Inspection on 16/11/06 for Capri

This inspection was carried out on 16th November 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Capri 20/06/07

Capri 21/11/05

Capri 18/08/05

Capri 06/01/05

Capri 11/08/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Capri 48 St Johns Road Sandown Isle Of Wight PO36 8HE Lead Inspector Liz Normanton Unannounced Inspection 16th November 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 Capri DS0000012471.V311635.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. Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Capri Address 48 St Johns Road Sandown Isle Of Wight PO36 8HE 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) 01983 402314 Isle of Wight Care Ltd Christine Jacqueline Basham Care Home 9 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (9) of places Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Three named people in the MD(E) category may be accommodated at the home. One person is accommodated in the PD category. This named person may remain at the home. 21st November 2005 Date of last inspection Brief Description of the Service: The home is registered in respect of 9 service users under the broad category of Older Persons, 2 additional places under the category of Dementia (elderly) and 1 category for older people suffering from a Mental Disability, the home may not accommodate any more than 9 service users. The home is located within St Johns Road, Sandown and is situated within easy access of the main shopping area, its facilities and amenities. The premises is a three storey town house that has been converted to provide residential accommodation and has seven single bedrooms and one shared room that is currently used by a couple. The accommodation for the service users is split between the ground floor and first floor with the second floor being used as staff accommodation. Access from the ground floor to the first floor is via the stairs or the homes stair lift. Fees: £350.00 per week to £511.00 per week. Capri DS0000012471.V311635.R01.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 undertaken on the 16/11/06 and focussed on what the commission considers to be core standards for a care home for older people as defined in the Department of Health (DOH) National Minimum Standards and looked for evidence of compliance with regards to requirements made at the last inspection. The information in this report has been collected from a variety of sources, which includes a pre-inspection questionnaire completed by the manager, five resident’s feedback questionnaires a visit to the home, discussion with three residents, manager, staff and one relative. Two residents’ care files and two staff files were audited. There have been issues with regards to poor recruitment procedures at the last two inspections with regards to the manager employing staff prior to ascertaining whether they were fit persons to work with vulnerable adults. At this inspection it was found that two new staff had been employed prior to the manager having obtained clearance from the Protection of Vulnerable Adult (POVA) list. If there has been no improvement in this area at the next inspection the CSCI will have to consider what action it will take to ensure compliance. The manager had complied with one of the two requirements made at the last inspection. There have been some improvements in the fabric of the home since the last inspection. Comments from residents indicated that the majority are satisfied with the service the home provides. What the service does well: What has improved since the last inspection? The manager reviewed and updated the complaints policy and procedure as required at the last inspection. A new carpet has been fitted to the lounge and dining room. Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 6 There has been redecoration to communal toilets, bathroom and front and back porch. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the home has a contract of terms and conditions of occupancy it was evident that not all residents have been supplied with a copy. Prospective residents needs are assessed prior to admission and the home does not admit people who’s needs it cannot meet. EVIDENCE: In written feedback from five residents they stated that they did not have a contract. Whilst examining three resident’s files, one was found to contain a contract of the terms and conditions of the home. In discussion with the manager they explained that they visit prospective residents at their place of residence and undertake a needs assessment. After gathering information the manager determines whether the home can meet an individuals needs prior to offering them a placement. Evidence of needs assessments were seen on three residents files. Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 9 A visiting relative spoken with confirmed that the manager had visited their parent at home. As their parent was not able to visit the home they had been to visit on their behalf and had chosen this home due to its size as they felt their parent would prefer to be with a smaller group of people which was more homely. The inspector was unable to speak with two of the more recently placed residents as one was in hospital and their partner was too distressed to discuss the placement arrangements. Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care which resident’s receive is based on their individual needs however those residents with mobility difficulties who require assistance should be supported using current moving and handling procedures. The medication policies and procedures generally ensure that medication is administrated safely however there was evidence of human error in this area. The principles of dignity and respect are generally put in to practice however the manager needs to ensure that all staff are regularly reminded to adhere to the home policy and procedures. EVIDENCE: The inspector viewed two residents care plans and found the information supplied had been drawn up from the needs assessment. The care plans contained details of personal contacts, medication details, personal care needs, mobility, preferred activities, food likes and dislikes etc. The information was detailed to enable staff to provide consistency of care. The care plans also Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 11 contained risk-assessments and separate falls assessments. The manager takes responsibility of reviewing the care plans monthly. Residents did not appear to be consulted at the review of their care plans. The manager explained that a resident having respite care did not have a care plan as she was only there for a short time and the staff were using the information in the needs assessment. The manager was advised to draw up a care plan for this person as there was some uncertainty as to how long the respite period would be as their partner was in hospital. In discussion with a visiting relative they said “ I am very happy with my mothers care.” In anonymous written feedback from five residents four stated that they were satisfied with their care whilst one commented that they only receive the support they require sometimes. In discussion with two residents one was very happy with the care whilst one was unhappy that the home did not have a shower and that it was not easy to have their hair washed. In discussion with the manager they explained that the home is planning to convert a ground floor w/c into a shower room in the future. The bath is equipped with a specialist hoist seat to enable people to get in and out. Whilst observing two staff transferring a resident from a seat to a wheelchair it was noted that they were using out of date moving and handling techniques by lifting the resident under the armpits which can be painful and puts all three at risk of injury if the resident were to fall. This matter was discussed with the manager who explained that the staff, have had moving and handling training and she would ensure that they used moving and handling equipment for future transfers. One resident with mental health difficulties was very upset and agitated as their partner was in hospital. The manager and proprietor were both able to calm them down and offered her them the opportunity to go out to take their mind off the situation. This offer was accepted. The home promotes residents health care needs. The district nurse who visits twice weekly is supporting one resident, who was described by the manager as very poorly. The home, have provided a specialist mattress for this resident to prevent pressure sores and creams are used to moisturise the skin. All residents are registered with a general practitioner (GP) from the local Sandown surgery. The older persons mental health team support resident’s with mental health problems. The home supports one resident with diabetes and staff, have been trained to take regularly blood sugar level checks using an Epiepen. Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 12 The home continues to use the Monitored Dosage System (MDS), which is dispensed by the pharmacist. Medication is received in to the home monthly and is recorded directly on to the Medication Administration Record (MAR) charts. The inspector viewed several MAR charts at random and found them to be accurately signed however there was a couple of omissions in relation to one resident over a two day period, this matter was raised with the manager who agreed to look in to it. Four staff including the manager are responsible for the administration of medication and have undertaken advanced medication training. In discussion with the manager they stated that the Pharmacy Team had contacted the home and have arranged to undertake a medication review. Personal care is provided in the privacy of resident’s own rooms or the bathroom. In discussion with a care manager prior to the inspection visit they confirmed that they are always able to visit their client in private. The district nurse team was contacted but did not return the call so the inspector was not able to discuss the issue of resident’s privacy and dignity with them. In discussion with the manager they stated that medical and examination treatment is undertaken in residents own rooms. All staff were observed calling people by their preferred name. There is a pay phone situated in the hallway of the first floor for the use of residents. There is screening provided in the shared room. During the inspection visit residents were observed being treated with dignity and respect however when assisting a resident to go to the toilet one member of staff was heard to ask the resident if they wanted to wee wee? Another resident sitting in the lounge heard this and said, “I do wish they wouldn’t say that”. This matter was discussed with the member of staff who explained that they only copy what the residents has said, they were advised that it would be better not to use this phrase in the presence of others to observe the residents dignity. The staff member agreed that on having them pointed out to them that their approach had not been appropriate. The matter was also raised with the manager. Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to choose their lifestyle, social activity and keep in contact with family and friends. The home is going to improve the number of activities available to residents. Residents receive a healthy, varied diet according to their assessed requirement and choice. EVIDENCE: The pre-inspection questionnaire returned prior to the inspection visit indicated that there is little in the way of activities provided by the home. This was evidenced by written feedback from four residents and discussion with a care manager prior to the inspection visit. In discussion with the manager they explained that the issue of limited activities was raised at the previous days team meeting 14/11/06 and that it was agreed that the home would have an activities co-ordinator on Monday and Wednesday who would organise resident led activities. The home does have an assortment of games, jigsaws that are easily available to the residents. The lounge is equipped with a television and music was being Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 14 played throughout the morning. In the afternoon one resident who had been out in the morning was observed crocheting a blanket in the lounge sitting with the older residents. The younger residents who are able go out in to the local community for walks, shopping to the pub etc independently and the home hopes to be able to support older residents to go out by providing additional staff twice a week. Resident’s have regular visits from relatives and friends with one person visiting their parent daily. The home is also visited by a chiropodist every eight weeks and the mobile hairdresser who comes fortnightly. At the time of the inspection visit one resident had a hairdresser who called in the afternoon to do their hair. The manager stated that this was a private arrangement, which had been in operation for many years. The district nurses and doctors are also regular callers to the home. One visitor stated that they had had Christmas dinner at the home over the past tow years so that they could be with their parent and were made most welcome. In discussion with a care manager prior to the inspection visit they stated that they always have the opportunity to visit their client in private. Those residents that choose to smoke are able to smoke in their own rooms during the day or out in the garden. The home has a no smoking in bedrooms policy during the night and ashtrays and cigarettes are removed from rooms with residents consent. Residents are encouraged to manage their own finances and the home only supports two with money management to ensure that they have sufficient to purchase cigarettes and toiletries etc. In discussion with the manager and staff they explained that the home does not have a set menu and offers a hot cooked lunchtime meal on a day- to -day basis, taking in to consideration the residents preferred choices, which are known by the staff. Written feed back from five residents and conversation with two in the home revealed that residents are very happy with the food provided. The lunchtime meal served at the time of the inspection was steak & kidney pie, roast potatoes and fresh carrots and cabbage and looked wholesome and was well presented and was a decent sized portion. One resident was observed having a meal brought up to their room, which is their preference and others had chosen to eat in the lounge or sit in the dining room. In discussion with the manager they explained that the meal times are flexible to meet the residents needs. Residents have asked for the teatime meal to be served later as they like to watch deal or no deal on television before they have tea. Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 15 It was evident from visiting residents, own rooms that they are able to bring their own personal possessions to the home. Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 16 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 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents have access to a robust, effective complaints procedure. The home generally does well to protect the residents from abuse however the manager has recently recruited staff without having first ascertained whether they are suitable to work with vulnerable adults. EVIDENCE: The manager has reviewed and updated the complaints policy and procedures as required at the last inspection. A copy of the complaints procedures was on display in the homes reception area. In discussion with the manager they stated that details on how to make a complaint are now included in the statement of purpose. There have been no complaints since that last inspection. In individual discussion with two staff they were able to demonstrate that they knew and understood the homes policy and procedures for dealing with complaints. One staff member explained that minor issues raised by residents are dealt with immediately to try to prevent an escalation in the problem, which could lead to a more formal complaint. Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 17 The home has a copy of the Isle of Wight Care Limited Adult Protection policy and procedure, which complies with the Isle of Wight Adult Protection Procedural Policy of which the home has a copy. There is an IOW No Tolerance poster and leaflets on display in the reception area. In discussion with two staff they were able to demonstrate that they understood how to recognise abuse and stated that they would follow the homes “ whistle-blowing” procedures without fail if they suspected adult abuse. In discussion with the manager they reported that adult abuse awareness training is planned for the staff team and will be done in house with the use of training materials, which includes watching a DVD. The homes policy and procedures regarding service users monies and financial affairs protect residents from financial abuse. The manager has recruited two new members of staff prior to establishing whether they were fit persons to work with vulnerable people details of this can be found under the evidence for staffing. Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 18 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 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home is residential and provides residents with a comfortable, clean and homely environment. There is need for some repairs and renewal. EVIDENCE: A partial tour of the building was undertaken and included all communal areas and several bedrooms, the laundry and garden. The garden is situated at the rear of the property and is enclosed to provide privacy and safety. The garden can be accessed via the lounge through a door which leads on to a balcony and stairs. It was observed that the balcony and stairs, which are made from wood, was rotten. In discussion with the manager they reported that they have already consulted a contractor to make repairs and that there are plans to have the balcony area extended to enable more Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 19 residents to sit out in the summer. Those with mobility difficulties can access the garden from the front of the house and through the garden gate. The resident described a shared bedroom as depressing and that their partner felt hemmed in when spending time in the room. The inspector noted that the room did no have a pleasant outlook as it looked out directly onto another house and natural light was limited, the room was dimly lit and the wall colour was peach giving it an overall gloomy feeling. It was noted that the carpets were very badly stained in two of the bedrooms and this was discussed with the manager who explained that they had been cleaned regularly, it was pointed out by the inspector that these carpets were past their best and now need replacing. A number of bed bases were also showing signs of wear and tear and were frayed. The bedrooms at the home were noted to be small and do not meet current standards but provide the same usable floor space as provided at 31st March 2002. The dining room and lounge are of an open plan design. The carpet in these areas has recently been replaced and both rooms were well furnished and nicely decorated and provided warm comfortable safe surroundings. The kitchen was noted to have worn and damaged work surfaces, which can be a potential health and safety risk. In discussion with the manager they reported that there are plans to redecorate and part refurbish the kitchen in 2007. Communal toilets and the bathroom have been redecorated since the last inspection. The front and rear porches of the home have also been painted. Radiators in resident’s bedrooms are fitted with guards to prevent burns in the event of a fall whilst the radiators in the communal areas are not guarded. In discussion with the manager they reported that the radiators in communal areas had been risk-assessed as a low risk due to there always being somebody present in these areas and to cover the radiator in the living room would restrict access. In written feedback from five residents and comments from two care managers the home was described as always being kept clean and tidy. In discussion with the manager it was reported that the home does not have an annual renewal programme and that work is done as required. Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 20 For those residents that choose to smoke the home have provided air purifiers to ensure that odours and fumes are contained, whilst nullified by the purifier. The laundry is situated outside in the garden and is accessed from the first floor by the fire escape and from the ground floor through the living room. The manager reported that occasionally laundry might be taken through the kitchen in extremely poor weather conditions, as this is the most convenient route. They explained that the laundry is concealed in laundry bags at all times to prevent the risk of spread of infection. The laundry floor had an impermeable concrete floor with paint peeling off. The manager explained they had been asked to paint the floor at a previous inspection and that this was done however the floor was slippery when wet and was not suitable so she has stripped it. Liquid soap dispensers and paper towels were available in all communal hand washing facilities. The home has a policy and procedures on infection control. The staff on duty were observed to be adhering to the homes infection control policy and procedures. Capri DS0000012471.V311635.R01.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and employed in sufficient numbers to fill the aims of the home and meet the changing needs of the residents. There are continued poor recruitment practices, which compromises the safety and welfare of residents. EVIDENCE: The home employs twelve staff not including the manager who are responsible for the day-to day operations of the home which includes caring, cleaning, cooking etc. The staffing roster demonstrated that there is sufficient trained, experienced staff, on duty throughout all shifts to meet the assessed needs of the residents. The pre-inspection questionnaire indicated that the home has two vacancies for night staff and that existing staff are currently covering these shifts. According to the pre-inspection questionnaire sent prior to the inspection visit the manager has met targets set in their training strategy with 50 of the staff team now having completed National Vocational Qualification (NVQ) at level 2 or above. Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 22 The inspector looked at the files of the two recently employed staff and found that they contained all the documentation as required in schedule 2 of the Care Homes Regulations. The Criminal Bureau Record (CRB) application forms had been completed and the manager was waiting for the disclosure forms to be returned. In respect of Protection of Vulnerable Adult (POVA) checks these had been obtained however the manager had employed both staff prior to receipt of the POVA clearance being obtained and was therefore not in a position to know whether these two staff were fit persons to work with vulnerable adults. The manager explained that the staff had only been in the home as part of their induction and were not expected to provide personal care until the POVA checks had been obtained and that they had been supervised by her at all times. It was explained to the manager that no applicants should be employed in any capacity until POVA checks have been obtained. In discussion with one member of staff they confirmed that the home provides staff with training relevant to the work they undertake. There was evidence of a training log and certificates of training included general hygiene procedures for minimising risk of infection, administration of medication, food hygiene awareness and manual handling. There are plans to provide training in new fire regulations and adult abuse awareness training. The home has an induction programme for new staff, which includes reading policies and procedures familiarizing themselves with the homes ethos and philosophy and mandatory training. In discussion with the manager they reported that they had been aware of the change in induction training and was trying to obtain the skills for care induction pack for future employees. Capri DS0000012471.V311635.R01.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, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the management of the home is good with the manager having positive relationships with both residents and staff. The homes quality assurance systems could be improved. EVIDENCE: The manager is experienced and qualified to manage the home and has completed the NVQ level 4 in management and the Registered Managers Award (RMA). There was evidence that the manager supports staff development and they intend to undertake staff annual appraisals this month. In discussion with staff they reported that they receive regular supervision. The manager was highly regarded by the staff and residents. Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 24 In discussion with the manager they reported that they consult with residents on a daily basis to ascertain if they are satisfied with the service. A suggestion/comment leaflet is available in the reception for relatives and resident’s area but the manager explained that these are not used. Residents meetings are held occasionally throughout the year. There is no planned annual renewal programme, the manager explained that items get replaced and work is undertaken as required. The homes policies and procedures have been reviewed and updated in December 2005. With regard to resident finances the home prefers the residents or their representatives to take responsibility for their own financial affairs. The home safeguards one resident’s money and has an arrangement with social services to supply one resident with their personal allowance. Money in safekeeping was kept in a locked facility and records and receipts of transactions are kept. Money contained in resident purse was checked against records and was found to be accurate. The home has policies and procedures in place for the health and safety of residents and staff. The staff team have undertaken mandatory training in the areas of health & safety. Fire alarm systems are checked weekly and records of tests are kept. Those staff responsible for food handling have had food hygiene training. Food is stored appropriately. Substances hazardous to health (COSSH) are kept in the laundry, which is situated in the garden separately from the home. At the time of the inspection the laundry did not have a door fitted and COSHH products were not stored as required. In discussion with the manager they reported that arrangements for the door to be replaced were in hand and that it would be lockable. Evidence was seen that the home undertakes regular servicing of boilers and central heating systems. There was also evidence that electrical appliances and systems are maintained. The home was last inspected by Environmental health in November 2005 and four requirements were made it was observed that the home have complied with the requirements. Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 25 The home has a certificate of liability insurance, which is displayed in the reception. The manager has undertaken a generic risk assessment of the home. The manager ensures compliance with relevant legislation by training and supporting staff in these areas. All accidents are reported and details serious injury reports reg37 are sent to the CSCI. Capri DS0000012471.V311635.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 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 3 Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES 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 OP19 Regulation 16 (2) (c) Requirement You are required to replace carpets in two residents bedrooms as discussed at the inspection. All staff employed at the home must undergo a rigorous and robust recruitment and selection process. (This was a requirement at the last inspection dated 21/11/05.) You are required to improve the homes quality assurance systems with the introduction of service user surveys to include stakeholders and relatives and the development of an annual renewal programme. Timescale for action 31/01/07 2. OP29 19 31/01/07 3. OP33 24 (1) (b) 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Capri Refer to Good Practice Recommendations DS0000012471.V311635.R01.S.doc Version 5.2 Page 28 1. Standard OP2 The home should provide each prospective resident with a sample contract, which should include fees charged. All existing residents should be provided with a contract of the terms and conditions of the placement. Capri DS0000012471.V311635.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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. 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