Inspection on 06/08/07 for Clover Lodge Care Home

This inspection was carried out on 6th August 2007.

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

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

Other inspections for this house

Clover Lodge Care Home 21/08/06

Clover Lodge Care Home 28/02/06

Clover Lodge Care Home 25/11/05

Clover Lodge Care Home 24/11/04

Clover Lodge Care Home 01/06/04

Clover Lodge Care Home 04/02/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Clover Lodge Care Home 68a Humberston Avenue Humberston North East Lincs DN36 4SU Lead Inspector Ms Matun Wawryk Unannounced Key Inspection 6th August 2007 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 DS0000002858.V348543.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. DS0000002858.V348543.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clover Lodge Care Home Address 68a Humberston Avenue Humberston North East Lincs DN36 4SU 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) 01472 816183 01472 211785 clover.lodge@btinternet.com Mr Gilfred Robert Bebbington Mr Mark Gilfred Bebbington Position Vacant Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places DS0000002858.V348543.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st August 2006 Brief Description of the Service: Clover Lodge Residential Care Home is a family-owned home situated in the village of Humberston, just outside Grimsby. It is within easy access to local bus routes. Clover Lodge provides a homely environment for up to sixteen people over the age of sixty-five years and under no other category. There is a well-maintained garden at the rear of the property with a patio area and a small courtyard at the side encompassing a water feature and pots of flowers. The home has parking spaces for approximately five to six cars at the side of the building. The home is a single storey building and has three shared and ten single bedrooms. Two of the single rooms and one of the double rooms have en-suite facilities. The home has a lounge, dining area and a conservatory. A new extension to the home was built a few years ago and the bedrooms within this prove popular because they lead directly onto the paved courtyard area. Information about the home and its services can be found in the statement of purpose and service user guide, both these documents are available from the manager of the home. A copy of the latest inspection report for the home can also be obtained from the manager. Information given by the manager indicates the home charges £329 per week. In addition people are expected to pay for hairdressing, private chiropody treatments, toiletries and newspapers/magazines. More up to date information on fees and charges can be obtained from the manager of the home. DS0000002858.V348543.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mrs Matun Wawryk, regulation inspector carried out this unannounced site visit in August 2007. The visit lasted eight hours. Prior to visiting the home we gathered information from a number of different sources. Questionnaires were sent to a selection of relatives, people using the service, staff and professional people for example district nurses and social services staff. Seven people living in the home, six relatives, eight staff, and one professional returned a questionnaire. Some of the comments received by these people have been included in this report. The manager completed and returned an Annual Quality Assurance Assessment within the given timescale, this questionnaire gave lots of information about the home. Information received by the Commission since the last visit in July 2006 was also considered in forming a judgement about the overall standards of care within the home. During the visit we spoke to eight, two relatives, a friend of one person, the manager, and four care workers to find out how the home was run and if the people who lived there were satisfied with the care and facilities provided. We spoke with people to check that their privacy and dignity was maintained, that people could make choices about aspects of their lives and that the home ensured they were protected and safe in a clean environment. We also looked around the home and looked at lots of records, for example; assessments of need made before people were admitted to the home, and the home’s care plans to see how those needs were met while they were living there, daily records, supervision schedules, menus, and other records relating to the running of the home. Information received by the Commission over the last few months was also considered in forming a judgement about the overall standards of care within the home. What the service does well: People living in the home and those who returned a questionnaire said they were satisfied with the overall care provided by the home. People were complimentary about the staff team stating they were kind and caring and supported them well. The home was welcoming and had a relaxed atmosphere. People living there said they were happy with their bedrooms and they can bring in their own possessions, making it feel more like home. DS0000002858.V348543.R01.S.doc Version 5.2 Page 6 People living in the home said they had good access to professional medical support when needed. People also said that they were able to access external services such as chiropodist and opticians as needed. People living in the home said they were offered a good choice of meals and they enjoyed the quality of food. Specific wishes were catered for and people said they had plenty to eat and drink throughout the day. Comments included ‘excellent food’, the food is lovely’. Relatives spoken to during the visit said they were made to feel welcome by staff when they visit and that they can visit when they please. One relative said the ‘staff are very good and helpful, they always acknowledge me when I come into the home’; another relative wrote in their questionnaire ‘the staff are very friendly and polite’. What has improved since the last inspection? What they could do better: New residents and their relatives are provided with information about fees and charges but further improvement is needed. It is important that each resident and or their representative knows what he or she is paying for and any terms of residency. The manager was advised to ensure everyone who is coming to live in the home is given a personalised statement specifically relating to the care, accommodation etc that they will receive for the fee being paid. This should be supplied, at the latest, at the point at which someone takes up residence in the home and should be updated as fees change. Full details about what information needs to be provided can be found in the revised Care Homes Regulations. DS0000002858.V348543.R01.S.doc Version 5.2 Page 7 Everyone living in the home had an individual plan of care, which told staff what care the person needed. These generally gave staff lots of information about what care the person needed. However in some cases the plans needed to be a little bit more person centred and needed to include more information about person’s social and recreational interests. This will help to make sure that people’s needs are clearly addressed and planned for and that they receive person centred care. Although the way staff handle peoples medication is generally safe some of the things staff were doing/not doing was not good practice and could put people at risk if not properly addressed. The manager has not yet submitted an application to register with the Commission, it important that an application is made. We would like to thank everyone who completed a questionnaire and/or took the time to talk to us at the visit. People’s comments and input have been a valuable source of information, which has helped inform this report 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. DS0000002858.V348543.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 DS0000002858.V348543.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): 1, 2, 3, 4 and 5 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 wanting to use the service undergo a full needs assessment, which tells staff about them and the support they need. People can decide whether the home is right for them because information is available about the home and the services provided. EVIDENCE: A Statement of Purpose and Service User Guide is available to people considering moving into the home and their relatives and friends. Both documents give lots of information about the home. Information in the service DS0000002858.V348543.R01.S.doc Version 5.2 Page 10 user guide (brochure) needs updating to include more information about fees and additional charges. We also recommend that other formats are looked at for the guide such as tape or pictures to make sure that it can be used by as many people as possible. The majority of people spoken to said they received sufficient information about the home to help them make an informed choice about the service before accepting the placement offer. One person spoken to said they had not seen or been issued with a copy of the service user guide. The manger is advised to ensure people considering moving into the are given a copy of this or have it explained to them. The manager currently only provides people who are privately paying for their own care with a statement of terms and conditions/contract. People and their families’ need to know what they are paying for and any terms of residency. The manager is advised to ensure everyone who is coming to live in the home is given a personalised statement specifically relating to the care, accommodation etc that they will receive for the fee being paid. This should be supplied, at the latest, at the point at which someone takes up residence in the home and should be updated as fees change. Full details about what needs to be included can be found in the revised Care Homes Regulations. Each person has their own individual file and three of those looked at had a needs assessment completed by the funding authority or the home before a placement was offered. Records showed staff develop care plans from the assessments, identifying the person’s needs and care requirements using information gathered from the individual and their family. This ensures staff know what they are expected to do for the person. There was no evidence in the files to show that the manager formally wrote to people or their representatives following an assessment to confirm the home was able to meet the needs of the person, this should now happen for new admissions. Several people were spoken to about their experience of moving into the home, one person said ‘ I was brought here to see the home and talk to the staff before I made the decision to stay’, another person said ‘this is the best home I’ve been in’. One visiting relative said ‘they had chosen the home for reasons such as: the friendly atmosphere, the location and the friendliness shown by the staff. Staff in interview confirmed that they understood the admission process and were aware of the importance of ensuring people moving into the home are made to feel welcome. Staff members on duty were knowledgeable about the needs of each person they looked after and had an understanding of their specific problems/abilities and the care given on a daily basis. DS0000002858.V348543.R01.S.doc Version 5.2 Page 11 Discussion with people showed they were satisfied with the care they received and all those who were able to express an opinion said they had a good relationship with the staff. Information in the Annual Quality Assurance Assessment questionnaire returned prior to the visit and discussion with the staff and observation on the day indicates that all the people living in the home are white/British. The manager said staff would be able to support individuals with specific cultural or diverse needs following a needs assessment being completed. And where necessary additional training and guidance would be provided to staff to enable them to be responsive to the person’s needs. The home does not accept intermediate care placements so standard six does not apply to this home. DS0000002858.V348543.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health and personal needs are met but failure to ensure care plans clearly describe all areas of need and some medication practices could put people’s health and welfare at risk if not fully addressed EVIDENCE: Case tracking took place for three people. The methodology used was a physical examination of care plans; written surveys to people living in the home, relatives, health and social care professionals and direct observation on the day of the visit. DS0000002858.V348543.R01.S.doc Version 5.2 Page 13 There was no indication during the visit that people’s health and personal care were not being met. Generally care plans gave staff lots of information about the persons health and care needs, but only limited information about the persons social needs. One person’s care plan(s)was very person centred and clearly set out the person’s routines and preferences for the way care should be delivered, although there were gaps for example, one person’s care plan had not been updated to reflect changes in their behaviour. The manager gave an assurance that she would address this as a matter of priority. Care plans for another person covering areas such as personal hygiene included phrases such ‘needs assistance with personal care’, ‘maintain privacy and dignity’. Staff should review these and make sure that specific person centred information is recorded. For example, does the person like a bath or a shower, what day or time do they prefer and who do they like to help them?, what can the person do for themselves. Providing this information will promote more individualised care. Some people or their representative had signed the care plans to show they agree with the content, however there was little evidence to show how people with memory related problems were consulted on a regular basis about their care, especially when staff were completing monthly evaluations. The manager should look at how staff could use a variety of different and creative methods to help people using the service to contribute to their own care plan There was evidence of professional input from dieticians, community psychiatric nurses and district nurses and everyone was registered with a GP. People spoken to that they have good access to their GP’s, chiropody, dentist and optician services, with records of their visits being written into their care plans. Risk assessments are completed around areas such as falls, pressure areas and nutrition. We saw that these were generally well-maintained and kept under review. Staff had been trained in manual handling people safely and moving and handling equipment was available. People had access to outpatient appointments and records and staff feedback showed they have an escort from the home if wished. Responses to the surveys indicated that most people and their relatives were satisfied with the level of medical support given to people living at the home. The AQAA states that procedures giving staff guidance about a range of matters relating medication practice are in place and that staff responsible for administering medication have received appropriator training. Medication systems were examined at this visit. Generally medication was being managed appropriately however there were a number of areas where improvement was needed. DS0000002858.V348543.R01.S.doc Version 5.2 Page 14 Controlled medication was in use in the home. One person had discontinued their medication several months previously. The medication had not been returned to the chemist and records indicated one tablet was missing. Staff could not give an explanation for this. It is important that controlled medication is handled in line with The Medicines Act 1968, and guidelines from the Royal Pharmaceutical Society. Medication not being used must be returned to the dispensing pharmacist without unnecessary delay and any errors including inability to balance medication must be reported to the Commission in a regulation 37 notice. The room used to store medication was noted to be very warm on the day of the visit, staff were not routinely monitoring the room temperature, this should now happen. Medication should be stored at a temperature that does not exceed 25 degrees Celsius, the maximum temperature recommended by most manufacturers. Staff were sometimes handwriting medication (transcribing) on to the medication administration record (MAR), a second member of staff was not witnessing the entry to confirm the information was correct. In order to ensure proper safeguards are in place a second member of staff should witness all hand written annotations on the MAR. Staff were not always signing the MAR to confirm quantities of medication received together with balances of medication stored in the home, this makes auditing supplies difficult. Medication that is prescribed as and when required or as directed did not have information to help staff decide when to give the medication. To ensure staff administer as when medication consistently we advise that written guidance is put in place for staff, this is particularly important where people have communication difficulties or memory related problems. As a matter of good practice the inspector also advises that patient information leaflets of medication supplied be obtained from the dispensing chemist and that these be kept in the medication cupboard. This will provide staff with up to date information on medication prescribed for each person. Comments from people and relatives showed they were satisfied with the care and support offered by the staff. Discussion with people using the service revealed that they are happy with the way in which personal care is given at the home, and they feel that the staff respect their wishes and choices regarding privacy and dignity. One person said ‘ I feel safe here’, another person said ‘the staff do a good job’. One relative said ‘ the staff are very good, they care for people properly’. One relative wrote in their questionnaire ‘the care home looks after my mum well she has plenty to eat and she is safe’. DS0000002858.V348543.R01.S.doc Version 5.2 Page 15 DS0000002858.V348543.R01.S.doc Version 5.2 Page 16 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 were seen to experience a full life with opportunities to take part in varied activities. People are enabled to keep in contact with family and friends and people receive a nutritious and varied diet that meets their assessed needs and choices. EVIDENCE: The home employs a part time activity coordinator; this person had only recently taken up the position and was in the process of reviewing the activity programme at the time of the visit. The activities on offer ranged from games to one to one sessions, shopping trips out, and occasional outside entertainers and singers. DS0000002858.V348543.R01.S.doc Version 5.2 Page 17 With one exception people spoken to and those who returned a questionnaire said they were happy with the level of activities available to them and there was enough to do in the home. Comments included “there are enough activities for me”, “you can have your hair done”, and “I’d like to get out more”, ‘I sometimes get bored’. As indicated on page 14 of this report care plans for addressing peoples individual social needs and how these are to be met had not been fully developed. The manager and activity coordinator both said these would be developed over the coming months. This will better ensure social and recreational activities reflect the choices and capabilities of everyone in the home. People living in the home who were spoken to said they felt staff listened to them. People said they were able to exercise choice in aspects of their life and daily routines regarding times of rising and retiring, preferences with bathing arrangements, personalising their bedrooms and general choices about meals. In discussion staff displayed a good knowledge of people’s needs, likes/ dislikes, family support of the people using the service and records contained information about people’s religious observances. Staff spoken to had an understanding of how to promote peoples privacy, dignity, independence and choice, staff said things `like ‘we try and get to know what people like as soon as they come in’, ‘we always make sure doors and curtains are closed’, ‘we don’t have any set routines’. People living in the home who were spoken to said visitors could come at anytime and could be seen in conservatory, dinning or sitting room. The home does not have a private area where people can see visitors in private other than their bedroom. The home provides three meals a day and a light supper. The manager said there were no restrictions on what food could be ordered and this was confirmed in discussion with other staff. Menus indicated that a choice of food was provided. Time was spent observing the lunchtime meal and staff were observed to communicate with people in a friendly and supportive way. People spoken to and those who returned a survey confirmed that the home provides a good standard of meals, which people enjoyed. Comments included ‘ the food is excellent’; ‘meals are plentiful and good variety served’, the food is ‘wonderful’. The home caters for people needing diabetic diets. The manager said other specific dietary needs would be accommodated where this was needed. DS0000002858.V348543.R01.S.doc Version 5.2 Page 18 DS0000002858.V348543.R01.S.doc Version 5.2 Page 19 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. This judgement has been made using available evidence including a visit to this service. A satisfactory complaints system was in place and people living in the home, staff and others are assured complaints and concerns will be listened to and any allegations acted upon. EVIDENCE: No complaints about the home had been referred to the Commission since the last inspection carried out in August 2006. A complaints procedure was available and records indicated that no internal complaints had been made to home since the last inspection. Staff spoken to said they had no complaints about the home and felt confident to raise issues of concern if they arose with the manager. People living in the home that were spoken to said they knew who to report concerns or complaints to. One visiting relative confirmed they were aware of the complaints process. Six relatives returned a questionnaire in response to DS0000002858.V348543.R01.S.doc Version 5.2 Page 20 the following question ‘do you know how to make a complaint about the care provided by the home’ all said yes. Information from the Annual Quality Assurance Assessment and discussion with the manager indicates the home has policies and procedures to cover adult protection and prevention of abuse and whistle blowing. People spoken to said they felt ‘safe’ in the home. When asked about abuse, what it was and what they would do if they suspected or saw or suspected any abuse staff stated that they would report it to the manager or senior care worker. Examination of a sample of individual staff training records showed staff had been provided with internal training in safeguarding adults. No safeguarding referrals had been made to the local authority since the last inspection. DS0000002858.V348543.R01.S.doc Version 5.2 Page 21 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, 21 and 26 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 are provided with a clean, comfortable and hygienic home that is well maintained. EVIDENCE: The home provides and maintains comfortable and clean facilities. A tour of the home was carried out and all areas were generally decorated and furbished to a good standard. Information in the Annual Quality Assurance Assessment DS0000002858.V348543.R01.S.doc Version 5.2 Page 22 indicated the home complies with the requirements of the local fire and environmental health departments. The communal areas were all well utilised during the visit; people living in the home who were spoken to commented on how happy and settled they were at the home. The conservatory was noted to be very hot on the day of the visit; the inspector advises that the room temperature is checked on a regular basis and where necessary remedial action is taken to reduce high temperatures. The home only has one bathroom. The manager stated that the owners of the home are intended to create separate shower room in the near future. All bedrooms seen were clean and tidy and were furnished and decorated in a homely style. Many people had furnished their bedrooms with a range of personal items, some bringing in items of furniture to reflect their own individual choice and taste. People spoken said they were happy with their rooms. Two people said their rooms were ‘small but sufficient for their needs’. Policies and procedures for the control of infection were in place and staff in interview confirmed a good understanding of infection control measures and confirmed adequate supplies of protective clothing. Equipment provision was also discussed with the staff and staff said the home was generally well equipped. The laundry requires refurbishment, however no requirements have been made about this because work was taking place to resite the laundry into a purpose built facility. Currently dirty laundry is not carried through food storage, preparation or dinning areas. People spoken to and their relatives said they had not experienced any particular problems with their laundry, and all said clothes were washed and ironed appropriately. DS0000002858.V348543.R01.S.doc Version 5.2 Page 23 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 this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff are trained and competent to carry out their work and there are enough staff on duty at all times to enable peoples needs to be met. EVIDENCE: The roles and responsibilities of staff are clearly defined and in discussion with the inspector staff demonstrated understanding of the management and reporting structures for the home. At the time of this visit there were 16 people living in the home. The manager said two care staff are normally on duty up to throughout the day and night. In addition the homes employs a part time activity coordinator. DS0000002858.V348543.R01.S.doc Version 5.2 Page 24 Information from the Annual Quality Assurance Assessment about the number of staffing hours provided, and information gathered during the visit about the dependency levels of the people showed the home was meeting the recommended guidelines issued in the Residential Staffing Forum Guidance. Staff spoken to said there was generally enough staff on duty at any one time to enable peoples needs to be met. Two staff returned a survey. In response to the question ‘are there sufficient numbers of staff on duty to enable residents needs to be met’ both said yes. Evidence from questionnaires and discussions with people during the visit confirmed that they were generally satisfied with the care they received. People commented on how kind and supportive the staff were. One person said ‘ I am very pleased with the care at the home, another person said ‘I am very happy with the staff’. Comments from other people included ‘staff to busy to sit and talk’, ‘ staff always busy’. The manger said the home had an equal opportunities policy and procedure, although the inspector did not examine this. Feedback from the manager, staff and information in personnel and training records showed the procedure is followed when employing new staff and throughout the homes working practices and staffs access to training. Employment records for four staff appointed since the last inspection were examined. Records were generally in good order. Relevant documentation to comply with Schedule 2 of the Care Homes Regulations had been obtained. New staff are provided with an induction and the manager had an induction programme, which meets Skills for Care Common Induction Standards specification and includes a competency assessment. The home had a training plan and examination of a sample of eight staff records evidenced that mandatory safe care had been provided. The manager now needs to develop a training plan which provides staff with training opportunites which reflect the needs of people living in the home for example, pressure area care, strokes, sensory imprairments and other conditions common to older people. This is needed to help care workers deliver up to date care methods and to ensure have a better understanding of the varied conditions common to people living in the home. Failure to provide this training may mean staff do not have all the knowledge and skills they need to meet the needs of people and this could impact on the care they receive. The home employs fifteen care workers; currently four staff have completed a National Vocation Qualification at level 2/3. This means the home has not yet achieved the target of 50 of care staff trained to level 2 or above. The Manager reported that she hopes to achieve the 50 target within the next six months. DS0000002858.V348543.R01.S.doc Version 5.2 Page 25 DS0000002858.V348543.R01.S.doc Version 5.2 Page 26 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, 37 and 38 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. An experienced manager manages the home and systems are in place to ensure people are consulted about the running of the home but further developments are need to ensure continuous improvement of the service. The health and welfare of people using the service is protected and promoted. EVIDENCE: DS0000002858.V348543.R01.S.doc Version 5.2 Page 27 An experienced manager runs the home and there was evidence to show the manager was committed to improving her personal skills and knowledge through training and development. The manager is currently not registered with the Commission. The importance of submitting an application was discussed and an assurance was given that an application would be submitted without further delay. Staff confirmed that moral was good and commented that there was a good team approach to the care delivery at the home. Evidence from staff interviews and staff surveys indicated staff consider the manager and senior staff to be approachable. Staff said they take issues raised seriously and take action to resolve matters where this is needed. Staff spoken to and returned staff questionnaires provided evidence that staff were happy working at the home and with the support that they received to carry out their tasks. Information gathered from the Annual Quality Assurance Assessment (AQAA) indicated that there are a range of policies and procedures in place for health and safety. Safe working practices are maintained by the provision of training to staff in the form of moving and handling, basic food hygiene, basic first aid, infection control and fire safety. A sample of staff training records were examined these showed staff had received this training and further training was planned. Improvements had been made to the homes quality assurance programme following the last inspection. The new system includes questionnaires to people, their carers, and other professional staff but not as yet the homes staff and audits. The manager now needs to produce an annual development plan, which identifies the quality areas of improvement for 2007/08 and clearly set out the standards to be achieved in this year and ensure this information is made available to residents, their relatives and relevant third parties. A summary of which should be included in the service user guide. The home does not manage the finances of people but keeps safe a small amount of personal allowance for several, usually deposited by relatives. This is accessible to residents as required. A sample of records were checked and these were found to be in good order. Staff interviews and supervision records supported the evidence that the staff receive a minimum of six formal recorded supervision periods per year and their supervision includes the philosophy of care in the home, their actual practice and career development needs. The staff also stated that they are also regularly offered informal supervision as and when they require it. Information in AQAA indicated that maintenance certificates were in place and up to date for all the utilities and equipment within the building. Accident DS0000002858.V348543.R01.S.doc Version 5.2 Page 28 books are filled in appropriately and regulation 37 reports completed and sent on to the Commission where appropriate. Safe working practices are maintained by the provision of training to staff in the form of moving and handling, fire safety and health and safety. First aid certificates for most staff needed renewal. A requirement was not made about this because staff had been booked to attend refresher training in September 2007. The manager had completed generic risk assessments for a safe environment within the home. Risk assessments were in place for fire, moving and handling and daily activities of living. DS0000002858.V348543.R01.S.doc Version 5.2 Page 29 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 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 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 2 X 2 X 3 3 X 3 DS0000002858.V348543.R01.S.doc Version 5.2 Page 30 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 OP2 OP37 Regulation 5(b)(c) Requirement The responsible person must ensure the homes statement of purpose terms and service user guide meet the criteria of Regulation 5 of the Care Home Regulations and includes the information asked for in The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2006 (for Regulation 5), which came into force on 1st September 2006. This is so people know how much they have to pay for their care, what they are getting for their money and the cost of any additional extra services they may wish to purchase. The registered person must ensure each person be given a personalised statement specifically relating to the care, accommodation etc that they will receive for the fee being paid. This should be supplied, at the latest, at the point at which someone takes up residence in the home. It is important that DS0000002858.V348543.R01.S.doc Timescale for action 30/09/07 Amended regulations 2006 2 OP2 OP37 5 30/09/07 Version 5.2 Page 31 fee information is widely available at an early stage to support people to make informed choices. Further information about this can be found in the revised Care Homes Regulations 3 OP7 OP12 16 (2) (m) (n) 15 (1) Each person living at the home must have a care plan in place addressing all their needs including social needs and how these are to be met. Plans need to be updated as peoples needs or behaviours change and need to include people’s routines and preferences for the way care must be provided. This will help to make sure that people’s needs are clearly addressed and planned for and that they receive person centred care. The registered person must ensure controlled medication is handled in line with The Medicines Act 1968, and guidelines from the Royal Pharmaceutical Society. Medication not being used must be returned to the dispensing pharmacist without unnecessary delay and any errors including inability to balance medication must be reported to the Commission in a regulation 37 notice. This is needed to ensure the health and welfare of people The registered person must ensure that a minimum of 50 of the care staff have achieved NVQ 2 or equivalent. Timescale of 01/10/06 not met The registered person should produce a written training plan that specifically reflects the DS0000002858.V348543.R01.S.doc 01/10/07 4 OP9 OP37 13 30/09/07 5 OP28 18 31/12/07 6 OP30 18 30/11/07 Version 5.2 Page 32 28 OP9 13 needs of older people. Providing staff with better training around the needs of people in the home will ensure they have all the knowledge and skills they need to meet the needs of residents and this will have a positive impact on the care they receive. The registered person must ensure written guidance is put in place to tell staff when they should administer as and when needed medication. This will ensure medication is administered consistently 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP1 OP31 Good Practice Recommendations The user guide to the home should be made available in a variety of formats such as audiotape or pictures, thereby ensuring the accessibly of this important information The registered person should ensure that the manager of the home completes an application to the Commission to be accepted as the registered manager of the home Staff should ensure that when a new medication sheet is started is added to the supplies on the medication record sheets. This should be done so as to ensure a running total is available at all times and an audit of stock is easy to carry out. The manager should make sure that where staff are hand writing medication onto the sheets (transcribing), two staff sign the entry to indicate they have both witnessed that the information on the sheet is correct. The registered person should obtain patient information leaflets of medication supplied be obtained from the dispensing chemist and that these be kept in the DS0000002858.V348543.R01.S.doc Version 5.2 Page 33 3 OP9 4 OP9 5 OP9 6 OP9 medication cupboard. This will provide staff with up to date information on medication prescribed for each person Medicines must be stored at the appropriate temperature and a record of temperature must be maintained for all areas where medicines are kept The manager should consider how staff could use a variety of different and creative methods to help people using the service to contribute to their own care plan. 7 OP7 DS0000002858.V348543.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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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