Inspection on 13/09/07 for College View Care Home

This inspection was carried out on 13th September 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

College View Care Home 05/09/06

College View Care Home 16/01/06

College View Care Home 27/09/05

College View Care Home 06/12/04

College View Care Home 23/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

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 College View Care Home 71 Bargate Grimsby North East Lincs DN34 5BD Lead Inspector Mrs Jane Lyons Key Unannounced Inspection 13th September 2007 09:00 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 DS0000002851.V351339.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. DS0000002851.V351339.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service College View Care Home Address 71 Bargate Grimsby North East Lincs DN34 5BD 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 879337 Mrs Katrina Peerbux Mrs Katrina Peerbux Care Home 12 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (12) of places DS0000002851.V351339.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: College View is a long established home situated in a pleasant central location of Grimsby, it is close to the local amenities of Scartho Village and local public transport. The building is Victorian in style maintaining much of the character and original features providing care for up to 12 service users. The home consists of two storeys serviced by stairs and a passenger lift. There are six single rooms, none of which are en-suite and three shared rooms, one of which is en-suite. All rooms apart from one are spacious. On the ground floor there is one unassisted bathroom containing a WC and on the first floor there is an assisted bathroom without a W.C. On each floor there are two W.C.’s for service users use. There are two lounges and one dining room, all of which are located on the ground floor. The home is surrounded by pleasant mature gardens including a paved area at the rear of the property. There is car parking space at the front of the property. The home is owned and managed by Mrs K Peerbux. There is a well-established staff team who have considerable experience working with this service user group. Weekly fees are: £345- £405. The home operates a system whereby the fees for single accommodation include a third party contribution. Additional charges are made for the following: toiletries, newspapers/magazines, hairdressing and chiropody. Information on the service is made available to prospective and current service users via the statement of purpose, service user guide and inspection report. Documents are made available prior to and following admission, copies are available on request. DS0000002851.V351339.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and the site visit took place over 1 day in September 2007. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last key inspection of the home on 5th September 2006 including information gathered during a site visit to the home. • • • The visit to the home lasted from 9 a.m. until 5 p.m. Eight residents spent some time chatting to the inspectors. The inspector also talked to two care staff, one visiting health care assistant, six visitors and the manager. Following the inspection the inspector had a discussion over the telephone with a care manager from the local authority. Questionnaires about the home were sent to all the people who use the service and their relatives and all the staff who work in the home. Seven relatives questionnaires, three of the staff ones and four from the people who use the service were returned at the time this report was written. The inspector also looked around the home and looked at lots of records including care plans, staff training records and other records about 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. The inspectors observed how staff and people who use the service worked together throughout the day. People’s views about the home and what was found during the visit have been used to write the report and make judgements about the quality of care. • • • • DS0000002851.V351339.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The management had worked hard to meet all the requirements and recommendations from the previous inspection report. Medication recording has improved; this better ensures that that there is no mishandling of medication and the resident’s health is looked after. A number of rooms have been redecorated and refurbished with a lot more work planned for the near future this means people who use the service live in more pleasant, better maintained surroundings. A number of the people commented that they were pleased with the improvements taking place. DS0000002851.V351339.R01.S.doc Version 5.2 Page 7 The management have consulted and spoken more with people who use the service and their relatives to make sure they are satisfied with and can influence services provided at the home such as care support, meals, activities and if they would like anything to change. People who use the service and their families have been made more aware of what to do if they had a concern or complaint; a written procedure is now provided in the hall. Staff make regular and thorough checks of bed rails when the have been provided to people who use the service which will help prevent any accidents happening with them. 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. DS0000002851.V351339.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 DS0000002851.V351339.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): 1,2,3,4,5 and 6 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. People who use the service and their relatives are provided with sufficient information to help them decide if the home is right for them. The admission process is thorough with staff ensuring that new residents feel welcome and secure. EVIDENCE: The service user guide and statement of purpose documents had been updated to provide prospective new service users and their families with current information about the service; the manager confirmed that they will be further reviewed on completion of the building and refurbishment programme to include more photographs and views from people who use the service. DS0000002851.V351339.R01.S.doc Version 5.2 Page 10 The people who use the service were provided with written contracts, which set out the terms and conditions of occupancy and included the room the service users would be occupying. Not all people who had been funded through the local authority had a copy of the homes’ terms and conditions in place which is advisable. There was good evidence that the manager routinely writes to service users or their representatives following the pre-admission assessment formally stating the home’s ability to meet needs. Four care files were examined. The care files contained evidence that service users needs had been assessed before they were admitted into the home. Copies of the Local Authority assessment and care plans were obtained prior to admission for those residents referred through the local Social Services care management teams. In addition to the pre admission assessment the home undertakes a further assessment of strengths and needs once the person has arrived. It is on the basis of both these assessments that the person’s plan of care is formalised. A relative of a person who had recently moved to College View told the inspector that they had visited a variety of homes in the area and had chosen College View as it is a “small home” and the atmosphere is friendly and inclusive; the staff had made them all very welcome and their relative had settled into the home very well. One of the surveys received detailed, “My mother believes the care home to be her home and is happy there.” Staff spoken with confirmed that they were always informed of new resident’s care needs and that the manager communicated a clear sense of direction about the importance of using an approach that was person centred and reflected the individual needs of people living in the home. The home provides care for a number of persons with needs associated with dementia and there was good evidence from the visit that these individuals were well supported and happy at the home. A survey received from a relative detailed “They treat my mum as an individual, always, even though she has Alzheimer’s and at times needs extra attention.” Discussions with one of the care manager’s indicated that the management and staff had worked very positively with the family of an individual recently admitted to the home. There was evidence to demonstrate that the care staff had accessed some service specific training courses over the last twelve months and that more courses are being arranged; this will help ensure that they have the skills to enable them to deliver up to date care methods and have a better understanding of the varied conditions common to the elderly. The home does not provide intermediate care support. DS0000002851.V351339.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 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. The health and personal care needs of people who use the service are well met in a way that respects their privacy and dignity. The medication systems at the home are well managed ensuring the promotion of good health. EVIDENCE: Case tracking of four care files was completed, which included examination of care records and discussions with people who use the service and staff. The home continues to produce and keep clear and well-written care plans for individuals which take into account their choices and decisions; the four examined set out the health, personal and social care needs identified for each DS0000002851.V351339.R01.S.doc Version 5.2 Page 12 person. Staff completed personal profiles detailing interests, hobbies, likes and dislikes. Detailed individualised plans had been developed from the assessments; there was good evidence that the plans had been updated when changes in need had occurred. Risk assessments were in place for tissue viability, moving/handling, nutrition and falls; these had been reviewed regularly and all high-risk areas had associated care programmes in place. One of case files evidenced that the person’s nutritional status had significantly improved in the two months since admission. The quality of the evaluation records was good with evidence of formal review meetings taking place. Care plans did detail clearly the support required from staff to meet resident’s needs associated with their dementia. There was good evidence that the home sought support from health care professionals such as G.P’s, Community Psychiatric Nurses, Specialist Alzheimer’s Nurse, dieticians and District Nurses when necessary. Care plans had been signed by the person or their representatives to acknowledge their involvement in the development of them and their agreement to them. Continence care is promoted and the inspector observed documentation recording the continence products supplied to the individual. Any concerns regarding pressure care are recorded and risk assessments clearly detail the type of pressure relieving equipment provided. Service users spoken to by the inspector said that when they had appointments for their healthcare needs these were always carried out in private. Visitors confirmed in surveys and discussions that when their relatives were ‘unwell’ the home always kept them up to date on any changes in their condition’. People who use the service told the inspector that the staff were always very kind and were very patient, they also said that they didn’t have to wait for assistance and that the staff had time to sit and chat with them. Relatives also commented on the kindness of the staff; other comments included “the care is first class” and “the staff are all very helpful, the care is very good”. People living in the home confirmed staff supported them well and treated them with respect. During the visit the inspector observed very positive interaction between the staff and people who use the service; staff were courteous and kind in their manner. Medication systems were examined; policies and procedures were in place which covered all areas of management. DS0000002851.V351339.R01.S.doc Version 5.2 Page 13 There was evidence that the staff are proactive in ensuring that service user’s medication is reviewed by the G.P. Temperature recordings of the medication storage room are taken daily which were satisfactory. The medication fridge had recently broken and the manager confirmed a new one was on order; medication requiring refrigeration was currently stored in the kitchen fridge in a separate, labelled container. Systems were in place to support self- medication, there were no individuals self- medicating at the time of the visit. Storage of all medications was found to be satisfactory. Transcribing records were completed satisfactorily and there was evidence that improvements had been made to the completion of the medication administration records; the manager completes monthly audits. Records of receipt and returns of medication were in place and up to date. All the care staff have now completed the safe handling of medications course; those staff who completed the course some time ago are now undergoing competency checks from the manager which involves observation of medication rounds. DS0000002851.V351339.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 this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are provided with choice and diversity in the meals and activities provided by the home, which met with their expectations although some felt that the amount of arranged activities and trips out had fallen in recent times. Relatives and visitors are made welcome and the home is developing better links to the community, which will further enrich the peoples social and leisure opportunities. EVIDENCE: Observation during the visit indicated that the home supports people who use the service to make decisions within their capabilities and operates flexible routines, these include the time people who use the service get up, go to bed, where they eat their meals and how they spend their time. One individual told the inspector how she liked to spend her time sitting in the hallway reading and another said that she likes to sit in different rooms during the day. DS0000002851.V351339.R01.S.doc Version 5.2 Page 15 Friends and relatives are welcomed into the home and evidence in the case records confirmed staff kept them appropriately informed of important issues concerning the needs of people living in the home and also that people who use the service were supported to keep in touch with friends and family. The inspector observed a large number of visitors to the home throughout the day, all friends and relatives spoken to said that the staff were very welcoming and supported their visits. One survey returned from a relative detailed “When I visit my mother the staff always ask me if I would like a drink and also tell me if my mother is having any problems.” Information gathered from the surveys and discussions with people who use the service indicated that the majority of people were generally satisfied with the activity programme and social events provided at the home. Evidence from the activity programme and records of participation indicated that although the home provided some regular organised events such as motivation therapist, activities and trips out there were a number gaps for days when nothing had been organised. Discussions with the care staff indicated that they continue to provide regular one- to – one sessions with individuals discussing aspects of their lives and looking at photographs, however these sessions were not always recorded. Staff confirmed that they had time to spend with the residents but needed more direction with the planning and provision of activities. All the people who use the service spoken to told the inspector how much they enjoyed the sessions provided by the motivation therapist. The home does not employ a dedicated activity organiser, all staff have responsibility for support in this area; three of the staff had accessed training in activity provision in 2006. Discussions with the manager confirmed that she was aware the activity programme had tailed off in recent months and that improvements would be made. The religious needs of people who use the service are documented in the care plans; the staff confirmed that there are regular church services (monthly) within the home and a number of residents like to watch “Songs of Praise” on Sundays. Details about advocacy services are made available for individuals; they are displayed in the home. Formal consultation with people who use the service and their families has improved since the last inspection; surveys have been issued and meetings arranged where they have the opportunity to influence the running of the service. Very positive comments were received from the people who use the service and their relatives about the quality of the meals provided at the home. Comments included “The meals are delicious” and “The food is always good here”. The meal served during the visit looked tasty and well presented. The majority of individuals use the dining room and the mealtime was seen to be a relaxed and social occasion with the staff interacting well with the residents; individual support was provided patiently and discreetly. The staff DS0000002851.V351339.R01.S.doc Version 5.2 Page 16 demonstrated a good knowledge of the individual residents’ nutritional needs and preferences. A number of individuals were receiving “fortified” diets; their weights are monitored regularly and any concerns are referred to community health services for support. Menu boards in the room display the weekly and daily choices; the manager confirmed that the menus had been reviewed following consultation; one of the suggestions had been to provide more roast dinners, which has been carried out. The kitchen was seen to be clean and tidy; the monitoring and recording of fridge/ freezer temperatures were well maintained. A recommendation made at the visit in Nov 2006 by the EHO to monitor the temperature of food deliveries to the home has yet to be implemented. DS0000002851.V351339.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. This judgement has been made using available evidence including a visit to this service. The home had a satisfactory complaints system with some evidence that people who use the service feel that their views are listened to and acted upon. Procedures are in place and training provided to staff to ensure a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has a complaints policy and procedure that is found within the statement of purpose and service user guide. It is also on display within the home. People spoken to showed a clear understanding about how to make their views and opinions heard and said “I would speak to the staff or the manager if I had any issues”. Interactions between staff and those people living in the home were observed to be warm and caring throughout the inspection visit, with staff giving time to ensure their individual needs were met. The pre-inspection questionnaire indicated that the home had received one complaint and the issues raised had not been fully substantiated. The complaints investigation records were examined which evidenced that the issues had been thoroughly investigated and the complainant had been informed of the outcomes. The commission had not received any complaints. DS0000002851.V351339.R01.S.doc Version 5.2 Page 18 The manager and deputy manager have accessed training in the management and handling of complaints since the previous inspection. People who use the service told the inspector that they felt safe and secure at the home. The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint in place. There was evidence that the staff had previously accessed training in safeguarding adults and all staff were scheduled to access an annual update. A number of staff had recently accessed training in challenging behaviour and further sessions were scheduled. When asked about abuse, what it was and what they would do if they saw a service user being abused, the staff answered correctly. DS0000002851.V351339.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 good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service felt at home at College View and the environment was warm, comfortable and suitable to their needs. However many areas in the home are now looking somewhat tired and shabby which impacts on the overall quality of the environment but this will be addressed with the major refurbishment programme which has recently commenced. EVIDENCE: The inspector made a tour of the premises of the home. The home was very clean and tidy and free from any offensive smells. The majority of areas in the home are now showing signs of age and the registered DS0000002851.V351339.R01.S.doc Version 5.2 Page 20 providers have developed a detailed and comprehensive refurbishment programme which will run alongside the works programme. The works programme will provide a first floor extension with two single ensuite rooms, alterations to shared rooms to provide single, en- suite accommodation, new bathing/ shower facilities and an extension to the lounge. Along with this work the electrical and plumbing systems will be upgraded. New laundry equipment will be installed, the dining room will be made larger with the removal of a false chimney breast, lighting in the communal areas will be improved, storage and staff facilities to be provided in the loft space and works to improve the outside of the property will include repainting all the woodwork, resurfacing of the drive and ramp provision to the doors to enable easier access. There have been delays with the start of the refurbishment programme, however, work has now begun; one of the relative’s surveys detailed, “Refurbishing and alterations seem to be taking a long time.” Two of the bedrooms have been upgraded so far and this has included redecoration, refurbishment, rewiring and re-plumbing work. One downstairs toilet has been refitted, a new fence erected in the front of the property, a new boiler has been installed and new beds provided in all the bedrooms. The manager confirmed that she is hoping all the work will be completed by Christmas. None of the residents spoken to expressed any concerns about the forthcoming works and upheaval, moreover they told the inspector that they considered the activity would be interesting. It was clear that they had been kept informed of the planned works and consulted where possible, a number of residents told the inspector the colours they had chosen for new décor in their rooms. There were several lounges in the home that the people who use the service could choose to socialise, or have some private time in. The toilets and bathrooms were all close to the communal and bedroom areas. All of the rooms in the home had a call bell system in them. People who use the service confirmed to the inspector that when the call bell is activated the staff were always quick to respond. The temperature of the hot water in the bathrooms was delivered at an acceptable limit to prevent scaling to people living in the home. Staff confirmed that there were adequate supplies of protective clothing; there were no specific infection control measures in place during the visit. DS0000002851.V351339.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. 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. This judgement has been made using available evidence including a visit to this service. Staffing levels were appropriately maintained so that the needs of the people who use the service could be sensitively met. Staff are well trained, appropriately supervised and competent to carry out their work. Recruitment practices afford sufficient protection for people who use the service. EVIDENCE: Discussions with members of staff, the manager and surveys received indicated that the home was adequately staffed. Levels of three care staff in the morning; two in the evening and one sleeping/one waking member of staff on night duty were usually maintained. In recent weeks due to staff sickness and annual leave the home has not always provided a third member of staff on the morning duty. The manager stated that she has monitored the workload very carefully during this time and would have provided agency staff if the workload had demanded this; people who use the service and staff on duty reported that the staffing levels had been satisfactory. The staff member on long-term sick leave was due to return to work that week. On the day of the visit there were ten individuals residing at the home, a small number of these people have quite complex needs, however, the morning routine was observed DS0000002851.V351339.R01.S.doc Version 5.2 Page 22 to be very calm and paced with staff ensuring their care was person centred and that individual attention could be spent with people who use the service. Staff retention at the home is very good with just one member of staff leaving in the last eighteen months. No new staff have been recruited since the previous inspection, given the staff recruitment procedures were checked at that time with no deficiencies identified, recruitment records were not checked at this visit. The home provides a stable workforce of experienced carers. The management and care staff showed a very good commitment to NVQ training; 85 of staff had achieved NVQ 2 in care or equivalent with five of the thirteen staff having achieved NVQ level 2 and five having achieved NVQ level 3. The deputy manager has started her NVQ level 4 in care with a further senior carer awaiting induction for this course. The manager kept an overview of the staff training to assist her in the planning of training in the home. The home provides a good staff training programme with staff accessing annual updates in statutory courses and a good variety of general and service specific courses; staff had recently accessed training in infection control, challenging behaviour and equality/ diversity. Improvements had been made to the recording of courses accessed by staff in their individual files; the manager develops an annual training and development programme, which is linked to the staff appraisals. Staff at interview and in surveys were very complimentary about the training they received. Senior care staff have also been attending regular “Train the trainer” courses provided by the local Primary Care Trust; these courses include general and service specific areas with the onus on the attendee cascading the training/ information to the remainder of the staff. The manager told the inspector that the senior staff require some more support in presenting the training for the staff at the home, which she will provide. Systems are in place for new staff to access the skills for care common induction standards. DS0000002851.V351339.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36 and 38. 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. People who use the service were satisfied that they lived in a home that was well managed and they were provided with appropriate opportunities; there was better evidence that their views were considered and acted upon in the development of the service. The safety of people who use the service and the staff at the home is well promoted and protected. EVIDENCE: The manager is a qualified nurse, has many years experience in providing care for the elderly and demonstrates sound management practices. She has DS0000002851.V351339.R01.S.doc Version 5.2 Page 24 completed her NVQ level 4 and Registered Managers Award and updates her skills and knowledge through regular attendance at training sessions. All the comments from staff were very positive about the management of the home; comments included “I feel Mrs Peerbux is a very supportive manager and will do her utmost to ensure her staffs and resident’s safety” and “The carers work with the best interests of the service users at heart, the manager and deputy are firm but fair with the staff and they are committed and dedicated.” The manager has developed a formal quality assurance programme and is now in the process of fully implementing it. Surveys have been issued to people who use the service, relatives and stakeholders, the results have been analysed and published; action plans have been developed and the manager is now working through these. Formal meetings with people who use the service and relatives have now been scheduled with the first meeting arranged for the following week; this said all the people spoken to during the visit were very positive about the standards of communication in the home. One relative wrote on the survey “The home has the advantages of a “small” home-everyone (staff) knows my mother and they can tell me about her the minute I walk in the door.” Staff confirmed that they had access to regular meetings, and that the management valued their opinion and suggestions. The homes policies and procedures manual had been reviewed and up dated recently. The manager has produced an annual development plan for the year, which clearly sets out areas that have been prioritised for development such as meals and activities. It is clear that regular management audits of care plans and medication records since the last inspection have had positive results. There were accurate and up to date records relating to any personal allowances the home keeps on behalf of the people who use the service. There was evidence that the home regularly writes to resident’s representatives to keep them informed of the personal allowance accounts. Checks on staff supervision records showed that the programme had been well maintained and the care staff had accessed the required amount of sessions (six) within twelve months. The supervision sessions with the staff are structured and cover all aspects of practice, philosophy of care in the home and any career or training/development needs of the individual. Staff had also accessed an appraisal session this year and there was good evidence that this linked to the training programme. DS0000002851.V351339.R01.S.doc Version 5.2 Page 25 Examination of maintenance records identified that checks and certificates were in place for installations and equipment. The fire safety equipment, checks and risk assessment were all in place and up to date. Training records show that staff have attended safe working practice up dates. Information examined in the home corresponds to that provided in the AQAA. The staff complete regular checks of the hot water temperatures to ensure the temperature is maintained close to 43ºC. Accident records were completed and in place; these are audited by the manager to review action taken to reduce reoccurrence. The manager has developed a comprehensive risk assessment to support the use of bed rails in the home; this covers all the areas identified by The Medical Devices Agency such as: type of rail used, height of bed, height of mattress etc. The home was utilising one set of bed rails at the time of the visit and checks are carried out regularly. DS0000002851.V351339.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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 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 X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 4 x 3 DS0000002851.V351339.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP2 OP12 Good Practice Recommendations The registered provider should provide all publicly funded persons with a copy of the “home’s” statement of terms and conditions. The registered provider must ensure that the activity programme is reviewed to ensure more regular sessions are provided for individuals, which suit their needs preferences and capacity. This will better ensure that the people who use the service are appropriately fulfilled and stimulated. The registered provider should ensure that staff carry out temperature recordings of foods delivered to the home. 2 OP38 DS0000002851.V351339.R01.S.doc Version 5.2 Page 28 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000002851.V351339.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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