Inspection on 10/12/07 for Coniston Lodge

This inspection was carried out on 10th December 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

Coniston Lodge 07/10/09

Coniston Lodge 14/07/06

Coniston Lodge 07/11/05

Coniston Lodge 29/06/05

Coniston Lodge 11/01/05

Coniston Lodge 14/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Coniston Lodge 43 Beaufort Road Southbourne Bournemouth Dorset BH6 5AS Lead Inspector Debra Jones Key Unannounced Inspection 10th December 2007 10:00 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 Coniston Lodge DS0000003932.V356388.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. Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coniston Lodge Address 43 Beaufort Road Southbourne Bournemouth Dorset BH6 5AS 01202 421492 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) kevin@coniston43.fsnet.co.uk Mrs Daphne Margaret Bailey Mrs Katrina Marlene Stephanie Bailey Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th July 2006 Brief Description of the Service: Coniston Lodge is registered to provide accommodation for eleven older people in what were two attractive converted houses now linked together at the ground floor. It is set on a corner plot in the residential area of Southbourne. Local bus services provide easy access to Bournemouth and Christchurch. There is plenty of on road car parking in neighbouring side streets. There is a large well-maintained garden to the side and rear of the home. The accommodation for residents in the home is over the ground and 1st floors with a passenger lift between. There are a variety of aids and adaptations around the building to allow residents to move about more independently. There are 11 single rooms, 4 of which have en suite facilities. There are additional communal toilets and bathrooms around the home. Situated on the ground floor are the residents lounge and dining room, both of which overlook the garden. The weekly charge currently ranges between £362 and £370. Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit took place on 10 December 2007. Debra Jones was the inspector who carried out the visit. The main purpose of the inspection was to check that the residents living in the home were safe and properly cared for and to review progress in meeting the requirements and recommendations made previously. Both Mrs Bailey’s – Daphne and Katrina, and Mr Kevin Bailey assisted the inspector in her work. The inspector was made to feel welcome in the home throughout the visit. A tour of the premises took place and a variety of records and related documentation were examined, including care records. Time was spent talking with residents in their bedrooms. Three requirements were made as a result of this visit and one was carried forward. Two recommendations were also made. Some good practice suggestions were discussed at the inspection and these are referred to below in this summary, intended to encourage further improvement. Prior to the inspection the home submitted to the Commission their completed annual quality assurance assessment (AQAA). This gave information about the service and it’s performance. This document was helpful in the planning of the inspection visit. The home also sent out comment cards on behalf of the Commission. Six were returned by residents and 6 by relatives. These are some of the comments they made. ‘It’s a lovely home and the garden is beautiful.’ (a resident) ‘My sister is exceptionally happy in this care home with all the attention she gets and the lovely meals she has.’ (a relative) ‘First class service.’ (another relative) ‘Very homely care.’ (another relative) When asked what do you feel the home does well? Relatives responded with the following comments:‘They always seem to find the time to have someone with them in the day room so that they don’t just sit without any stimulation.’ ‘Everything.’ ‘Kind considerate care.’ ‘Cares for people in their care. Always make visitors feel very welcome. When you go in they always chat with you, tell you anything necessary about the person you are visiting and always an offer of a drink.’ I find Coniston Lodge to be a very caring friendly and happy place. The staff seem to be well trained and always smiling. They sit with the residents in the lounge and are genuinely keen and interested in their job. The house is very homely which is just the right environment for my mother, the rooms are Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 6 comfortable and nicely maintained and the gardens are always ablaze with colour and very well kept. Mrs Bailey the owner is exceptionally competent as well as very happy and well experienced in running a care home.’ When asked how do you think the care home can improve? Relatives said:‘I really do not think they could improve.’ ‘I don’t think it can.’ Comments from residents at the visit included:‘I am very pleased so far.’ ‘I am quite content.’ ‘It’s fantastic, very, very good. ‘It’s all sorts of little things that make it good. ‘This is the best place I’ve been to, very high class.’ What the service does well: Coniston Lodge provides a homely, relaxed and comfortable environment with a welcoming and friendly atmosphere. The home is well presented and has attractive gardens. The home is kept clean and smells pleasant. A good admissions procedure is in place that ensures that only people whose needs can be met are offered places at the home. Prospective residents and their representatives have the opportunity to visit the home to see if they like it before they move in. The home has a good care planning system in place to ensure that staff have the information they need to meet the health and personal care needs of residents. A range of community health professionals support the care staff in looking after residents. Residents confirmed that they felt well treated. Residents are encouraged to exercise choice in their daily lives. Activities are on offer at the home that people can join in with if they choose to. Visitors are always welcome at the home and residents are encouraged to maintain and develop relationships with other people in the home, with their families and friends and to maintain links with the local community. Meals are varied and the dining area is pleasant and comfortable. The complaints and adult protection procedures reassure residents and their representatives that the well-being and comfort of residents is important to the home and that any concerns raised will be properly investigated and resolved. Sufficient numbers of well-trained staff are on duty throughout the day and night to be able to meet the needs of the residents. Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 7 The home is well managed and organised with the care, contentment and safety of residents being central to the way the home is run. What has improved since the last inspection? What they could do better: The home needs to confirm in writing to prospective residents that, based on their pre admission assessment, the home is able to meet their needs. Further improvements should be made to the medication administration system to make sure that residents get their medication as prescribed i.e. signing and countersigning handwritten entries on the medication administration records and setting up a system to track medicines that are not supplied in monitored dosage packs. As part of the recruitment process the home needs to ensure that they have all the documentation required by law, which is there to safeguard residents from unsuitable people working at the home. Such documentation includes confirmation that the person is not on the Protection of Vulnerable Adults (POVA) list, suitable up to date references and a full employment history. The home must comply with requirements made by the fire service. In addition to the 4 requirements and 2 recommendations made in this report the following good practice suggestions are made that the home are urged to adopt and act upon. The home is encouraged to • Routinely ask about any history of falls when carrying out their pre admission assessments. • Introduce a system to evidence that they are reviewing care plans at least monthly. • Obtain the clinical triggers available on the CSCI website in respect of continence, dementia, falls and nutrition. Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 8 • • • • Ensure that all people who may have to help move or handle residents have appropriate training to do this. Make the statement, required by law, by prospective staff as to their mental and physical health more explicit. Introduce a system to evidence that they are reviewing policies and procedures annually. Always make accident records clear as to whether staff came across accidents, if they had been told about them or if they had witnessed them. 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. Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 9 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 Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 10 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): 3 and 4. Standard 6 is not applicable to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good admissions procedure enables prospective residents to make informed decisions about admission to the home and ensures that only people whose needs can be met by the home are offered places there. EVIDENCE: The home is clear about their limitations and of the level of need that they can meet. Two files of recently admitted residents showed that prior to them moving to the home their needs were assessed by the home. Whether the person had a history of falls or not was not clear. People from Coniston Lodge visited one of the prospective residents at another home in order to carry out the pre admission assessment, the other new resident had visited the home with a relative, who had already looked around the home. Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 11 The home has not been confirming in writing to prospective residents the outcome of the pre admission assessment. Of the six residents who returned comment cards all said that they had enough information before they moved to the home in order to decide if it was the right place for them. One commented ‘All my questions were answered and my family visited the home on several occasions. Katrina and Mrs Bailey came to see me before moving to Coniston Lodge.’ Five remembered that they had received a contract. Coniston Lodge DS0000003932.V356388.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, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to provide staff with the information they need to meet the health and personal care needs of residents. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Residents said the home looked after them well. Care plans seen were of a good standard. They flowed from the assessments made by the home, were straight forward, easy to read, were of an appropriate depth to the level of needs of the residents, to the point and informative about their needs and of how the home was to meet them. Plans see were signed by the residents to show that they had been involved in devising them and that they agreed with their content. Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 13 There was no evidence to show that plans were reviewed monthly, but there was nothing to indicate that the care plans were not up to date in respect of the needs of the residents. Both Daphne and Katrina Bailey were very knowledgeable about the care needs of the individuals and the steps that the home is actively taking to support them. Care plans now include sections on medication and moving and handling. When asked ‘do you get the care and support you need?’ Five of the six residents who returned comment cards prior to the visit replied ‘always’. The other said ‘usually.’ One commented ‘I like it here.’ When asked ‘do the staff listen and act on what you say.’ All six residents who replied said ‘yes.’ One commented ‘They make me very welcome.’ One resident spoken with said ‘they give me a hand when necessary.’ All the relatives who responded by comment card said that the home ‘always’ gave the support or care to their relative that they expected or agreed and met the needs of their relative. Five out of six said that they were kept up to date with important issues. Daily notes support and evidence the delivery of care to residents. These give a good picture of the daily lives of residents, the care that is delivered to them by staff in the home and by visiting community health professionals such as GPs, district nurses and chiropodists. A separate record is kept of such visits. Residents are also accessing other community health services such as audiology. Of the six residents who returned comment cards five said that they ‘always’ received the medical support they needed. The other said that they did ‘sometimes.’ One relative commented ‘my sister recently had a fall and fractured her hip. Mrs Bailey telephoned me immediately as my sister was being put in the ambulance.’ Medicines prescribed by doctors are safely stored. They are only administered to residents by Daphne and Katrina Bailey who have received training in this work. Some medication administration records (MARs) were reviewed. These were up to date and properly completed as to the medicines received and administered. Any allergies known were clearly recorded, and where there were none known this was also noted. Where handwritten entries had been made to the printed records these were not countersigned by the other competent person to confirm accuracy. The home has a system for returning unused medicines to their pharmacist and appropriate records are kept. Some residents are prescribed medicines to take ‘when required.’ In all cases residents are able to make the decision as to when they want these medicines. Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 14 Some medicines are prescribed with a variable dose e.g. take one or two. It was clear from the records if one or two had been given. Most medicines arrive in the home in a monitored dosage system. A sample spot check was done of some paracetamol tablets that were not in this system e.g. tablets in boxes. It was not possible to tell from the records how many tablets should have been on the premises. Katrina Bailey said that she would stock take the medication at the time of the next delivery and introduce a simple system to address this. Staff were seen to be treating residents in a respectful and dignified way during the course of the inspection and were polite and courteous. Staff were reassuring, supportive and quick to respond to anything residents needed or wanted. Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of activities is available for residents to participate in should they choose to. People are generally encouraged to make choices about their life style and to maintain contact with their family and friends. The meals in this home are wholesome and varied and are served in a pleasant environment. EVIDENCE: Coniston Lodge is a family run home where residents are supported to live their lives as they choose. There are some structured activities run by staff and an entertainer visits at least every 3 months. References to visitors, outings and activities are made in daily notes. Residents talked to the inspector about their interests and how they like to spend their days e.g. joining in with what was on offer at the home, entertaining their visitors and listening to story tapes. Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 16 Every morning some residents get together to do a crossword puzzle in the lounge. Residents also enjoy playing word games. Most like to join in with these and admitted at times things got ‘quite competitive.’ ‘In the mornings we go to the lounge as a group.’ ‘I go to the lounge when I want to. That’s how I have got to know people.’ Recently a mobile clothes shop came to the home, which proved popular and some residents got new clothes to wear for Christmas. A hairdresser visits and the home has a selection of videos and CDs available for use. Some residents are still quite mobile and independent and go out to day centres, clubs and to church. Residents are encouraged to use the garden when it’s not too hot. Of the six residents who returned comment cards 5 said that it was ‘always’ the case that there are activities arranged by the home that they can take part in; 1 said that this was true ‘usually.’ Residents said that their friends and relatives are made welcome at the home. Residents can receive their guests in the communal areas, their own rooms or the garden. ‘My visitors are always made welcome with a cup of tea.’ All relatives who returned comment cards said that the home helped their relatives to keep in touch with them. People are encouraged to make choices about how they live their lives at Coniston Lodge. They can do as they wish, choose to eat what they like and join in with activities as it suits them. Preferences such as when they like to get up and go to bed are respected and residents confirmed this. ‘I get things when I want them.’ One resident spoken with was popping back to bed for an hour in the afternoon as she felt a bit off colour. All relatives who replied by comment cards said that they felt that the home supported people to live the life they choose. Menus are based both around the known likes and dislikes of the residents and on striving to provide a good wholesome diet. Residents are well able to say what they enjoy and to make their preferences clear. All residents spoken to praised the food. One resident commented ‘ the food is nice and I am eating better since I have been here.’ Another said ‘the food suits me down to the ground. It’s good and very nicely presented.’ Daphne and Katrina Bailey do the cooking. The meal served on the day of inspection was turkey drummers, grilled tomatoes, mashed potato, broccoli, carrots and cauliflower. Dessert was stewed apple and custard. People can have whatever they want at teatime. Residents can have meals where it suits them. The home has a pleasant dining area that residents can eat in if they wish. Other residents prefer having their meals in their rooms. Food records are kept. These show the variety of the meals provided. Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 17 Prior to the inspection the Commission received six comment cards from residents. Five of the six said that they ‘always’ liked the meals at the home and the other one said that they liked them ‘usually.’ Comments included ‘Very, very nice!’ Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a complaints procedure. Policies and staff training in abuse protect residents from harm. The way that complaints have been dealt with show the home eager to put things right quickly and to learn from the concerns raised with them. EVIDENCE: The home has a complaints policy / procedure that meets the standard and regulation. This is displayed on the notice board at the home. Two complaints have been received by the home since the last inspection. The home responded quickly to the complaints made and put right what had gone wrong for residents. Katrina Bailey felt that they had learned from these and had put measures in place and amended policies and procedures to prevent such complaints being raised in the future. The home were reminded of their need to inform the Commission of events that adversely affect residents as required by law. None have been received by the Commission. The comment cards sent to residents asked the question ‘Do you know who to speak to when you are not happy?’ Six residents sent back cards. All Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 19 answered ‘always’ to this question. ‘Sure I would if I was unhappy about anything.’ ‘If I was not satisfied I would say.’ In respect of knowing how to make a complaint all said yes ‘always’. The six relatives who returned comment cards all said that they would know how to make a complaint if they needed to. When asked if the service had responded appropriately if you or your relative have raised concerns about their care? Two said ‘always’ and 2 ‘usually.’ The home has an adult protection policy. Abuse is covered in the National Vocational Qualification training that staff undergo and during the induction programme. Katrina Bailey also did some specific training around the protection of vulnerable adults earlier this year. Prior to any members of staff commencing employment at Coniston Lodge the Protection of Vulnerable Adults list is checked to ensure their suitability, however the results of this check are not always obtained by the home before staff begin working there. Since the last inspection visit the home has not made any referrals to the Protection of Vulnerable Adults list. Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in comfortable, safe and well-maintained surroundings, which are clean with no unpleasant odours. EVIDENCE: Coniston Lodge is a family run home with a warm and friendly atmosphere. The home is well decorated throughout. The lounge and dining room are bright, attractive places to sit and eat. The garden is well maintained, attractive and accessible. Garden furniture is available for those wishing to sit outside. The garden boasts summer houses and an aviary. Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 21 There are a number of communal bathing areas in the home. One of the baths is in the process of being renewed and a new hoist is being installed. Four bedrooms have en suite facilities. Residents are mostly mobile and can choose where they spend their days. Some need a little assistance to get about. Aids and adaptations are available throughout the home and some residents with particular needs have their own personal equipment to assist with their independence. Where residents need equipment to aid independence, such as zimmers and rollators, the equipment was seen to be to hand. Other useful aids and adaptations are around the home for use by all e.g. raised toilet seats and grab rails. Residents are able to, and do, personalise their rooms with furniture and general belongings. There is a passenger lift in the home, enabling easy access between the ground and first floor. There are emergency alarm bells throughout the home. Residents are able to have keys to their bedroom doors and lockable storage in their rooms for personal belongings of importance if they want them. Since the last inspection more of the radiators and pipe work that might pose a risk to residents have been attractively covered. Those considered to be high and medium risk have now been covered. Appropriate washing machines are in place to manage residents’ laundry, including a new tumble drier. On the day of the visit the home was clean and there were no unpleasant odours. Five of the six residents that returned comment cards said that the home is ‘always’ fresh and clean, with one saying this was the case ‘usually.’ One commented ‘It is so clean.’ One resident spoken with said that their laundry was ‘beautifully done.’ Another said ‘You send it off and it comes back that day.’ Coniston Lodge DS0000003932.V356388.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient, well trained and qualified care staff are employed and deployed to ensure that the care needs of residents can be met. However residents are not currently fully protected by the home’s recruitment procedures. EVIDENCE: Staffing rosters are in place that show who is on duty and when. Rosters show all staff on duty, their full names and their designations i.e. what job they do. Care staff are on duty during the day and evening. They also carry out housekeeping and cleaning duties. The Bailey family are in addition to this. Daphne and Katrina Bailey always administer medications and usually cook the main meal of the day. At night two people are available. Daphne Bailey sleeps on the premises and the call bell system extends to the home of Kevin Bailey should he be needed to assist Daphne at any time. Kevin has not had training in moving and handling. Residents were asked are the staff available when you need them? Five said this was ‘always’ the case and one said ‘usually.’ Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 23 Five of the six relatives who returned comment cards thought that the staff at the home had the skills and experience necessary to look after people properly. Out of the 5 care staff employed at the home 3 have a qualification at NVQ level 2 in care or above. This exceeds the Department of Health target of 50 of care staff having level 2 in care. Staff files are kept that demonstrate the recruitment process in action and most documents required by law that relate to staff are on file, including staff contracts of employment. The files of two members of staff who recently started working at the home were reviewed. Both had application forms and full employment histories. One did not have the required POVA 1st check or Criminal Record Bureau disclosure certificate and one had a POVA 1st check confirmation dated the day after they had started working at the home. Both had references on file but in both cases not all references were current, or they were addressed to ‘whom it may concern’ rather than showing that the reference was supplied in response to a request by the home in relation to the post the person had applied for. Both had information about the person’s health but the statement as to the person being physically and mentally able to do the job was not explicit. Training is taken seriously at the home. All staff have an individual training and development programme. Staff mostly either have, or are studying for, National Vocational Qualifications. In addition over the past 12 months people at the home have had training in advance medicines management, diabetes, falls awareness and risk assessment, and first aid. Evidence was seen to show that the home is now using the industry standard induction programme developed by Skills for Care. Coniston Lodge DS0000003932.V356388.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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well organised and the care, contentment and safety of residents is at the heart of the daily management and running of the home. Good management practice, systems in place, and records kept, confirm the health and safety of people in the home. EVIDENCE: Daphne Bailey is an experienced proprietor and is at the home daily. Katrina Bailey is the registered manager. She is an experienced manager, has a National Vocational Qualification (NVQ) at level 4 in management and is in the Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 25 process of completing an NVQ in care at level 4. One of the home’s senior carers already has a NVQ level 4 in care. Kevin Bailey deals with maintenance issues and management / administrative tasks. Prior to this inspection visit the home completed an annual quality assurance assessment (AQAA), which they submitted to the Commission for Social Care Inspection. This identified what the home feels they do well and sets out their plans for improvement over the next twelve months. The home sent out and made available comment cards for the Commission as requested before this visit. Comments came back from 6 residents and 6 relatives. All were generally positive about the home. In addition the home has carried out their own quality audit. They sent out comment cards in June 2007. Comments included ‘I am so happy with the home’ and ‘very good, could not ask for more.’ A range of policies and procedures underpin the care delivered at the home. The home reported that most were last reviewed in 2004. The home holds money for one resident. There are appropriate records of transactions, records are signed, running balances show how much money the person has or owes, and receipts are kept. An up to date insurance certificate was on display along with Coniston Lodge’s registration certificate. The home’s fire risk assessment was seen. This was last reviewed in May 2007. The Dorset Fire and Rescue Service visited in July 2007 and will be following up the concerns they raised in respect of doors in the home. Steps are being taken to put intumescent strips in place around doors to satisfy the fire department and further protect residents in the event of a fire breaking out. Fire records were in place. An external company carries out regular checks of the fire equipment. Internal checks are being carried out and records showed this. Fire training and fire drills are taking place, the last one being in October 2007. New staff have fire training as part of their induction. Information submitted prior to the inspection visit confirmed that equipment and facilities are being appropriately maintained e.g. the passenger lift and the emergency call bell system. Accident records were looked at. Accident forms seen were generally well completed. Records were not always clear as to whether staff came across accidents, if they had been told about them or if they had witnessed them. Data Product sheets are now available near to where products are stored or in use. Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Coniston Lodge DS0000003932.V356388.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. 1. Standard OP4 Regulation 14 Requirement Prior to admission the registered person must confirm in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service user’ s needs in respect of his health and welfare. The registered persons must ensure that there is evidence that before starting to work at the home people are not on the Protection of Vulnerable Adults (POVA) list. Applicants for posts at the home must be asked to provide their full employment history and any gaps in their employment history must be explored and documented. (Timescale of 01/08/06 not met) The home must comply with regulations made under the Regulatory Reform (fire Safety) Order 2005. DS0000003932.V356388.R01.S.doc Timescale for action 01/02/08 2. OP18 13 01/02/08 3. OP29 19 01/02/08 4. OP38 23 01/03/08 Coniston Lodge Version 5.2 Page 28 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 OP9 Good Practice Recommendations The home should follow guidance from the Royal Pharmaceutical Society including ensuring that prescribed medicines that are handwritten on the MAR chart have been copied correctly. The person making the entry should sign it and a second trained / competent person should countersign. A system should be developed to track medicines that are not supplied in blister packs e.g. paracetamol. 2. OP29 References should only be accepted when they are supplied in response to a request by the home in relation to the post the person has applied for. Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Coniston Lodge DS0000003932.V356388.R01.S.doc Version 5.2 Page 30 - 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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