Inspection on 20/06/07 for Capri

This inspection was carried out on 20th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 16/11/06

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 Neil Kingman Unannounced Inspection 20 June 2007 10:15 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.V338725.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.V338725.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.V338725.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. 16 November 2006 Date of last inspection Brief Description of the Service: Capri is a home providing care and accommodation for up to nine older people, with some capacity for older people with illness associated with mental health. It is one of two homes on the Island owned by Isle of Wight Care Ltd and is managed by Mrs Christine Basham. The home is a three storey town house located in St Johns Road, Sandown about a quarter mile from the shops and amenities of the town. All but one of the rooms arranged over two floors are for single occupancy, four having ensuite facilities. Access to the first floor is via a stair lift. A couple currently occupies the one en-suite shared room. Communal areas consist of an open plan dining room leading to a sitting area. There are toilet facilities on each floor and an assisted bathroom on the first floor. Externally there is a hard standing at the front of the home, and a lawn and patio at the rear with some seating for use by those who use the service. Weekly fees range between £369.25 and £385. The manager states that a copy of the home’s service user’s guide is provided to all residents or their representatives where applicable. Capri DS0000012471.V338725.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the results of an evaluation of the quality of the service provided by Capri and brings together accumulated evidence of activity in the home since the last key inspection on 16 November 2006. This report also focuses on the home’s response to three outstanding requirements identified at the last inspection. Part of the process has been to consult with people who use the service. To this end we have received written responses to several surveys, i.e., seven from people who reside in the home, one from a visiting relative, three from health professionals and two from social services care managers. Included in this inspection was an unannounced site visit to the home by an inspector on 20 June 2007. The registered manager Mrs Basham was on duty and available throughout the day. At the visit we had an opportunity to speak with all staff on duty, several residents as a group and in private, and a friend of a resident who was visiting at the time. We also looked at a selection of records. Prior to the site visit the manager sent to the Commission a detailed selection of information about the service including an Annual Quality Assurance Assessment (referred to as ‘the assessment’ during the report), which has been used with other information to inform the various judgements made about the service. What the service does well: The home’s assessment describes the service as providing value for money because they charge the basic social services rates, have adequate staffing levels with a dedicated well trained team, which provides all the day-to-day personal care for people who live in the home. People who use the service are able to choose their lifestyle, social activities and keep in contact with family and friends. They are supported to maintain their independence, including regular contact with the services and facilities in the community. Nutritional needs are satisfied with a varied and balanced diet of good quality food. Capri DS0000012471.V338725.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Capri DS0000012471.V338725.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.V338725.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service and their representatives have a written contract/statement of terms and conditions with the home. The manager ensures that peoples’ care needs will be met by undertaking a proper assessment prior to them moving into the home. The home does not provide dedicated accommodation for short-term intermediate care or specialised facilities for rehabilitation. EVIDENCE: Contract It was recommended at the last inspection that the home should provide each prospective resident with a sample contract, which should include fees charged. In addition, all existing residents should be provided with a contract of the terms and conditions of the placement. Capri DS0000012471.V338725.R01.S.doc Version 5.2 Page 9 The manager confirmed that she had met the recommendation and it was noted that copies of a statement of the terms and conditions of residence signed by the resident or their representative were available on their files. Pre-admission assessment People should know that their needs will be met when they move into a home. An important part of ensuring this happens is the pre-admission assessment process. It had been noted at previous inspections of Capri that this standard had been met. During this site visit the manager described the home’s admissions process in general, and specifically in relation to the newest person to be admitted: • • • The manager visits the person who may want to use the service either at their home address or hospital where applicable. The manager visited the most recently admitted resident at the hospital and carried out a pre-admission assessment of needs, recording information on a form designed for the purpose. People who may want to use the service are encouraged to visit the home prior to admission, as was this individual, who was invited to view the home and stay overnight. In the event, due to circumstances the individual’s representative visited, met with staff and the other residents and viewed the accommodation. A copy of the pre-admission assessment was available on the resident’s file. The home’s policy is to carry out pre-admission assessments on every person who wants to use the service including those who are referred in emergency situations. Intermediate care People who live at Capri tend to be long term. The home does not provide dedicated accommodation for short-term intermediate care or specialised facilities for rehabilitation. However, respite care is provided if there is a room available. Capri DS0000012471.V338725.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice within the scope of the home’s environmental space. EVIDENCE: Care planning – The home has a system of care planning with an individual personal plan for each resident. At the last inspection it was noted that there was no care plan in place for a person using the home’s respite service. At this site visit the newest admission to the home was a person receiving respite care and a care plan had been drawn up for this individual. We looked at a sample of three plans. The intention was to look at the outcomes for people who use the service in general by assessing all areas of care for those sampled. Capri DS0000012471.V338725.R01.S.doc Version 5.2 Page 11 The sample included the newest admission to the home, this person having moved in during April 2007, a female who was largely self-caring and physically active and a male with mobility difficulties. On the positive side, the sampled care plans were noted to be well structured, to include a care plan review sheet showing monthly reviews were being carried out, and a needs assessment setting out the need/goal/action for areas of care including: • • • • • • • • Mobility, including a history of falls and manual handling assessment Medical condition Communication Maintaining a safe environment Emotional & spiritual needs Tissue viability Sleeping and daily activities Eating and drinking Records are kept of professionals’ visits and include the date of the visit, details and the outcome. Risk assessments and daily recording of important information are kept separately. In discussions with the manager it was recognised that personal plans would benefit from the inclusion of more information especially under the heading of ‘action’. Currently information is kept to a minimum, which suggests staff already know without referring to plans, what each person needs and wants. The same can be said of risk assessments, where there is the minimum of detail recorded of action taken to minimise risks. The inclusion of more detailed information would give plans a more person centred feel and better evidence the quality of care and support being provided. Health and access to care services The manager confirmed, and records evidenced the regular contact with GPs, optician, dentist, chiropodist and mental health specialists. People spoken with said that the home was very quick to contact a doctor if they needed one, a typical comment being, “I had a pain in the back of my leg and the manager called the doctor straight away.” During the site visit we had an opportunity to speak at length and in private with a resident and her visiting friend. Comments were very positive, especially regarding the care provided by staff. Another person regarded the staff as, “Excellent.” Records showed and discussions with care staff confirmed that while one resident was currently vulnerable to pressure sores the risk was low. The manager and staff were very clear about what was required to ensure that Capri DS0000012471.V338725.R01.S.doc Version 5.2 Page 12 pressure sores did not develop, i.e., suitable equipment, good liaison with the District Nurse and care practices. The manager said, that all those who use the service are registered with Sandown Medical Centre where a choice of several GPs is offered. Other healthcare professionals visit the home on a regular basis and more specialist ones e.g., Community Psychiatric Nurse and Psychiatrist are called upon as and when required. All the responses to the residents survey taken as part of the inspection process were very positive; indicating the home always provides the care support and medical support that residents need. There were mixed messages in the responses from care professionals: “They try hard to keep people in the home, but sometimes they need more care than the home can provide.” “Capri has some very challenging clients and staff and manager deal with these challenges very well indeed.” “Care service provides a relaxed atmosphere, supportive, caring on my visits.” Medication Medication is dispensed by means of a monitored dosage (blister pack) system by staff who have completed medication training, and been deemed competent by the manager. The home has a policy and system to ensure residents’ medication is stored, administered and recorded safely. During the site visit we looked at the arrangements in place and noted medicines were stored under secure conditions in a purpose built metal cabinet and accurate records maintained. In common with records in care plans there was a lack of detail noted in the information about the circumstances in which PRN (as required) medicines should be administered. The manager said she understood the reason behind the need for more detail and resolved to address this issue. Privacy, dignity and respect The importance of treating people who use the service with dignity and respect is covered in the induction training for new staff. On the day of the site visit we toured the building and spent time with residents in the communal areas and in their own rooms. There were opportunities to observe staff at work. Staff knocked before entering rooms and spoke kindly to people. The interactions between them were warm and Capri DS0000012471.V338725.R01.S.doc Version 5.2 Page 13 friendly and banter was good-natured. Those people able to give an opinion were full of praise for the staff and their approach to care and support. Residents can use the facility of the home’s portable telephone to make and receive calls and there is a pay phone on the first floor landing for their use. Space limitations are covered later in the report. Capri DS0000012471.V338725.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to make choices about their life style and activities are offered to suit their individual needs and expectations. Friends and family are made to feel welcome and can visit at any time. Residents’ nutritional needs are satisfied with a varied and balanced diet of good quality food. EVIDENCE: Routines and activities – The home’s assessment indicates that activities are arranged twice weekly and are service user led, and younger people are encouraged to go out in the local community. It also highlights more organised social events and activities in their plans for improvement in the next twelve months. One comment in the visiting professionals survey was, “There never appears to be any social activities going on in the home.” A visiting relative indicated that they had not visited the home at times when activities were taking place, as they tended to visit only at weekends. Capri DS0000012471.V338725.R01.S.doc Version 5.2 Page 15 Five responses to the residents survey indicated there are always activities arranged by the home that they can take part in, one indicated usually, and one sometimes. At the site visit the manager said that since the last inspection one of the care support workers does extra hours on Mondays, Wednesdays and Fridays to spend time on a one-to-one basis with people, taking part in various games, arts and crafts and nail manicures etc. This was in evidence with one resident when we arrived for the site visit. The younger residents, of which there are four are able to go out into the local community for walks, shopping, to the pub etc., and one attends a day centre in Ventnor. In discussions with these people it was clear they felt supported to maintain their independence. Visiting arrangements – Friends and relatives are encouraged to visit the residents with their permission. Details of visiting arrangements can be found in the statement of purpose and are generally unrestricted. People can receive visitors in their own rooms or either of the two communal areas. One friend of a resident who was visiting at the time of the site visit said she was always made welcome by staff and offered a drink. Personal autonomy and choice – Residents were spoken with individually in the lounge and in private. Those who were able to express views said they were given choices regarding routines in the home, e.g., times of rising, going to bed, activities, meals, personal care, going out etc. The manager confirmed that everyone has either a family member or a solicitor to support them independently of the home. People are encouraged to bring with them pictures, ornaments and personal items for their room. During the tour of the building it was noted that some rooms were personalised, and reflected the residents’ individual tastes and preferences. The management of residents’ finances is covered later in the report but in a general sense they are encouraged to handle their own financial affairs for as long as they are able. Meals and mealtimes – During the site visit we had an opportunity to observe residents over lunch. The atmosphere in the dining room was quite sociable. Staff were available to assist as and when required. Capri DS0000012471.V338725.R01.S.doc Version 5.2 Page 16 Food served looked appetising and was well presented. All residents spoken with made very complimentary remarks about the food provided by the home. One spontaneously said, “We have lovely meals here.” Two people prefer to take meals in their own rooms but others eat as a group in the dining room. Routines around meals are very flexible as some go out for meals and one takes a packed lunch to the day service. In discussions with the manager and staff it was explained that the home does not have a set menu but looks at food a week ahead and offers a hot cooked lunchtime meal on a day-to-day basis, taking into consideration peoples’ preferred choices, which are known by the staff. The home does not currently have a dedicated cook but care staff take turns in producing the meals. This seems to work satisfactorily and there were no concerns raised from anyone. In fact all responses to the residents survey indicated they always or usually liked the meals. It was noted that drinks and light snacks were offered through the day between meals. The home’s kitchen is on a domestic scale. It was understood from conversations with the manager and staff that they were making arrangements for the following day when new worktops were to be fitted throughout. Capri DS0000012471.V338725.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home treats residents’ complaints seriously and responds appropriately. The home’s policies, procedures and practices ensure that residents are safeguarded from abuse. Procedures for responding to suspicion or evidence of abuse are robust. EVIDENCE: Complaints – A copy of the home’s complaints procedure is on display on the wall in the reception area. The manager agreed to up date the procedure with the new Southampton address for the Commission for Social Care Inspection (CSCI). It was noted that details on how to make a complaint are included in the statement of purpose. The manager confirmed that there had been no complaints since the last inspection. In discussions with all staff on duty it was clear they understood the home’s policy and procedures for dealing with complaints and those who use the service said they felt confident about taking any concerns to the manager if they were unhappy about anything. Capri DS0000012471.V338725.R01.S.doc Version 5.2 Page 18 All eight responses to the residents survey indicated they knew how to make a complaint. In the care managers survey one indicated the home usually responded appropriately to issues raised and one always. Safeguarding adults – The home has a copy of the Isle of Wight Care Limited Adult Protection policy and procedure, which follows the guidance in the Isle of Wight Social Services 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 discussions with staff they showed an understanding of how to recognise abuse and were very clear about the importance of reporting issues of concern without delay. They also were aware of the home’s “ whistle-blowing” procedures. Staff and the manager confirmed that safeguarding adults training has been completed in house with the use of training materials, which includes watching a DVD. Since the last inspection there has been one safeguarding of adults referral, which was dealt with appropriately by the home. Capri DS0000012471.V338725.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 - People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service The physical design and layout of the home enable residents to live in a safe, clean, homely and comfortable environment. However, there are limitations caused by a lack of private and communal accommodation provided for people who use the service. All areas of the home are kept clean, hygienic and there are no unpleasant odours. EVIDENCE: Environment – Capri has been a residential care home for older people in Sandown for many years. It is not purpose built and there is evidence from observations during the site visit and comments received in surveys that it has its limitations in terms of private and communal space. Capri DS0000012471.V338725.R01.S.doc Version 5.2 Page 20 Comments from visiting care managers and health professionals illustrate the point: “A very small home with limited space needs, could be improved.” “Ideally people would be in their own rooms, in privacy, for GPs visits. This is difficult to achieve in practice since visiting times are unpredictable.” Communal space comprises an open plan lounge, which rises up to a dining area. Other than residents’ own rooms there is nowhere else for people who use the service to receive visitors, which means that conversations in communal areas can be overheard. The home’s office is located in one of two rooms on the second floor. These rooms are accessed via very steep and narrow steps. The manager said that the other room used to be the night staff ‘sleep-in’ room but this was no longer the case. As a consequence the ‘sleep-in’ staff member uses a ‘put-you-up’ in the residents’ lounge. While there was no evidence that people are disadvantaged the situation is far from ideal and just goes highlight the shortage of usable space. The manager said that it was not a viable option to make the rooms on the second floor more accessible. On the positive side there were other comments in the survey: “The care service provides a relaxed atmosphere, supportive, caring on my visits.” “Provides a small friendly environment for residents.” “Provides a homely, friendly environment for people with mental health difficulties.” All areas of the building are accessible to the current resident group, including the rear garden where residents can sit when the weather is fine. Following the requirement made at the last inspection the rotted wooden steps from the lounge have been replaced with a metal fire escape. Those with mobility difficulties can access the garden from the front of the house and through the garden gate. The home is generally comfortable, reasonably well furnished and decorated. There was evidence of improvements since the last inspection with redecoration of five residents’ rooms, the lounge and dining areas, and the hallway and stairs. The manager confirmed that the requirement at the last inspection to replace two carpets was carried out in November 2006. Capri DS0000012471.V338725.R01.S.doc Version 5.2 Page 21 However, consideration was now being given to replacing them with a more appropriate floor surface. We carried out a tour of the building with the manager and noted residents’ rooms to be reasonably clean, homely and in several cases well personalised. The first floor is accessed via a stair lift where there is an assisted bathroom with WC. The manager said that plans were in place to completely upgrade this room in the next few months. Five of the eight rooms occupied by residents have an en-suite facility. There is a separate toilet on the ground floor near to the dining and lounge areas. Residents spoken with during the inspection said they were very happy with the accommodation provided. Cleanliness The home does not employ separate domestic staff but adopts an holistic approach with staff performing care/support duties and also domestic and catering tasks. In conversations with staff the arrangement seemed to work well in what is considered by them to be a small, homely environment. A separate laundry is located 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 confirmed that soiled articles are sealed in laundry bags at all times to prevent the spread of infection. The laundry floor had an impermeable concrete floor with the paint stripped off. The manager explained they had been asked to paint the floor at a previous inspection and when completed the floor was found to be slippery when wet and was not suitable so she had stripped it. However, she confirmed that it was now painted with an impermeable transparent sealant. Liquid soap dispensers and paper towels were available in all communal hand washing facilities. The home has a policy and procedures for the control of infection. All staff have received training in infection control procedures. Capri DS0000012471.V338725.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): 27, 28, 29 and 30 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home are deployed in sufficient numbers, are trained and given the necessary skills and experience to meet the needs of the people who live there and support the smooth running of the service. EVIDENCE: Staffing levelsThe home employs thirteen care support staff. There are two main shifts throughout the day when a minimum of two staff are on duty. There are two hours in the afternoon between 14:00 and 16:00 when, according to the manager only one member of staff is required. All staff spoken with on the day of the site visit supported this. With just seven people resident in the home at the time of the site visit, four being self-caring, staffing levels were considered adequate for peoples’ needs. Overnight there is one care support worker who sleeps in. The manager works flexibly each day, sharing her time with another home that she manages nearby. Capri DS0000012471.V338725.R01.S.doc Version 5.2 Page 23 NVQ training – Records showed and the manager confirmed that currently four of the thirteen care staff have achieved the NVQ at levels 2 or 3. A further four care support workers are currently undertaking the training. When these people have successfully completed the training programme the minimum standard of 50 NVQ trained staff will have been met. Recruitment Individual staff recruitment files were available for inspection. However, these were checked at the last inspection and there have been no new staff recruited since that time. The manager is very clear that no new staff would commence working in the home without, at least them having Protection of Vulnerable Adults (POVA First) clearance, as to do so would place vulnerable people at risk of abuse. This had been a requirement at the last inspection. Staff training – While there have been no new staff to undertake an induction programme the manager has now accessed the Common Induction Standards recommended by ‘Skills for Care’. She confirmed that all new staff would start the new programme. The home has individual training records with certificates in place to evidence training achievements. These were available for inspection and were looked at by way of dip sample. Staff training includes: Manual handling Food hygiene First aid Health and safety Dementia awareness Medication Safeguarding vulnerable adults Fire training Infection control Capri DS0000012471.V338725.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): 31, 33, 35, 36 and 38 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness and respect. However, the quality assurance systems developed by the qualified and competent manager need to be fully implemented before their effectiveness can be determined. EVIDENCE: Management – The registered manager Mrs Christine Basham has been in post since 2003. She is fully qualified having achieved the NVQ at level 4 in care and the Registered Managers Award (RMA). In addition, she updates her knowledge, skills and competence with periodic training in care related subjects specific to the service provided by the home. Capri DS0000012471.V338725.R01.S.doc Version 5.2 Page 25 There was evidence during the inspection that the manager is highly regarded by the staff and residents. She supports staff development and annual appraisals and formal supervision sessions are in place. Quality assurance – There is no annual development plan or formal quality assurance systems at Capri. The manager said that with the size of the home and type of service the home provides the approach is more informal as she is in very close touch with the residents on a day-to–day basis. The residents, staff and the results of our surveys supported this. From discussions and observations it was clear that they consult with residents on a daily basis to gauge continued satisfaction with the service. A suggestion/comment leaflet is available in the reception for relatives to make comment. However, the manager explained that they tend not to be used; therefore, she has developed structured residents and visiting professionals surveys, which are planned to be implemented at the end of June 2007. Residents meetings are held about every two months. Additionally, other areas that inform the home’s quality assurance are: • • • • Regular in-house care plan reviews. Regular staff meetings and supervision sessions. Yearly care review with social services care managers and the person who uses the service. Maintenance and renewal records, although there is no formal planned programme. Residents’ monies – The home prefers the residents or their representatives to take responsibility for their own financial affairs. However, arrangements are in place to safeguard one resident’s money and there is an arrangement with social services to supply another with their weekly personal allowance. The system was checked and found generally to be in good order, with receipts for purchases kept. In discussions with the manager it was recommended that transactions be double signed to ensure both the resident and staff are better protected. Health and safety – The home’s pre-inspection information sent to the Commission by the manager confirmed that policies and procedures are in place to ensure safe working practices in the home. A sample of records was viewed during the site visit Capri DS0000012471.V338725.R01.S.doc Version 5.2 Page 26 including accident records, fire alarm tests, public liability insurance, and gas and electrical tests, all of which were in good order. Staff training records showed, and staff confirmed that statutory training is scheduled and updated in manual handling, first aid, fire training, infection control and food hygiene. Capri DS0000012471.V338725.R01.S.doc Version 5.2 Page 27 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 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 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.V338725.R01.S.doc Version 5.2 Page 28 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 OP33 Regulation 24 Requirement To ensure that the homes quality assurance systems include service user, relatives and stakeholder surveys and the development of an annual renewal and improvement programme. This is required to demonstrate the home is run in the best interests of those who use the service. (This requirement remains outstanding from the last inspection) Timescale for action 31/07/07 Capri DS0000012471.V338725.R01.S.doc Version 5.2 Page 29 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 People who use the service and staff would benefit from additional information being recorded on the care plans and risk assessments to ensure consistency of care and better evidence the quality of care provided. Residents’ financial transactions should be double signed by staff to afford better protection for both. 2 OP35 Capri DS0000012471.V338725.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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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