the age of 65 years who require personal care by means of old age. The home is registered under the category of dementia for 15 service users with personal care and dementia care needs. The home is registered to provide nursing care for 30 service users. Calway House, is situated in a quiet residential area not far from Taunton town centre. The building is arranged over three floors with a shaft lift giving access to all floors. The home is fitted with appropriate aids and adaptations. The gardens have been professionally landscaped and provides safe and pleasant areas for service users to enjoy. Calway House in owned by Somerset Care Ltd which is a not for profit organisation. The registered manager is Verity Underhill and the responsible individual is Marion Osborn. The home has achieved the Somerset Social Services Quality Rating. The home’s current fee range is between £575 and £670 per week. Fees charged are dependant on the individual’s assessed needs and room to be occupied. Extra charges are met by service users for hairdressing, newspapers, magazines, chiropody and personal toiletries. Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 5 Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on the 20th June2007 by inspectors Gail Richardson ,Kathy McCluskey and CSCI Pharmacist Mr Brian Brown. A tour of the home took place and all the bedrooms; communal areas, kitchens and laundry were seen. There were 83 service users and 3 day care resident currently residing at the home. 37 service users were receiving residential care, 15 service users were receiving residential dementia care and 30 service users were receiving nursing care. One resident was in hospital. The inspector’s spoke to 14 service users, and 11 members of staff, the deputy manager was available throughout the inspection. Prior to the inspection the home completed a CSCI Annual Quality Assurance Audit about service provision, staffing, resident admissions, complaints procedures, meal times and arrangements made for community health care support for residents. Comment cards about the service were also received at the CSCI from 12 residents and relative/visitors, 10 staff and 7 visiting health professionals. Records relating to care, medications, staff, finances and health and safety were examined Inspectors observed that the atmosphere within the home appeared relaxed and the service users appeared comfortable. All staff spoken too by the inspectors appeared knowledgeable about the residents in their care and were seen to treat them with dignity and respect. The focus of this inspection visit was to inspect relevant key standards under the CSCI ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are; - excellent, good, adequate and poor. What the service does well: Some comments received by residents included “I am happy here at Calway, it is made to feel like home and it does”, “Care is always very good both day and night” and “Since I came here I have been satisfied and comfortable.” Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 7 Relatives confirmed that they are made welcome and kept informed of changes in their relative’s condition as necessary. One relative stated that the food was good; the home was clean and warm when needed. Many comments received were very complimentary about the staff and high lighted that some staff provide a very good standard of care and both residents and relatives commented that the staff are friendly and caring. Several positive comments were received from residents and relatives regarding activities provided. One relative commented that “A Commendable effort made by the activities supervisor to help keep residents interested and occupied.” The environment including the layout, furniture and fittings of the home are excellent and provide residents with a good standard of accommodation. Appropriate specialist equipment is supplied as required to support residents identified needs and the standard of hygiene of the home was observed to be excellent. The admissions process examined, ensures that the home does not accept admissions until a full needs assessment has been made and the registered manager is confident that these needs can be met within the home. Prospective residents and their relatives can visit the home, have a meal and talk to other residents about what it is like to live at the home. This is to enable them to make an informed decision about living into the home. What has improved since the last inspection? What they could do better: Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 8 Comments received from relatives indicated that staffing levels did not always meet service users choice and needs. In one case a relative stated that repeated requests for assistance has to made. Several surveys received commented on the use of agency staff. One relative commented that the home should employ more of their own staff as residents did not like the constant changing of staff. Comments received about the quality and quantity of the food varied with personal choice. The home are aware of these opinions and evidence was available of ongoing changes to the menus and the choices available to meet residents requests. Care plans examined evidenced an improvement in the care plan process, however some areas of risk did not have a plan of care to address and reduce this risk. The staff application form requires amendment to include confirmation of the response to the Rehabilitation of Offenders Act. The registered manager is also recommended to request a minimum of 10 years employment history and all gaps identified should be explored and documented, this is to protect residents from the risk of abuse. The complaints procedure should provide a clear documented outcome to all complaints investigated to specify if the complainant is happy with the outcome. The registered manager is recommended to review the homes practice of locking the ground floor lounge door to allow access to the garden without the need for residents having to ask for the doors to be unlocked. The registered manager must ensure that staff induction is completed within 12 weeks to ensure staff are appropriately trained to meet residents needs and that all staff receive one to one supervision a minimum of 6 times per year to meet the National Minimum Standards. The home must ensure that substances hazardous to health are stored securely under the COSHH guidelines and are not accessible to residents as there is a possible risk of ingestion. All records should be stored in line with the Data Protection Act and records evident on the nursing unit should be stored securely to maintain the confidentiality of residents. Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 9 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. Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 10 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 Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 11 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 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to be able to provide prospective service users and relatives with sufficient information for them to make an informed decision about the home. All prospective service users receive a pre admission assessment by the registered manager to ensure the home can meet the assessed needs identified. EVIDENCE: When asked if a resident received enough information prior to admission one resident stated “The deputy came and explained to us”. Pre admission assessments were available for the 5 service users who were case tracked at Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 12 inspection. The forms used to record details at this time are being reviewed and developed to ensure all information is recorded. Of the 12 surveys returned 4 residents confirmed they had received a contract, 4 had not and 4 remained blank in this area. Ten residents felt that they had received enough information prior to admission and 2 did not. Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 13 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 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user has a care plan, however in the 3 cases examined at inspection, the assessed areas of need were not all reflected in the plan of care. Despite this the staff appear to provide the care required and the outcomes for service users appeared to be good. The management of medications systems was mostly good. Staff were observed to treat service users with dignity and respect. EVIDENCE: The inspectors examined 5 care plans from pre admission, care plan, risk assessment and review. The care plans were seen to have improved since the last key inspection and now provided more detail to ensue resident’s personal preferences and the involvement of the residents and relatives in the care planning process. Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 14 The home uses a computerised care plan system but ensures a hard copy is available. This hard copy is used to discuss and review each month with the residents. Reviews had been undertaken regularly and recorded and 8 staff confirmed that they were involved in care planning. A daily record is maintained and it was discussed with the deputy manager that staff must ensure that this records reflects the identified care needs. Some areas identified as a risk were not all reflected within the care plan and may present a risk to residents of staff not being fully aware of actions required. Another care plan did not give any indication for staff of how to ensure mobility was promoted and maintained for a resident. This was discussed with the deputy manager and clinical lead nurse. We looked at the Medication Administration Record (MAR) charts for 13 people resident at the home. We found that most of the hand written entries that had been made were signed by two members of staff and dated. The medicines were found to be securely stored in medicines rooms, however concern was raised over the storage of some large boxes on an open shelf of one of the trolleys, meaning these medicines were not stored securely during the medicine administration round. We found that the home were not aware when a 3 monthly injection was next to be administered to one person and action was taken by the home to confirm the date of next administration whilst the inspectors were in the home. The deputy manager also suggested introducing a system to ensure that this date is flagged using the electronic diary in the care plan system in future. We found that for one service user the MAR chart was marked to indicate that the home had no stock available. However there was a record to indicate that the home had received a stock of this medicine before the dates indicated and the bottle had then been found and started. No action had been taken during the period marked as not available to obtain a further supply. The home had carried medication audits and it was of concern that these issues had not been picked up. More concerning in this respect was the failure to administer medicines as prescribed when it was available in the home to administer. We also found a stock of insulin syringes that had been emptied from their original containers meaning that the date of expiry was no longer present to check. On checking the stock of controlled drugs throughout the home no discrepancies were found. Surveys asked, do you receive the care and support you need?, 5-always, 5usually and 2-sometimes. When asked if staff listen and act on what you stay 11-always, 1-never. Surveys asked are the staff available when you need them?, 4-always, 8usually and when asked if they receive the medical support they need ? ,4always, 6-usually, 1-sometimes and 1-blank. Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 15 7 visiting health professionals completed surveys and comments included “I think the residential and dementia care unit is excellent and shows a good understanding of patients needs” and “The residential side is run more efficiently” However a comment received about the nursing unit indicated that care and communication are less effective in this area and sometimes it appears residents needs are not well known to staff. One comment indicated that the home does not always follow the best healthcare pathways available to them. One comment received indicated that some improvement had been noted but contact with the surgery could be managed in a more organised fashion. Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. There is a wide range of opportunities for social stimulation and service users are supported to join in with organised activities or pursue their own interests. The meals in the home are of a good quality and a wide range of choice is available. EVIDENCE: The home employs Activity Organisers for each unit of the home. The inspector observed that service users have access to a variety of activities and are supported to maintain any activity preferences. Service users are able to choose whether to join in with activities or to pursue their own interests. The inspectors spent time chatting with service users and observed service users moving freely around the home and garden area. Service users stated that there were no strict routines in the home and that they were free to decide how and where they spent their time. It was noted that the ground floor lounge doors were locked and residents needed to ask for Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 17 the doors to be unlocked, this practice is recommended to be reviewed to ensure residents have access and choice. Service user meetings take place which are used as an opportunity to express group opinions. The inspectors discussed activities provided in the dementia care unit and observed the care being given. The activities support the specific needs of these residents and included daily living tasks and a reminiscence room. Residents were seen to be cared for in a calm and individual way, with dignity and respect, which reflected in the general, settled and relaxed atmosphere in the unit. The inspectors observed that lunch was a pleasant dining experience and residents were supported in a discreet and appropriate manner. Residents of this unit had access via one patio door to an attractive and secure garden area. The décor of this unit reflected the personal tastes and experiences of the residents. Resident’s surveys asked if there were activities available to take part in, 5always, 3-usually, 3-sometimes, 1-blank. One survey stated that “I would like to go out on more trips” another said they “Liked the knitting afternoon” “The activities here are first class due to our organiser” One comment stated that activities are available “Except when short staffed” The inspectors discussed the meals with several residents and the response was mostly positive. The home is making some changes to the menu and has improved the way the choice of menu is offered to residents in the dementia care unit. On the day of inspection the lunch was a choice of Pork Chops or Cheese pancake with tomato sauce. There was accompanying potato, spring cabbage and carrots. The vegetables were served separately to ensure residents choice. Desert was baked apple and cream or mandarin jelly delight and fresh fruit. Tea was a choice of Tuna and mixed bean salad or carrot and coriander soup and bread roll, Victoria sponge or strawberry shortcake. Supper of cake and sandwiches is available. Surveys asked if residents liked the meals at the home?, 4-always, 4-usually, 3-sometimes,1-never. Comments received about the meals at the home were varied and included “Could do with a bit more”, another stated “Very good, lots of variety”, “I eat them, its adequate”, “Unsatisfactory”, “Food is lovely at all times”, “Always very good”, “Very good and varied”, “Could be improved” One comment received by survey said that “the resident is happy and feels we are a family and she belongs” One comment regarding the administration of medication was that the administration of medication at mealtimes is offensive and unhygienic, this was Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 18 discussed with the deputy manager at inspection and inspectors were told that this practice had been stopped. Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 19 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 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff and residents are confident that the homes management team would appropriately deal with any complaints or concerns. Policies, procedures and training are available to staff to ensure they have the knowledge to prevent service users from the risk of abuse. EVIDENCE: When asked who a resident would speak to if not happy one comment received was “Staff are very good and will listen”, and “The deputy listens to me “ and another stated “I speak to my Key worker” and another said they would “Speak to the manager” Surveys asked, Do you know who to speak to if you are not happy? , 7-always, 4-usually, 1-sometimes and ten residents stated they knew how to make a complaint. The complaints record was examined and it was noted that all complaints had been recorded and responded to within an agreed timescale. The complaints documentation should provide a clear documented outcome to all complaints investigated to specify if the complainant is happy with the outcome. Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 20 Staff training records indicate that abuse awareness training takes place as part of the induction process for new staff. Policies and procedures regarding whistle blowing, management of aggressive behaviour and abuse awareness are available for staff to view, these policies are reviewed and updated regularly and were of a good standard. 9 out of the 10 staff surveys received confirmed that that they had information about protecting vulnerable adults and how you report any concerns about poor care practice or allegations of abuse. All 10 staff surveys received confirmed that a Criminal Record Bureau Check had taken place. Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 21 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 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Calway House provides a comfortable and clean environment, which meets the needs of the service users. The home is finished and decorated to a high standard and specialist equipment is available where there is an assessed need. EVIDENCE: The home is divided into 6 units with specialist care being provided in the nursing and dementia care units and the remaining units providing residential care only. Each unit has its own communal lounge and dining area and the day care unit also has a light and spacious dining and sitting area. All communal areas are well furnished and decorated. Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 22 All areas of the home are accessible to people with all levels of mobility with stairs and lift access to all areas available. The front hall area of the home also contains a small shop and well equipped hairdressing salon and this area leads onto an well maintained and attractive garden area which is on a landscaped for easy access around three sides of the home. Most ground floor rooms have direct access to the gardens. All bedrooms seen by the inspector were comfortably furnished and had been personalised to reflect the tastes of the individual service user. Service users are able to bring personal effects and small items of furniture with them when they move to the home, which gives rooms an individual homely feel. Service users confirmed that they had chosen their rooms or had been offered a change of room when rooms had become available. En- suite facilities were available in all bedrooms. All service users who were asked were delighted with the accommodation at the home. Various aids and adaptations have been put in place to assist service users to maintain their independence. There are handrails to assist with physical mobility and clear signage to help people to orientate themselves. Surveys asked if the home is clean and fresh and comments included “Very much so”, “Home is very clean “ “I am always very impressed with the cleanliness” and “The home is clean and no odours are smelt around the building” The home has an in house laundry which provides clean laundry of bed linen, towels and personal clothing. Two comments were received relating to difficulties with the laundry systems for the return of personal items even when clearly labelled. Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 23 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 adequate This judgement has been made using available evidence including a visit to this service. The staffing arrangements are adequate to meet the needs of the service users, recruitment is required to minimise the use of agency staff and develop a strong staff team. The recruitment procedures need development to protect service users from the risk of abuse. EVIDENCE: The deputy manager confirmed to inspectors that recruitment of new staff is ongoing and the use of agency carers in the residential units continues. The nursing unit now almost fully staffed by the homes own staff and is benefiting from becoming a more stable staff team. Comments surrounding the homes staff were very positive and included “The staff are all very helpful and kind”, “Staff help and smiles, help better than a bottle of medicine, we thank them” and “Ordinary staff are very good”. “When I ring the bell, they come very quickly” and “ feel they try to do the best they can for the people in their care”. However comments surrounding staffing levels and the use of agency staff included, when asked if residents receive the care and support they need comments included “Depend on who are on. Too many agency that don’t know.” Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 24 One relative commented “Lots of agency staff are a waste of space, come once and never again, old folk don’t like change every day”. One relative commented that “Staff communication appears poor, breaks are taken at the busiest times” and a further relative commented that call bells should be answered sooner, “these ring for a long time and this is a great concern for relatives.” Also commented was “Office to relative communication is poor”. The inspectors examined assessed dependency levels of the residents and looked at staff rotas including the amount of agency staff used in the previous week. The homes staffing levels are assessed as needing Residential units, including day care in total 10 carers in the morning, 7 in the afternoon and 5 overnight plus the deputy manager. Nursing Unit 1 RGN at all times 7 carers in the morning, 7 in the afternoon and 3 overnight. On the day of inspection these levels were met, there was 1 agency care staff working in the home, the total number used had reduced from previous rotas seen. Two comments about cleaning staff serving meals were received; one stated, “ I strongly object to being serve my meals by the person who has just cleaned the toilets, due to staff shortages.” This was discussed with the deputy manager at inspection who was unaware of this practice and will ensure it is reviewed. Staff commented that “All staff are helpful and easy to approach” and a further staff commented that they felt “it would be beneficial to residents and staff to have 2 staff nurses on duty”. Staff surveys confirmed that out of the 10 surveys received 9 staff felt they received adequate induction and supervision when commencing employment at Calway House. All staff confirmed they had received manual handling training and 9 staff felt they were clear of service users needs before visiting them and were aware of which duties they must not undertake. Staff training records examined confirmed that staff have undertaken the required mandatory training and an ongoing programme of updates is maintained. Recruitment files examined evidenced that the induction programme for staff is not always completed within the 12-week timescale indicted by the Common Induction Standards. This was discussed with the management at inspection. The recruitment processes are mostly complete, however the staff application form requires amendment to include confirmation of the response to the Rehabilitation of Offenders Act. The registered manager is also recommended Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 25 to request a minimum of 10 years employment history and all gaps identified should be explored and documented. Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 26 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 36 37 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All staff, service users and visitors spoken to were positive about the manager and felt able to raise concerns and felt that their ideas are listened to. Care Staff are adequately supervised. The storage of records is not in line with the Data Protection Act Further improvements are required to ensure the health and safety of service users.. EVIDENCE: The manager Verity Underhill is working hard to improve standards within the home. Staff and service users spoken with at the inspection were positive regarding the management style of the manager. Staff confirmed that they are Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 27 able to discuss their concerns with the management of the home and review areas of practice causing concern. A Head of Nursing Katrina Marks and new Head of Residential Care Gill Cornwall, support Verity and further support is given by the area manager for Somerset Care Ltd. The home has sent out quality assurance surveys this month to residents and relatives and the deputy manager explained that they will audit and action responses received. The home operates a system by which all service users personal monies are stored individually and clear records kept of money spent and receipts kept. Clear audit trails and records of checks on resident’s finances handled by the home were kept. A limit of £50 is maintained on all service users monies stored within the home. The policies and procedures for the safe storage of records and documents in most areas meet the requirements under the Data Protection Act. The inspector noted that care plans and daily record hard copies were noted to have been left on one nurse’s station unattended for a period of time. This was noted at previous key inspection and discussed again with the deputy manager at this inspection. 9 staff surveys confirmed that they received regular supervision; at inspection one staff confirmed that they had not received regular supervision. Records relating to who had and had not received supervision were forwarded to the CSCI offices with explanation that 3 one to one supervisions take place and 3 staff meeting supervisions take place for each staff member. Maintenance records were noted to be well organised and up to date, these included: Service of the fire system Weekly fire alarm tests Emergency lighting checks Fire equipment servicing COSHH reviews Pat Tests Hardwiring certificate All 10 staff surveys received confirmed that they were provided with protective clothing necessary equipment to do your work safely, one staff requested alternative protective clothing, which the management confirmed they will provide. It was noted that washing up liquid and a cleaning solution was available in the nursing unit (Cedar) dining room and the staff dining room, which were accessible by service users. Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 28 It is recommended that all substances hazardous to health be stored appropriately to reduce the risk of accidental ingestion It is recommended that the recording of accidents is developed to audit accidents for trends and repeating incidences such as time and place documented the action taken as a result of this audit and review. Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 29 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 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 17 3 18 3 4 2 4 3 3 3 4 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 2 1 Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 30 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 OP9 Regulation 13(2) Requirement Timescale for action 01/08/07 1. OP38 12(1)(a)( b) Medicines must be administered as prescribed and the home must have an audit system in place that highlights failure to administer The manager is required to audit 01/09/07 all accidents and identify any incidences or trends. These trends require risk assessment and a plan of action to reduce the risk of further accident/injury to service users. The home must ensure that substances hazardous to health are stored securely under the COSHH guidelines and are not accessible to residents as there is a possible risk of ingestion. 30/07/07 2. OP38 12(1)(a)( b) 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 Good Practice Recommendations DS0000016059.V336312.R01.S.doc Version 5.2 Page 31 Calway House 1. 2. Standard OP7 OP16 The manager is recommended to continue staff training and review of Care planning to ensure all areas of need are identified. The complaints procedure should provide a clear documented outcome to all complaints investigated to specify if the complainant is happy with the outcome. The registered manager is recommended to review the homes practice of locking the ground floor lounge door to allow access to the garden without the need for residents having to ask for the doors to be unlocked. The registered manager is recommended to request a minimum of 10 years employment history and all gaps identified should be explored and documented. The staff application form is recommended to be amended to include confirmation of the response to the Rehabilitation of Offenders Act. All records should be stored in line with the Data Protection Act and records evident on the nursing unit should be stored securely to maintain the confidentiality of residents. 3. OP20 4. OP29 5. OP37 Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Calway House DS0000016059.V336312.R01.S.doc Version 5.2 Page 33 - 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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