Inspection on 04/09/07 for Campania

This inspection was carried out on 4th September 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

Campania 27/07/06

Campania 21/02/06

Campania 12/07/05

Campania 20/12/04

Campania 07/07/04

Similar services:

Clouds House

Closereach

Westcliffe House

Hilldales

Longreach

Chandos House

Cherry Orchards Camphill Community Ltd

Broadreach

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

CARE HOMES FOR OLDER PEOPLE Campania 18 - 20 Ellenborough Park South Weston Super Mare North Somerset BS23 1XN Lead Inspector Sandra Jones Key Unannounced Inspection 09:30 4 5 September 2007 th th 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 Campania DS0000020283.V346321.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. Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Campania Address 18 - 20 Ellenborough Park South Weston Super Mare North Somerset BS23 1XN 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) 01934 626233 01934 420789 www.notarohomes.co.uk Notaro Homes Ltd Robert Clive Oldridge Care Home 37 Category(ies) of Learning disability over 65 years of age (37), registration, with number Mental Disorder, excluding learning disability or of places dementia - over 65 years of age (37), Old age, not falling within any other category (37) Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May provide personal care only for persons over the age of 45 years in categories MD (E) and LD (E). May accommodate persons from the age of 45 years who are suffering from Alcohol Related Brain Damage (ARBD), within the registered numbers of 37 who require personal care only. 27th July 2006 Date of last inspection Brief Description of the Service: Campania provides personal care for up to 37 older people. The home is an older property situated beside Ellenborough Park in Weston Super Mare. There are 37 single rooms. Two passenger lifts ensure level access throughout the building. There is a secluded patio area to the rear of the building. Campania is approximately half a mile from the town centre, and a short walk from the sea front. The home is owned by N Notaro Homes Limited. Mr Notaro owns several other care homes in the town. They share a minibus and pool training resources for staff. £664.95 is the weekly fees charged at the home. Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection visit was conducted unannounced over two days in September 2007 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedures. During the site visit, the records were examined, a tour of the premises was conducted and feedback sought from individuals and staff. “Have your say” surveys were sent to individuals living at the home, their relatives, health care professional and staff. Feedback was received at the Commission from fifteen people living at the home, six relatives, two staff and one Care Manager. Prior to the visit some time was spent examining documentation accumulated since the previous inspection, including the AQAA (Annual Quality Assurance Assessment) and notified incidences in the home, (Regulation 37’s). This information was used to plan the inspection visit. There are thirty people currently living at the home and six were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. The views of the manager, staff and people using the service were gathered either by face-to-face discussions or by surveys. What the service does well: The people living at the home made the following comments through the “Have your Say” surveys. “It’s a lot more than I expected”, “ Everything is good here”, “Treated well here, I like to help out when I can. Eg. Hovering”. Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 6 The six relatives that responded through “Have your say surveys” made additional comments about what the service does well and these are some of their comments, “Most staff seem to really care about residents”, “I feel that Campania home and the patients are well looked after”, “Respects their clients needs and encourage a degree of independence”, “ I am always informed of any problems and am always met with a smile, I feel its homely and welcoming” and “It projects a genuine feeling of caring about the individuals welfare.” The five individuals consulted about the standards of care at the home said that they received information about the home on admission and they know how to make complaints and who to approach with complaints. Individuals also said that they were treated well by the staff. What has improved since the last inspection? What they could do better: As a result of this inspection visit, documentation received from the home and, observations of the individuals at the home and their comments, advice must be sought from the Central Registration Team (CRT) about the current registration. While the home admits individuals within the agreed age range of 45 years and over, a large proportion of the people accommodated fit into the 45- 64 years age range. For the people at the home to make positive choices about social inclusion, occupation and education, changes in the conditions of registration must be taken into account by CRT. The number of requirements made are proportional and not all the gaps in the legislation have been identified as requirements within this report. The manager must ensure that requirements made within the text are considered and actioned to meet legislation. These findings relate to medication, meals times, training and Quality Assurance. Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 7 Requirements that focus on care planning were made to support a person centred approach to meeting individuals needs. Risk assessments, strategies and agreements must be developed for activities that may involve an element of risks. Terminology used in reports must be factual and not subjective to prevent staff from making judgements about behaviours described. Policies about consuming alcohol, which includes the arrangements for attending AA meetings, must be appended onto the Statement of Purpose. This will ensure that people wishing to live at the home have sufficient information to make decisions about moving into the home. Records of complaints must include the individuals level of satisfaction with the outcome of the complaint to support the procedure for individuals that are not satisfied with the outcome of the investigation. 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. Campania DS0000020283.V346321.R01.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 Campania DS0000020283.V346321.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The manager assesses individuals needs before admission to the home takes place. An admission procedure must be developed to enables people wishing to live at the home to make an informed choice about moving there. Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 10 EVIDENCE: Feedback from individuals at the home were sought through face to face discussion and “Have your say” surveys The most recently admitted person to the home confirmed that a booklet “Everything you ever wanted to know about Campania but couldn’t remember” was provided during the admission process. Nine of the fifteen “Have your say” surveys from individuals at the home indicate that information about the home was provided before they moved into the home. Six relatives also responded through “Have you say” surveys and three people said that they always receive enough information to make decisions about the care home and three state it was usual. The manager described the home’s admission procedure, however, the criteria for living at the home is not included within the home’s Statement of Purpose. An admission procedure must be appended onto the Statement of Purpose and must specify the criteria for living at the home along with the age and range of needs that can be met at the home. The manager conducts an assessment of needs for people wishing to live at the home, based on their health, cognitive abilities, emotional wellbeing and medication needs. Within the assessment, the individuals daily living skills and mobility needs are also assessed. The manager said that the assessments take place before admission and assessments are likely to occur in hospital. There are seven vacancies and referrals are mainly from social workers and hospitals. Campania DS0000020283.V346321.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The care planning systems must be more effective so that individuals can benefit from receiving an individualised and consistent service. Individuals can expect sensitive and prompt support for their personal and health care needs from a skilled staff team. Medication systems must be made safer. Risk assessments must be completed for managing aggressive and violent behaviours and protocols for people that consume alcohol at the home must be made clear about breeches. Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 12 EVIDENCE: The case records of six individuals living at the home were examined during the inspection visit. A pre-admission assessment is conducted to assess the needs of people wishing to live at the home. Home’s care plans are section into communications, eating and nutrition, family involvement, independent living skills and recreation. Medication, mobility, personal care, alcohol control and spiritual needs also form part of the care plan. For each area of need, the goals and outcomes are identified and action plans developed. Care plans are signed and dated by the person compiling the care plan. However, care plans are not signed by the person whose care plan it is. Action plans must be more detailed in respect of meeting the needs and must use a person centred approach to meeting needs. The manager acknowledges that improvements in the care planning process are necessary. It was stated that during the transition of the home basic methods of working had to be introduced before person centred care was used. From the care plans examined it is evident that individuals may exhibit aggressive and violent behaviours. Action plans must be clear about the way incidents of aggression and violence are to be consistently managed by the staff at the home. “Have your say” surveys were used to seek information from individuals living at the home, their relatives, health care professional and staff about the standards of care provided at the home. Fourteen individuals stated through the surveys that they receive the care and support they need and one person said their needs were sometimes met. During the site visit five people were consulted about their experience of the care planning process and one person was aware of their care plan. A senior support worker on duty explained that it was an expectation that care plans are devised with the individual and the purpose of the care plan was to ensure that their needs are being met. Five “Have your Say” surveys from relatives state that the home always meet the needs of their relative and three stated it was usual for the home to meet individual needs. Two people are likely to go out and have alcohol and protocol that guide the staff on the quantities that can be consumed by these individuals are in place. However, protocols are not clear about breeches of the agreed quantities. The manager must address the terminology used on reports to describe behaviours. Members of staff must only record factual and objective information, as subjective information will lead the staff to make judgements about behaviours exhibited. Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 13 Individuals mobility needs form part of the care planning process, risk assessments and Manual Handling assessments are undertaken for each person living at the home. Manual Handling assessments are completed following risk assessments that assess the risk of falls and the individuals dependency levels. The manager has recognised the importance of nutrition for people that have Korsakoff’s syndrome and within the care plans nutrition and diet is included. Nutritional assessments are based on a scoring system for weight, ability to eat, appetite, skin type and age. The overall total will give the level of risk and lead to further action. GP’s, multidisciplinary and chiropodists visits are recorded separately from the care plan and include the date and outcome of the visit. It is clear that individuals have access to medical, chiropody, attend hospital appointments and have visits from community health care professional. A “Have your say” survey was received from a care manager and it states that the home always meets the health care needs of the individual. The care manager said, “Very proactive”. Members of staff described the systems in place that ensure advice from health care professionals is consistently followed. It was stated that a record of visits to health care professionals is maintained and key information is on a white board for all staff to read case files. Five people at the home said that staff accompany individuals on health care visits. Four relatives indicated through the “Have your Say” surveys that the home always keep them informed about important issues and one said it was usual for the home to keep them informed. The homes philosophy of care is included within the Statement of Purpose and the principles of care are described within the philosophy. The home’s approach towards Privacy and Dignity are included within the principles of care. Individuals were consulted about the arrangements that respect their privacy and dignity. It was stated that staff knock and wait for an invitation to enter their personal space, bedrooms are single and staff use the correct form of address. During the consultation, one person stated that the staff at the home open mail. The rights of individuals was then discussed with the manager who explained that on one occasion mail was opened in error and provided documented evidence that the staff responsible had apologised for this error. Staff were also asked about the way they ensure individuals have privacy and dignity, it was stated that there is an expectation that staff knock on bedroom doors before entering, personal care is conducted in private and provided by the same sex gender. Risk assessments are based on smoking, choking, alcohol abuse, road safety, mobility and using electrical equipment. Once the risk is identified, risk assessments are completed detailing the effects, controls and action plans. Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 14 Where staff manage individuals tobacco, cigarettes and lighters, risk assessments must be completed. A record of accidents and incidents are maintained at the home. There is a log of accidents and it is evident that two people have mobility needs and records of GP’s visit show that persistent falls are monitored and action taken. Medications are administered through a monitored dosage system and the records of administration show that staff sign the records after administering the medication. Homely remedies are administered from a stock supply when required by the person and medication administration records are signed after administration. However, a record of the balances is not currently maintained. A record of medication no longer required is maintained and signed by the pharmacist to indicate receipt of the medication for disposal. While medication leaflets are kept, profiles must provide more information in terms of the purpose of the medication and side effects. Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Support systems in place must be further developed for individuals to lead active and interesting lifestyles and to be valued members of the community. EVIDENCE: The “Everything that you ever wanted to know about Campania” booklet states that their aim is to seek to provide the person with a structured meaningful day. Living, working and recreation form part of the care planning process. The activities undertaken by the person and support needed is included in the persons care plan and they show that individuals enjoy in-house and community based activities. Seven “Have your say” surveys from individuals indicate that activities are always arranged by the home, three say it is usual and four say that sometimes activities are organised. Individuals made the following comments” There are but I like to keep myself to myself” and “I enjoy going for walks”. Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 16 Individuals consulted during the inspection confirmed that activities are organised at the home, one person said that there are Karaoke evenings and another stated that they undertake household chores. A member of staff on duty said that there is an expectation that staff spend 1:1 time with individuals. Staff take individuals out for walks, play board games and puzzles. “Have your say surveys” from one relatives stated that the home always supports people to live the life they choose and five state that it is usual. The following comments were made by relatives through the surveys “Whenever practicable and where this does not cut across the clients best interest”, “Could do with a little more supervised time” and “There is not enough staff to take them out for a walk in the afternoon” The arrangements for visiting the home are included within the booklet and state that family and friends involvement is encouraged. Four relatives stated through the “Have your say” surveys that the home always assist the individual to keep in contact with family and friends and two relatives said it was usual. Five individuals were consulted during the site visit about maintaining links with family and friends and one person said that they are expecting visitors in the near future. There is an expectation that to maintain levels of independence, individuals living at the home participate in housekeeping tasks. As the home is for people that misuse alcohol, strict rules exist about consuming alcohol and breeches of the Alcohol Policy may result in termination of residency. Rules about smoking are also in place, which is that smoking is permitted in designated areas only. Five individuals were consulted about the rules and expectations of the home. One person stated that smoking is permitted in designated areas only and although there are rules about alcohol, this individual no longer consumes alcohol. Another person said that they consume alcohol and they follow the policy of two cans per day. Three individuals were critical about the way the home operates. It was stated that individuals are not supported to attend AA meetings, individuals at the home were seen drinking in front of other people and individuals are not allowed out after 7:30 pm. The manager was consulted and stated that individuals are encouraged to attend AA meetings, alcohol can only be consumed after the evening meal and in their bedroom and only one person is at risk of leaving the property unsupervised after 7:30 pm. The manager must append the Alcohol Policy that must include the arrangements for visiting AA meetings and the intake of alcohol within the Statement of Purpose. The manager was consulted about advocacy and it was explained that independent advocacy is not used because the individuals currently accommodated have input from their social workers, 50 of the people at the home have involvement from their relatives and the Court of Protection is involved with one person. Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 17 Feedback about the meals provided was sought from the people at the home and the following comments were made. “ The food is not good and alternatives are provided”, “ The food is good,” The food is okay for older people” and “Meals okay and they cater for diabetic diets”. One person said that there was a small kitchenette upstairs for individuals to make their refreshments and at night sandwiches and biscuits are available. Surveys from six individuals state that the food is always good, eight stated that the food is usually good and one said it was sometimes good. One person stated through the survey that the meal times are to close to each other and the manager agreed that meal times must be looked at. During the inspection members of staff were observed serving the meals and alternatives were offered to individuals that did not like the choice of meals available on the day. Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Individuals can expect their concerns to be listened to and to be protected from abuse. EVIDENCE: The Complaints procedure is included in the information provided to people wishing to live at the home. A large print version is also in the foyer of the property so that the people for whom its intended can read the procedure. Since the home was registered as Campania, six complaints were received from individuals and their families and three letters of compliments were also received at the home. The nature of the complaints, the actions taken and the outcome are recorded in the Complaints logbook. The level of satisfaction must be included to fully evidence the procedure for people that are not satisfied with the outcome of the investigation. Individuals giving feedback about making complaints stated that they would approach the manager with complaints. “Have your say” surveys from individuals at the home about complaints indicate that they always know who to speak to when they are not happy. Two stated that they usually know who to speak to and four said that they sometimes knew who to speak to if they are unhappy. Thirteen people stated in the survey that they know how to make a complaint and one person said they did not know how to make a complaint. Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 19 Five relatives indicated through the survey that they know how to make a complaint about the care provided and three people said that the care home always responded appropriately. Whistleblowing, Managing Suspected Third Party Abuse of a Service User and the North Somerset “No Secrets” guidance show the home’s commitment towards safeguarding adults. The Third Party Abuse of a Service User policy must be reviewed to follow “No Secrets” guidance. The manager said that there were no outstanding Safeguarding Adults referrals. Two members of staff were consulted about the factors of abuse and the actions that must be taken when comments of alleged abuse are made. Members of staff are aware of the expectations that allegations of abuse must be reported to the manager. It is evident from incident reports that one person will become physically aggressive towards staff and other people living at the home. The manager must develop strategies for managing potentially aggressive and violent behaviour, which safeguards individuals from abuse. Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home must be better maintained so that individuals can benefit from living in a comfortable environment. The care home is clean and free from unpleasant smells. EVIDENCE: Campania is registered to accommodate up to 37 people. The property is close to the beech, shops, and parks and on bus routes. It is arranged over three floors with bedrooms on all floors and shared space on the ground and first floor. There is a passenger lift to support people to move around the home more easily. Shared space consists of a ground floor lounge, smoking and dining room and on the first floor there is a second lounge, games room and computer room. Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 21 During the site visit communal areas, bathrooms and toilets were viewed. From the tour of the property it is evident that the downstairs corridor and stair carpets are in need of attention. The walls in the assisted bathroom and the ceiling in the third and first floor bathroom require urgent remedial attention. Two housekeeping staff undertake laundry at the home. There is a large laundry equipped with industrial washing machine that have sluicing facilities. Feedback about the environment was sought from five individuals. One person said that they maintain their bedroom tidy, another commented on the suitability of their bedroom. Additional comments were made about bedrooms and bathroom being lockable. One person said that people living at the home were entering their bedroom. The manager said that staff are given master keys to enter bedrooms daily and keys to bedrooms are accounted for. Fourteen “Have your say” surveys from individuals state that the home is always fresh and clean and one person said it was usual for the home to be clean. Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. A competent staff team who are well supervised supports individuals. Training must be improved to ensure the staff are skilled and qualified to meet the changing needs of the people at the home EVIDENCE: The staff rota shows that generally three people are rostered until 8:00 pm, with two waking night staff. Ancillary staff are employed to cook meals, clean the home and housekeeping staff for laundry. The manager and deputy work office hours during the week. The manager said that there is one vacancy. Seven “Have your say” surveys from individuals at the home state that staff are always available when they are needed, six said it was usual for the staff to be available and one said it was sometimes. Two staff responded through the surveys and one person said that usually there are enough staff to meet the needs of the people at the home. One member of staff was consulted during the site visit about the staffing levels and it was stated that staffing levels are tight and hopefully will improve with the recent recruitment of more staff. Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 23 Two surveys from staff state that they are provided with training that is relevant to their role and keeps them up to date with new ways of working. Two staff giving feedback said that vocational qualifications is accessible to staff. Documentation from the home indicates that three staff have NVQ leve2 and one person has NVQ level3. The manager said the aim is to access for the staff, NVQ training that is specific to people with alcohol related problems and to encourage staff to undertake vocational qualifications. The personnel files of the four most recently employed staff were examined and completed application forms, written references and Criminal Records Bureau (CRB) disclosures and POVA First check. The two staff that responded through “Have your say” surveys stated that CRB’s were undertaken before they started work. A member of staff was consulted about the training provided at the home. It was stated that medication, Mental Capacity, Dementia, Safeguarding Adults, and Manual Handling training was recently provided. A recently appointed member of staff said that the home induction programme follows from the trial period. Five individuals consulted about the staff said that the staff treat them well. The survey from the care manager stated that the care staff always have the right sills and experience to support individuals at the home. “This placement is very successful to date” was an additional comment made to support their response. Two surveys from relatives state that staff always have the right skills an experience and three stated it was usual for the staff to have the right skills and experience. Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 24 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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Individuals can expect to live in a safe environment and to be re-assured that standards will be the subject of ongoing monitoring and, the Quality Assurance system must be further developed. EVIDENCE: The manager was consulted about the direction of the home and it was stated that systems and training were areas that required improvement. In terms of training the manager said that he was undertaking NVQ level 4 and developing staff skills to meet the needs of the people at the home was a priority. Members of staff said that the manager was approachable and uses an open approach to leadership. Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 25 Staff confirmed that systems such as monthly staff meetings, eight weekly individual supervision ensure staff are supported to maintain consistency of care at the home. The manager said that the external manager undertakes Regulation 26 visits and copies of the report show that the external manager visits monthly and reports on the conduct of the home. The manager said that questionnaires and anonymous feedback are used to seek the individuals level of satisfaction with the standards of care in the home. It was also said that the system will work better if there is more control over allocated budgets. The Quality Assurance system must be drawn together so that the individuals can influence the future plans of the home. Facilities exist for the safekeeping of cash on behalf of the people at the home. It was stated that individuals have cash in safekeeping and currently nominal amounts of cash are withdrawn from individuals personal bank accounts for safekeeping at the home. The manager ensures that the home complies with associated legislation to ensure individuals live in a safe environment. A competent contractor undertakes annual checks of the passenger lift, gas central heating and portable electrical equipment. Fire risk assessments were formulated and reviewed six monthly, which incorporates checks and practices of the fire system and training of staff. Campania DS0000020283.V346321.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 2 x x x 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 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 2 x x 3 Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 27 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 OP1 Regulation 4 (1) (c) Sch. 1.8 Requirement The admission procedure that includes the criteria for admission at the home must be appended onto the Statement of Purpose. The age range and needs that can and cannot met at the home must also be included. Care plans must incorporate the likes, dislikes and preferred routines of the individual . Care plans must show that the person was involved in the development of their care plan Care plans must be more detailed to guide the staff to consistently meet the individuals needs. Risk assessment for people that at times exhibit aggressive and violent behaviours must be devised and must specify the actions to be taken by the staff to manage these situations. Agreements with individuals that consume alcohol and that staff manage cigarettes and lighters must be developed. Within the agreements the actions to be DS0000020283.V346321.R01.S.doc Timescale for action 30/01/08 2 3 4 OP7 OP7 OP7 12 (3) 15 (1) 15 (1) 30/01/08 30/01/08 30/01/08 5 OP18 13 (4) (c) 30/12/07 6 OP7 17 (1) (a) Sch3.q 30/12/07 Campania Version 5.2 Page 28 7 8 OP14 OP13 12 (4) (a) 4 (1) (c) Sch. 1.17 9. 10 OP18 OP19 13. (6) 23 (2) (b) 11 OP16 22 (3) taken for breeches of the agreements must be specified. The manager must ensure that factual information is used to describe behaviours. The Alcohol Policy, which must incorporate the arrangements for visiting AA meetings and protocols for consuming alcohol on the premises, must be appended onto the Statement of Purpose. The home’s Abuse policy must follow “No Secrets” guidance. The carpets in the corridor and stairs and, the ceilings in bathrooms must be repaired/replaced. Records of complaints must include the individuals level of satisfaction. 30/01/08 30/04/08 30/11/07 30/12/07 30/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Campania DS0000020283.V346321.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Regional Office 4th Floor Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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