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Inspection on 27/09/06 for Calway House

Also see our care home review for Calway House for more information

This inspection was carried out on 27th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The environment of the home is only recently registered and is decorated to a high standard.All communal rooms and dining rooms are well equipped and spacious. All service users benefit from spacious single bedrooms, all of which are fitted with en-suite facilities. Staff training is well organised and staff are encouraged to undertake training to further their career development. The ground floor has been decorated in line with current best practise for people with dementia. The dementia care unit was pleasant and homely with creative activity planning and support evident. Activity planning in the home is well resourced and developmental in its approach to supporting all areas of the home with appropriate activities. All service users spoken to were complimentary about the kindness and thoughtfulness of the staff. The exterior of the home is laid to individual seating areas and accessible pathways. Service users were seen using the garden facilities and confirmed that they found access easily around the garden.

What has improved since the last inspection?

There were no requirements or recommendations raised at the previous inspection. The home has now completed all building works and is registered for a total of 83 beds with CSCI.

What the care home could do better:

The standard of care planning is varied. The manager is recommended to ensure that all staff are trained in care planning to ensure an equal high standard of care plan recording. The registered manager is required to review the medications systems in the Laurel unit to ensure that all medications are documented correctly and administered to the correct prescription. Temperature readings in all medication rooms requires review. The variety of meals at tea time requires review. Further review is also recommended of the method of displaying choices of menu in the Dementia Care Unit. The inspectors discussed with the manager that the process of recording accidents and incidents is reviewed to ensure that a clear audit of all accidents is made available.The storage of washing-up liquid in two areas of the home was noted and discussed with the Registered Manager, who confirmed that this is highly unusual and would be dealt with.

CARE HOMES FOR OLDER PEOPLE Calway House Calway Road Taunton Somerset TA1 3EQ Lead Inspector Gail Richardson Unannounced Inspection 27th September 2006 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 Calway House DS0000016059.V311505.R02.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.V311505.R02.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.V311505.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. One named service user who is under the age of 65 years A condition is made that Mrs Ann Delbane, RGN, is employed by the home as Clinical Lead to support the Registered Manager for a minimum of 37 hours per week. 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. 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 £361 and £650 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.V311505.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on the 27th September 2006 by inspectors Gail Richardson and Kathy McCluskey over 7 hours. A tour of the home took place and all the bedrooms; communal areas, kitchens and laundry were seen. There were 63 service users and 6 day care resident currently residing at the home, 1 service user was in hospital. 31 service users were receiving residential care, 10 service users were receiving residential dementia care and 15 service users were receiving nursing care. The inspector’s spoke to 14 service users, and 14 members of staff, the Registered manager was available throughout the inspection. Prior to the inspection the home completed a CSCI pre-inspection questionnaire 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 8 residents, 4 staff and 3 visiting health professionals. Records relating to care, medications, staff, finances and health and safety were examined The atmosphere within the home appeared relaxed and the service users appeared comfortable. All staff spoken too by the inspectors confirmed that they were happy to be working at the home and were noted to treat service users with respect and dignity at all times. The inspectors would like to thank the service users and staff for their time and hospitality through out the inspection. 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: The environment of the home is only recently registered and is decorated to a high standard. Calway House DS0000016059.V311505.R02.S.doc Version 5.2 Page 6 All communal rooms and dining rooms are well equipped and spacious. All service users benefit from spacious single bedrooms, all of which are fitted with en-suite facilities. Staff training is well organised and staff are encouraged to undertake training to further their career development. The ground floor has been decorated in line with current best practise for people with dementia. The dementia care unit was pleasant and homely with creative activity planning and support evident. Activity planning in the home is well resourced and developmental in its approach to supporting all areas of the home with appropriate activities. All service users spoken to were complimentary about the kindness and thoughtfulness of the staff. The exterior of the home is laid to individual seating areas and accessible pathways. Service users were seen using the garden facilities and confirmed that they found access easily around the garden. What has improved since the last inspection? What they could do better: The standard of care planning is varied. The manager is recommended to ensure that all staff are trained in care planning to ensure an equal high standard of care plan recording. The registered manager is required to review the medications systems in the Laurel unit to ensure that all medications are documented correctly and administered to the correct prescription. Temperature readings in all medication rooms requires review. The variety of meals at tea time requires review. Further review is also recommended of the method of displaying choices of menu in the Dementia Care Unit. The inspectors discussed with the manager that the process of recording accidents and incidents is reviewed to ensure that a clear audit of all accidents is made available. Calway House DS0000016059.V311505.R02.S.doc Version 5.2 Page 7 The storage of washing-up liquid in two areas of the home was noted and discussed with the Registered Manager, who confirmed that this is highly unusual and would be dealt with. 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 DS0000016059.V311505.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Calway House DS0000016059.V311505.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 3 4 5 Standard 6 is not applicable. The overall quality rating for this section is assessed as good. 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. Prospective service users, relatives and friends are able to visit the home prior to admission to assess quality, suitability and facilities of the home. A Service User guide is available to all service users to ensure that prospective service users has the information they need to make an informed choice about where they live. EVIDENCE: The home has a Statement of Purpose and Service user Guide which are made available to service users, prospective service users and their representatives. These documents provide information regarding the services offered by the Calway House DS0000016059.V311505.R02.S.doc Version 5.2 Page 10 home and have recently been updated to reflect the increased registration of the home. Prior to admission service users and their representatives have the opportunity to visit the home to view prospective rooms and communal areas. One service user confirmed that prospective service users are invited to lunch and to view the rooms available. Four service user records were examined. Each service user had received a pre-admission visit by the Manager and in the case of service users requiring nursing care, the head of care of the nursing unit will also be involved in this assessment. Their needs were assessed and documented, further information from other health care professionals is also taken into account. Service users surveys confirmed that 4 service users had received a contract and 4 had not. The manager confirmed that there have been some delays in producing contracts and administration staff at the home was dealing with this issue. Calway House DS0000016059.V311505.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 The overall quality rating for this section is assessed as adequate Care plans are generally well formulated and give clear information to enable staff to meet residents’ health and social care needs. Care plan training for staff is recommended to ensure that all care plans meet the required standard. Medication systems are not satisfactory and require further review to ensure that all service users are protected by the homes policies and procedures for dealing with medicines. Service users confirm that they are treated with dignity and respect at all times. EVIDENCE: The home has continued to use a computerised care planning system. There is a hard copy available to staff and it was this copy that inspectors examined. It was noted in the day of inspection that the computer was not accessible, staff confirmed that this happens regularly. Calway House DS0000016059.V311505.R02.S.doc Version 5.2 Page 12 The daily record was being recorded on hard copy and this runs concurrently with the record maintained on the computer. Service user computerised care records are password protected. Individual records are kept for each of the residents. Four care plans were inspected, each reflected current identified health and social care needs. The care plans examined contained an assessment of each area of need and a further plan of care for that need, they also contained risk assessments for areas such as moving and handling, falls and dependency rating. The detail provided was of a good standard and reflected the individual preferences of each service user. However not all care plans examined were to the same standard and it is recommended that further staff training be made available to ensure that a consistent level of care planning is undertaken. The manager is recommended to ensure that all care plans should evidence a person centred approach to care planning. The plans contained details of involvement from visiting health 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. Service user surveys confirmed that all service users felt they received the medical support they wanted, However , it was noted that there was no evidence of input from service users in care planning and there was no evidence of service users preferences following death. All service users who spoke with the inspectors were very complimentary about the staff , comments included; “The staff are lovely”, “I have found the staff to be generally good humored” and “The staff will do anything for you”, and “Staff listen to what you say – most of the time “. The inspectors witnessed staff interacting with service users throughout the home. At all times the service users were treated with respect and dignity. The medication systems throughout each unit of the home varied. The home uses the monitored dosage system (MDS) with pre-printed medication administration records (MAR). Medicines are appropriately stored and administered by senior staff who have received appropriate training. The systems in place in the residential areas were generally satisfactory. Some areas require review, specifically, the recording of PRN medication is required to specify if this medication is for regular administration or as required. The Laurels evidenced gaps in the Medication Administration Records, there was suitable indication as to the reasons for these omissions. Furthermore, the Calway House DS0000016059.V311505.R02.S.doc Version 5.2 Page 13 range of doses to be given for some medication was not specific on the Medication Administration Records The visiting Community Pharmacist on 20/04/06 has also highlighted these areas. The recording of temperature readings of medication fridges and the actual temperatures is a cause of concern. The laurels, had not been regularly recording the range of fridge temperatures and the remaining units had consistently recorded the range but in three areas of the home it was not the correct range required and no action had been taken. The manager must ensure that the maximum and minimum range of temperatures is recorded in each medication room and each medication fridge. The home is required to ensure the correct storage of refrigerated medications. A homely remedies policy is in place and stock is available. Service users who wish to self medicate as supported to do so. A risk assessment is in place for each medication and lockable storage is provided in each service users bedroom. At the last two inspection it was noted that the temperature of the room storing medicines was exceeding the limit of 25C. At this inspection it was again evident. The home is taking action to address this issue. Calway House DS0000016059.V311505.R02.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 The overall quality rating for this section is assessed as excellent. Service users are able to choose how and where to spend their day and have access to a range of varied activities. Activity staff are now available in each unit to ensure that the lifestyle experienced in the home satisfies their social and recreational needs. The home offers a varied and wholesome menu and is able to cater for special diets. Further development of displaying menu options is recommended to ensure all service users are able to exercise choice at mealtimes. EVIDENCE: The home has recruited a further activity co-ordinator which as enabled each unit of the home, including day care, to have a designated activity staff member. Some activity co-ordinators have received training in activity planning and reminiscence. The activity staff have surveys the service users life history and preferences and have tailored the activities to support their findings. On the day of inspection service users from around the home were seen playing scrabble in the downstairs dining room. One to one interaction was also taking place. Calway House DS0000016059.V311505.R02.S.doc Version 5.2 Page 15 An activity plan sheet was evident around the home. The home has also provided in the past a newsletter, the manager confirmed that this may be continued in the future. Service user surveys confirmed that when asked if there were activities arranged by the home that you can take part in ; 3-always, 4-usually 1- sometimes. One comment made was, “I appreciate the bingo sessions and knitting we do and go to skittles etc “. Trips out have been planned and a men-only trip to the pub was planned for the near future. The inspector observed activities being undertaken in the dementia care unit. These were based on activities in a domestic setting and included jobs around the home, cooking and cleaning and hanging out washing. Service users appeared settled and content and staff interactions were noted to be unhurried. The unit has a cat which service users were observed stroking and handling. this appears to be a positive outcome for service users well being. The recording of activities undertaken and any comments related to the activity are currently being recorded on each unit. This record was not seen at this inspection. Visitors were seen throughout the day with their relatives in either their bedrooms or communal lounges. One service user confirmed that visiting family were always made very welcome. Service users were able to confirm that they got up and went bed when they choose to and the details of this preference are recorded in the service users care plan. Service users rooms were personalised to each individual’s own tastes with personal items and small pieces of furniture. All meals are prepared and cooked on the premises. Service user comments were generally positive. The cook was able to demonstrate that specific preferences of diet are catered for and this was further evidence in the service users care plan. The menus are set by head office but specific requests can be catered for. Service users were aware of the choice for lunch that day and the menu was also displayed in the dining rooms located on each floor. Lunch was observed to be a social experience and the dining rooms were attractively laid and staff were seen to be supporting service users in an appropriate and discreet manner. Lunch being served on the day of inspection was; Beef and Parsnip Pie or salmon and Broccoli Bake. Each was served with boiled potato, and a selection of fresh vegetables. Desert was Lemon Meringue Pie or Jelly and Ice Cream. Calway House DS0000016059.V311505.R02.S.doc Version 5.2 Page 16 Service users have a light evening meal and a hot milky drink with care and biscuits around 7:30pm. The choice available for the evening meal were commented by two service users to be limited. This was discussed with the manager. Comments received from service users included ; “I like most meals “, ” The choice of meals is good and I can always have something different if I don’t like the daily choice.” It was also discussed with staff and the manager that a further need to provide a more appropriate method of menu selection is recommended in the dementia care unit to ensure that service users are able to make an informed choice of meal. This will be explored by the management of the home and is currently on the agenda for further discussions. It was also discussed that a more substantial supper be offered to service users in the dementia care unit with suitable snack alternatives being supplied. Calway House DS0000016059.V311505.R02.S.doc Version 5.2 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 the following standard(s): 16 17 18 The overall quality rating for this section is assessed as good. The home encourages the views of service users and their representatives. An appropriate complaints procedure is displayed. Service users legal rights are protected. The policies and procedures regarding protection of residents are of a high quality and are regularly reviewed and updated. EVIDENCE: The home displays an appropriate complaints procedure which is headed, ‘Seeking your views’. This document also contains contact details for CSCI. The home and CSCI have received one complaint since the previous inspection which was addressed and an outcome agreed within a suitable timescale. It was discussed with the manager that the recording of complaints be logged together as current practice is that the complaint details are stored in the service users care plan. Service users were able to confirm who they would complain to and this was also supported by the same response from the service users surveys. All service users are registered to vote and have the choice of a postal vote or the opportunity to visit a voting station. Calway House DS0000016059.V311505.R02.S.doc Version 5.2 Page 18 Policies are in place to protect the service user. Staff are aware of whistleblowing policies and have received training in abuse awareness. Calway House DS0000016059.V311505.R02.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 22 23 24 25 26 The overall quality rating for this section is assessed as excellent. 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. The building works are now completed. The home is provides specialist equipment to ensure the needs of service users are met and the homes environment is able to meet the assessed needs of the service users. The home takes appropriate steps to reduce the risk of the spread of infection. EVIDENCE: Calway House is a new purpose built home with accommodation arranged over three floors. The home is divided into areas catering for specified need. There are residential , nursing and dementia care units. 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. Calway House DS0000016059.V311505.R02.S.doc Version 5.2 Page 20 Also located on the ground floor is an additional very large lounge/dining area, which on the day of inspection was being used by 6 day care service users. Corridors are wide and are fitted with grab rails and were noted to be clear and uncluttered. Ramps are appropriately sited. All areas of the home are fitted with a nurse call system and during this inspection, staff were noted to respond to call bells promptly. A shaft lift gives access to all floors, the lift has the facility of voiced instructions giving service users with visual impairment an indication of floor and arrival. There is an assisted bathroom/toilet on each floor, plus a separate toilet on each floor. All are able to accommodate wheelchair users. Two service users commented that using the new baths was a comfortable experience. 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. Many bedrooms and lounge areas on the ground floor have French doors opening out small seated areas for individuals to have access to seating, flower pots and bird feeders. Larger garden areas have been attractively landscaped with wheelchair access and service users were seen enjoying the garden area. In the front reception area of the home is a small shop selling toiletries and other small useful items, there is also a hairdressers salon. Service users commented that these were convenient within the home and also places of social gathering. The general standard of cleanliness was good and there was no malodour noted. The cleaning staff confirmed that they received sufficient training and that they considered the domestic hours sufficient to maintain the hygiene of the home. Service user surveys confirmed that all service users were happy with the standard of hygiene in the home. One comment made was “Clean and fresh – spot on “ Calway House DS0000016059.V311505.R02.S.doc Version 5.2 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 The overall quality rating for this section is assessed as good. The home’s staffing levels are sufficient to manage the current care needs of residents. Further recruitment is required to support the homes staff team. The home follows robust procedures for the recruitment of staff. EVIDENCE: On the day of inspection there were noted to be sufficient staff to ensure all service users needs were being met. ! supervisor and 1 shift leader covered the home with 2 care staff on each of the residential units. The nursing unit was staffed by 1 qualified staff and 3 care staff. This was to be increased later in the day when a new admission was received. The same amount of staff was planned for the afternoon shift. The night shift was covered by 1 supervisor and 2 care staff for the residential areas, 2 care staff for the dementia care unit and 1 qualified and 2 care staff for the nursing wing. The home is currently recruiting for staff and is using agency staff to supplement the homes staff team. Service users made several comments regarding this issue with reference to the lack of continuity caused by changing of staff. Service users surveys confirmed that 4 service users felt there were always staff available when you needed them and 4 said usually. Calway House DS0000016059.V311505.R02.S.doc Version 5.2 Page 22 The manager explained that a change in the management of the units of the home has been made to give ownership f the wings to the supervisors, enabling them to have a more active managerial role in the running of their allocated wings. Further training is planned for a team training day to cover areas including management. The manager feels that by arranging rotating monthly meetings for service users and relatives this may address some issues she has with the visibility of her role within the home. Manual Handling up-dates, fire training, health and safety and food hygiene are planned throughout the year to ensure all staff have the facility to be trained and remain updated. 75 of staff employed are trained to NVQ level 2. The home follows robust recruitment procedures. This was ascertained on examination of recruitment records for 3 of the most recent staff members. Records contained information as required in Schedule 2 of the Care Homes Regulations 2001. This included enhanced CRB checks and, where appropriate, POVA First checks. The manager was reminded that all gaps in employment histories must be investigated and recorded. Calway House DS0000016059.V311505.R02.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 35 36 37 38 The overall quality rating for this section is assessed as good. The home benefits from the positive leadership style of the management of the home. The management of resident’s monies in the home is subject to regular and robust auditing by the home to ensure that resident’s monies are handled safely by the home. Records inspected were maintained generally well and were stored in most areas in a confidential manner. Staff are appropriately supervised and supported. The Health and Safety of service users and staff are good. EVIDENCE: Calway House DS0000016059.V311505.R02.S.doc Version 5.2 Page 24 The Registered Manager Verity Underhill is a Registered Mental Nurse with many years of management experience. She has completed The Registered Managers Award Level 4 and has recently been registered by CSCI. She is new to this role and has undergone an induction period. Discussions with the inspectors confirmed that she has a clear understanding of the needs of the service users living at the home. A Head of Nursing Ann Delbane and Head of Residential Care Jo Fenn, support Verity and further support is given by the area manager for Somerset Care Ltd. Quality Assurance was not inspected at this inspection. 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 staff were able to confirm that staff appraisal and supervision does take place. The inspectors was able to access training records which included staff appraisal/supervision. 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 were noted to have been left on one nurse’s station unattended for a period of time. This was discussed with the manager at inspection. All maintenance records had been seen at a recent site visit to register the home for the completion of the building works and were satisfactory. Records of in house alarm checks, emergency lighting checks and external maintenance of fire fighting equipment were all satisfactory. It was noted that washing up liquid was available in the dementia care dining room and the staff dining room, which was accessible by service users. It is recommended that all substances hazardous to health be stored appropriately. It is recommended that the recording of accidents and incidents is reviewed to ensure that all accidents are recorded in the accident log and not in the incident log. Therefore a clear audit of all accidents will be able made. . Calway House DS0000016059.V311505.R02.S.doc Version 5.2 Page 25 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 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x 3 3 3 3 1 Calway House DS0000016059.V311505.R02.S.doc Version 5.2 Page 26 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 The registered manager is required to ensure that all medication systems are maintained to a satisfactory standard. This includes : Ensure that there are no gaps in the Medication Administration Records . Hand transcribed entries to the Medication Administration Records are signed by 2 staff members. Variable doses are recorded. The dose of medication is clearly written on the Medication Administration Records. 2. OP9 13(2) The manager is required to ensure that the medications fridges and storage rooms have a recorded range of temperature and action taken should the temperature not be within the correct range. The manager is recommended to DS0000016059.V311505.R02.S.doc Timescale for action 01/11/06 01/11/06 2. OP38 13(4) 01/11/06 Page 27 Calway House Version 5.2 ensure that substances hazardous to health are not stored in areas accessible to service users. 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 OP7 Good Practice Recommendations The registered manager is recommended to ensure that all staff are trained in care planning to ensure an equal high standard of care plan recording and to ensure a person centred care approach to care planning. The registered manager is recommended to review and improve the methods of displaying the choice of menu in the Dementia Care Unit. The Registered Manager is recommended to review the process of recording accidents and incidents to ensure that a clear audit of accident occurred is available. 2. 3. OP15 OP16 Calway House DS0000016059.V311505.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 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.V311505.R02.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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