CARE HOMES FOR OLDER PEOPLE
Calway House Calway Road Taunton Somerset TA1 3EQ Lead Inspector
Kathy McCluskey Announced 20 September 2005
th 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 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 D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Calway House Address Calway Road, Taunton, Somerset, TA1 3EQ Telephone number Fax number Email 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 324186 Somerset Care Ltd Mrs Jane Elizabeth Lynch PC Care Home only 34 Category(ies) of Old age (34) registration, with number of places Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: One named service user who is under the age of 65 years Date of last inspection 31st March 2005 Brief Description of the Service: Since the last inspection, Calway House has completed Phase 1 of its new build programme. This consists of a new pupose built home that, at present, is registered to accommodate up to 34 service users over the age of 65 years who require personal care by means of old age. The home is not regisitered under the category of dementia. The home is not registered to provide nursing care. Calway House, is situated in a quiet residential area not far from Taunton town centre. The building is arranged over two floors with a shaft lift giving access to the first floor. 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 Jane Lynch.The responsible individual is Marion Osborn.The home has achieved the Somerset Social Services Quality Rating.
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This is an overview of what the inspector found during the inspection. This is the first inspection since service users moved into their new purpose built home. This announced inspection was conducted over one day (7hrs) by CSCI Regulation Inspectors Kathy McCluskey and Jane Poole. The manager Jane Lynch and the deputy manager Jo Fenn were present throughout the inspection. The inspectors spent the morning talking to service users and staff and unobtrusively observing interactions between staff and service users. All communal areas of the home and a selection of bedrooms were seen. The afternoon was spent examining records relating to staff, service users and health and safety. The inspectors would like to thank service users, staff and the management for their time and cooperation with the inspection process. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well:
Calway House provides a new purpose built home for service users. All service users now benefit from spacious single bedrooms, all of which are fitted with en-suite facilities, which consist of a toilet and level access shower. Service users spoken with during the inspection stated that they really liked their rooms. The home encourages service users to personalise their bedrooms and service users are welcome to bring items of their own furniture if they so wish. The home has been well designed for service users with mobility difficulties and appropriate aids and adaptations are in place. The manager should be commended for her attention to detail when adding the final touches to the home. The ground floor has been decorated in line with current best practise for people with dementia.
Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 6 The home is registered for 34 service users who require personal care by means of old age. The home has been designed to enable service users to live in smaller groups of 17. The home has beautiful and interesting gardens which have been professionally landscaped. All service users spoken with stated that they felt safe at the home. The home is very effectively managed by Jane Lynch. Jane has a wealth of experience and training and promotes an open an inclusive style of management. Service users benefit from a staff team who have been appropriately trained. It was apparent to the inspectors that staff were committed to ensuring that service users received a good standard of care. Staff were heard communicating with service users in a kind and respectful manner. The atmosphere was relaxed and any assistance offered to service users was seen to be carried out in an unhurried and respectful manner. Service users spoken with had nothing but praise for the staff and all commented on their kindness. As part of this inspection, CSCI comment cards were sent out to service users and visitors/relatives. All made positive comments regarding the care received and stated that staff treated them well. All service users have a plan of care. A selection were examined during the inspection and were found to be very well maintained. Appropriate assessments had been completed and the needs of individual’s were clearly identified, as were instructions for staff on how needs should be met. The inspectors were able to see evidence that service users were involved in the care planning and review process. The home takes appropriate steps to ensure that the health needs of service users are met. Service users are supported to attend appointments as appropriate. The home has established excellent links with other professionals. CSCI comment cards were received from a visiting G.P and district nurse and comments regarding the care and service that the home provided were positive. The home provides a wholesome and varied menu where choices and special diets are catered for. Service users views about the food were mixed. The majority of comments appeared to relate to a previous problem with the meat being ‘tough’. This appears to have now been rectified. Service users have opportunities to join in with the home’s varied activities programme. The home employs a very enthusiastic and motivated activities co-ordinator who also overseas day care service users.
Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 7 The home takes appropriate steps to reduce the risk of harm or abuse to service users. Detailed procedures, information and training is in place for staff. The home follows robust recruitment procedures. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors. What has improved since the last inspection? What they could do better:
This question was put to service users spoken with at the inspection. Many stated that they would like staff to be able to spend more time chatting to them. This was also indicated by staff spoken with. This was discussed with the manager at the time of the inspection who stated that this would be discussed at the forthcoming staff and service users meetings. All ground floor bedrooms have patio doors that open out onto the beautiful garden areas. Some service users informed the inspectors that they do not use these doors as it ‘sets off an alarm’ and that they ‘don’t like to bother the staff’ This was also noted to have been raised in the home’s ‘Seeking your views’ questionnaires. The manager stated that she was already in the process of trying to establish whether the alarms could be disabled during the day. Apart from lounges and dining areas on each floor, the home has a very large lounge/dining area on the ground floor. This appears to be used for day care visitors and activities. Service users living on the ground floor are unable to access this area independently as it is located behind a locked door, which is fitted with a keypad. Service users living on the first floor could access this
Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 8 room via the lift. It was discussed with the manager that the home should make this area more accessible to all service users. The manager stated that this should be rectified once the second phase of the new build is complete. In the interim, it has been recommended that the use of the keypad is viewed to enable all service users to access this area independently. As the manager expressed some concerns about the safety of service users, in that they could access the kitchen door, consideration should be given to fitting an appropriate keypad to the kitchen door. 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. Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 9 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 Standards Statutory Requirements Identified During the Inspection Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5 Standard 6 is not applicable as the home is not registered to provide intermediate care. Prospective service users are able to make an informed decision about moving to the home. The home takes appropriate steps to ensure the assessed needs of service users can be met. EVIDENCE: The home has updated the Statement of Purpose to reflect the new build and staffing structures. Copies were made available to the inspectors. The home’s current fee range is between £349 and £460 per week. Extra charges are met by service users for hairdressing, newspapers, magazines, chiropody and personal toiletries. Service users receive either a statement of terms and conditions from Social Services or if privately funded a full Somerset Care contract. Both clearly outline financial arrangements and services available.
Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 11 Prospective service users are fully assessed at their home or in hospital, by the manager or the deputy to ensure that the home is able to fully meet their assessed needs and expectations. A pre-admission assessment is completed and the home obtains assessments from other professionals as appropriate. Evidence of this was seen in the care plan for the most recent service user. Prospective service users and/or their representatives are encouraged to visit the home prior to making a final decision about whether to move to the home. One of the most recent service users was able to inform the inspectors that they had made an informed decision about moving to the home. The service user stated that they had visited the home with a family member and had been able to see the available bedroom. The service user stated that they had been very happy with the admission process and were made to feel very welcome. The home avoids emergency admissions and will only consider if a detailed and up to date assessment is available from appropriate professionals. Service users living at Calway House have a range of needs and abilities. The inspectors were able to see evidence, through staff training programmes, that the home is providing training for staff in the care of people with dementia. This is felt to be positive as there are an increasing number of service users with some memory loss or with the early stages of dementia. The home confirmed good support and input from specialist health care professionals. Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 The home’s care planning systems are clear and consistent. The home follows appropriate procedures for the management and administration of service users medicines. EVIDENCE: Four service user care plans were examined at this inspection. Care plans seen were personalised and clearly identified the individual’s assessed needs. Instructions for staff on how needs should be met were detailed and easy to follow. The manager stated that they were in the process of developing social histories for service users. Progress will be followed up at the next inspection. Appropriate assessments were in place which included reducing the risk of pressure sores and falls, moving and handling needs and nutrition. All records seen were well maintained and up to date. Care plans are reviewed on a monthly basis. The inspectors were also able to see documented evidence
Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 13 of detailed 6 monthly reviews. It was positive to note that the service users, wherever possible, had stated who they wished to be present at their review. The home takes appropriate steps to ensure that service users have access to appropriate healthcare professionals. Details of all visits are maintained in the individual’s plan of care. Records seen indicated that service users receive regular visits from G.P’s, dentist and chiropodist. Specialist healthcare professionals such as those specialising in mental health, are accessed where there is an assessed need. At the time of the inspection one service user was being seen regularly by a district nurse who was treating a ‘healing’ pressure sore. The inspectors were able to see that the service user had an appropriate pressure relieving mattress in place. All care and equipment required was also identified in the individual’s plan of care. As part of this announced inspection, 8 completed service user comment cards were returned to the CSCI. Five service users indicated that staff respected their privacy, two felt ‘sometimes’ and 1 indicated that their privacy was not respected. This was discussed with service users at the time of the inspection and no concerns were raised with the inspectors. Service users spoken with stated that staff assisted them with personal care in a dignified manner. All 8 service user comment cards indicated that staff treated them well. Seven indicated that they felt well cared for, with one indicating ‘sometimes’. All indicated that they felt ‘safe’ at the home. The CSCI received 7 comment cards from relatives. All indicated that they were satisfied with the overall care that their loved on received. This was also indicated in quality questionnaires recently sent out by the home. The inspectors examined the home’s procedures for the management and administration of medication. The home uses the monitored dosage system (MDS) with pre-printed medication administration records (MAR). Medicines were found to be appropriately stored on each floor and are administered by the senior member of staff of duty. MAR charts seen had been appropriately completed. Photos of service users were in place to aid identification. Records and storage arrangements for controlled drugs were found to be well maintained. Daily temperatures are maintained for the fridges storing medication and temperature of the room. The latter should be closely monitored, with action taken as appropriate, as the temperature was noted to exceed the limit of 25c.
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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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 The home has an activities programme. It is uncertain whether this is currently meeting the needs and expectations of all service users at the home. The home has produced a wholesome and varied menu though feedback from service users was varied. EVIDENCE: The home employs an activities co-ordinator for 24 hours a week. This person also takes responsibility for service users visiting for day care and assists them with a bath where required. The maximum number of service users that would visit the home at any one time for day care, is seven. The inspectors were informed that the activities co-ordinator has a delegated member of the care team to assist her with activities each afternoon. The home provided the inspectors with a copy of their activities programme. This included external entertainers, mystery trips and tea dances. On the day of this inspection, some service users joined in with flower arranging in the morning and flexercise in the afternoon. Information was seen to be displayed for service users on each floor. Activities usually take place in the large lounge/dining area on the ground floor.
Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 15 The inspectors were able to meet with the activities co-ordinator during the inspection and her enthusiasm and commitment to ensuring that service users have opportunities for meaningful activities was very apparent. Records maintained were examined and these also identified one to one time spent with individuals. The activities coordinator stated that, with the new building layout where service users live in smaller groups of seventeen, she found it more difficult to encourage service users away from their ‘home’ lounges to the activities lounge. Feedback from service users regarding the provision of activities was ‘mixed’. Of the 8 completed CSCI service user comment cards received, only 2 indicated that the home provided suitable activities. A relative indicated that activities were not always appropriate for service users with a hearing or sight impairment. Many service users informed the inspectors that they would like it if staff had more time to ‘sit and chat’ to them. This was also indicated in a completed questionnaire sent out by the home. Staff spoken with stated that they ‘did not have time for quality time’ with service users. Comments raised were discussed with the manager at the time of the inspection who agreed to look into the issues and discuss at forthcoming staff and service user meetings. This will be followed up at the next inspection. The home welcomes visitors at any reasonable time in accordance with the wishes of the service user. Service users are able to choose where they see their visitors and can use the privacy of their own bedroom if they so wish. Of the 7 CSCI relative/visitor comment cards received, all indicated that they could visit their relative/friend in private and that they were always made to feel welcome. No relatives/visitors requested to see the inspectors during the inspection. Within their agreed plan of care, service users are encouraged to exercise choice and control over their lives. Service users informed the inspectors that they choose what time to get up in the morning and what time they go to bed. It was evident to the inspectors that service users choose how to spend their day. Service users living on the first floor are able to access the large lounge/dining area on the ground floor. Service users on the ground floor are dependant on staff assistance to access this area as it is located behind a door which is fitted with a key-pad.
Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 16 Service users views regarding the food was varied. This was also reflected in CSCI comment cards and in the homes service user questionnaires. Service users spoken with stated that the food was ‘alright’ and that ‘some days were better than others’. All service users stated that there was enough to eat and that they were able to make a choice. Comments from the home’s survey and service user meetings related to ‘the meat being tough’. The manager stated that this had been addressed. The inspectors were able to see lunch being served on each floor. The majority of the service users were seen to utilise the dining room on each floor. Tables were attractively laid and refreshments were available. The vegetables and the potatoes were placed in serving dishes on the tables so that service users could help themselves. Meals are taken to each dining room in a hot trolley where care staff serve the food. Two service users were visiting for day care. They were observed eating their lunch in the large lounge/dining area on the ground floor with the activities coordinator present. Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 17 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 and 18 The home has a satisfactory complaints procedure in place. The home takes appropriate steps to reduce the risk of harm or abuse to service users. EVIDENCE: The home displays an appropriate complaints procedure which is headed, ‘Seeking your views’. The home’s complaints records were examined. No complaints have been received since the last inspection and no concerns have been raised directly with the CSCI. Service users are encouraged to express their views at regular meetings or at any time. Service users spoken with informed the inspectors that they would not hesitate in raising any concerns with the management or care staff. This was also indicated in all 8 CSCI service user comment cards received. At the time of this inspection, the home is taking appropriate steps to reduce the risk of harm or abuse to service users. Appropriate policies are in place for staff and the home ensures that staff receive appropriate training regarding safeguarding service users from abuse. The home follows robust staff recruitment procedures which include enhanced CRB checks and, where appropriate, POVAFirst checks. All service users are registered to vote.
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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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 Service users live in a new purpose built home which provides a safe and very comfortable environment. Service users have the benefit of single bedrooms with en-suite facilities. Apart from access to one lounge, the home has been suitably designed and equipped to maximise service users independence. EVIDENCE: Calway House is a new purpose built home with accommodation arranged over two floors. Service users moved into the new home in April of this year. The existing home has now been demolished and a further ‘new build’ is well under way. On each floor there is a good sized lounge and separate dining room with kitchenette area. On the ground floor there is also a smaller ‘quiet’ lounge, which is temporally being used as a smoking room as the home has one service user who smokes.
Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 19 Also located on the ground floor is an additional very large lounge/dining area. This is located behind a door, which is locked via a key pad and appears to be used at present for day care service users and activities. Service users living on the ground floor are unable to access this area independently because of the key pad. This was discussed with the manager at the time and the inspectors were informed that this arrangement should change once the second phase of the new build is complete. Corridors are wide and are fitted with grab rails. Ramps are appropriately sited. All areas of the home are fitted with a nurse call system. A shaft lift gives access to the first floor. There is an assisted bathroom/toilet on each floor, plus a separate toilet on each floor. All are able to accommodate wheelchair users. Bedrooms are located on each floor. Bedrooms and communal areas are arranged to enable service users to live in smaller groups of 17. All service users are accommodated in spacious single bedrooms, which have an en-suite toilet and level access shower. All bedrooms are fitted with a telephone & television point and computer point. A selection of bedrooms were seen and these were noted to be very comfortable and personalised. Service users spoken with were very positive about their bedrooms. All outside areas are accessible to wheelchair users. The home has several garden areas which have been professionally landscaped. The gardens provide beautiful safe areas for service users to enjoy. Building works are on-going in some areas. Many bedrooms and lounge areas on the first floor have French doors opening out onto the garden. Some service users explained to the inspectors that they did not use their patio doors as ‘it sets the alarm off’ and that they ‘don’t like to bother the staff’. This was also noted to have been raised by service users in the home’s questionnaires. This was discussed with the manager at the time who is in the process of trying to rectify. Progress will be followed up at the next inspection. Service users, who have lived at Calway House for some time, were asked what they thought of their new home. All were positive about their bedrooms though little comment was made regarding the communal areas. Quite a few service users spoken with stated that they preferred the ‘old Calway House’. It is acknowledged that the manager and her team worked very hard to ensure that the transition for service users, from the old building to the new, was relaxed and caused as little distress as possible. Service users spoken with were very complementary about the manner in which the move was managed.
Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 20 All areas of the home were seen to be very comfortable, clean and free from malodours. The home has a large very well equipped laundry area. Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 21 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Service users are cared for by a well trained and committed staff team. The manager has agreed to look into concerns regarding the numbers of staff on duty. The home follows robust recruitment procedures. EVIDENCE: The inspector was provided with copies of the home’s staff rotas and staffing is arranged as follows: - Morning – 1 shift leader, 1 supervisor covering both floors, 2 carers based on the ground floor and 1 carer on the first floor. A care support worker, whose responsibilities are mainly cleaning, is located on each floor. - Afternoons and evenings – 1 supervisor and 1 care support worker covering both floors, 2 carers on the ground floor and 1 on the first floor. - Nights are covered by 2 waking care staff. In addition to care hours, the home employs an activities person for 24 hrs a week. Cooks, kitchen assistants and laundry staff cover 7 days a week. Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 22 In addition to the registered manager, the home employs a deputy manager, 7 care supervisors, 17 care staff and 7 care support workers and 3 care relief workers. Comments from staff, service users and CSCI visitor comment cards indicated that they felt that there were not enough staff on duty. This was discussed with the manager who stated that staffing levels have actually increased since moving to the new home even though the number of registered places had decreased. The manager stated that she intended to discuss staff and service user concerns at forthcoming meetings. Progress will be followed up at the next inspection. The manager emphasised that staffing levels would be increased where required to meet an increase in dependency levels. Service users did not raise any concerns regarding staff’s ability to meet their care needs, nor did they say that they felt rushed. In fact, service users were very positive about the staff team and all commented on the kindness shown. Information provided by the manager indicated that, of the 24 care staff employed, 11 have achieved a minimum of an NVQ level 2 in care and the remainder are working towards this. Somerset Care are committed to the on-going training of staff and provide staff with excellent training opportunities. The manager has arranged training for staff in the care of older people with dementia. Some staff have already completed this. This is felt to be very positive. Both of the home’s cooks are working towards an appropriate NVQ level 2. The home follows robust recruitment procedures. This was ascertained on examination of 3 staff recruitment records. All contained information as required in Schedule 2 of the Care Homes Regulations 2001. This included enhanced CRB checks and, where appropriate, POVAFirst checks. Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 23 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36, 37 and 38 Service users and staff benefit from an experienced and committed manager who promotes an open and inclusive style of management. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors. EVIDENCE: The registered manager, Jane Lynch, has been in post since October 2003 and has had over 7 years experience in managing Somerset Care homes. Jane Lynch is committed to the care of the service users and of the training and development of staff. She is an appointed first aider, an NVQ assessor (D32/33/34) and a moving & handling training. Jane has also completed the NVQ level 4 award in management and has a strong interest in dementia care. Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 24 Service users were very positive about the way their move to the new building was managed. The manager went to great lengths to ensure that this was carried out in a manner which caused as little stress and anxiety to service users as possible. Service users, staff and visitors were kept fully informed of events right from the initial planning stage. The home is running a competition for service users at present, inviting them to come up with suggestions for the naming of the new ‘units’. The manager holds regular meetings for service users and staff. Minutes are maintained. Minutes were seen relating to the last service user meeting. This was held on 24/08/05. Appropriate and meaningful topics were discussed including, the forthcoming CSCI inspection, how service users were settling in to their new home, staffing, food and activities. It was apparent to the inspectors that service users were encouraged to express their views. Meetings were held for staff in June and July of this year. Topics discussed included forthcoming training, staff routines, activities and medication. Service users and staff spoken with at the inspection indicated that they were kept well informed. All 8 completed CSCI service user comment cards indicated that service users knew who to speak with should they have any concerns. The home regularly seeks the views of service users and relatives through their quality questionnaires. These were last sent out in August and the inspectors were able to see a number of completed questionnaires. These will be analysed by the manager once more have been received. Comments indicated that both staff and relatives were happy with the care provided. Some comments, already raised in this report included the food, staffing and access through alarmed patio doors. Staff are supported through regular supervision sessions. These are carried out at least six times a year. Appropriate topics are discussed which includes training needs. The home manages small amounts of pocket money for service users where requested. Records seen were well maintained. Receipts are obtained for transactions. Balances were not checked at this inspection. All records seen at the time of the inspection were appropriately stored in accordance with the Data Protection Act 1998. At the time of this inspection, the home is taking appropriate steps to ensure the health and safety of service users, staff and visitors. This was ascertained
Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 25 by a tour of the premises, discussions with staff/service users and on examination of the following records: FIRE SAFETY – The home conducts weekly checks on the home’s fire detection systems and monthly checks on emergency lighting. Records were seen. Fire detection systems and fire fighting equipment are serviced by an outside contractor on an annual basis. This was last carried out on 07/02/05. ELECTRICAL SAFETY – The home’s portable appliances (PAT) are tested annually. This was last carried out in August 2005. The home has an up to date electrical hardwiring certificate. GAS SAFETY – The home has an up to date Landlords Gas Safety certificate. ACCIDENTS – The home maintains appropriate records for all accidents. All accident records were seen to be appropriately stored in accordance with the Data Protection Act 1998. The manager analyses accidents monthly and takes appropriate action where required. HOT WATER OUTLETS/SURFACES – The home maintains records of monthly checks on all hot water outlets. Records seen indicated that bath hot water outlets were within HSE recommended limits. To reduce the risk of injury to service users, all hot water outlets have been fitted with thermostatic controls. EQUIPMENT SERVICING – The following equipment, used to move or transport service users, was serviced by an external contractor in accordance with LOLER regulations: - The three mobile hoists and slings were serviced on 02/09/05 - The two bath hoists were serviced on 26/08/05 - Wheelchairs were serviced on 08/04/05 - The shaft lift was serviced on 09/09/05 - The home’s electronic sit-on scales were calibrated on 13/07/05 - To ensure the safety of service users, all upstairs windows are restricted, low heat surface radiators are installed and any free standing wardrobes are secured to the wall. - The home has a qualified first aider on every shift. Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 4 4 3 3 3 3 3 3 Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 27 NA 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP20 Good Practice Recommendations The registered person should review the use of the keypad lock to the large lounge/dining area and, if appropriate, should consider fitting a suitable locking devise on the kitchen door Calway House D53-D02 S16059 Calway House V244167 200905 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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