CARE HOMES FOR OLDER PEOPLE
Critchill Court Lynwood Close Frome Somerset BA11 4DP Lead Inspector
Ms Sue Hale Unannounced Inspection 12th July 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Critchill Court DS0000016011.V299916.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. Critchill Court DS0000016011.V299916.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Critchill Court Address Lynwood Close Frome Somerset BA11 4DP 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) 01373 461686 01373 453114 carol.mohide@somersetcare.co.uk Somerset Care Limited Mrs Carol Ann Mohide Care Home 49 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (33) of places Critchill Court DS0000016011.V299916.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Registered for 33 persons in category OP and 16 persons in category DE (E) One service user, named elsewhere, under the age of 65 Date of last inspection 24th January 2006 Brief Description of the Service: Critchill Court is a purpose built residential service supporting 49 older people with personal and social care needs. Situated in a quiet residential area of Frome, it is a short walk away from the local shop and approximately threequarters of a mile away from Frome town centre. The home is set in good sized gardens, which includes an enclosed courtyard area. Critchill Court is situated on the ground floor with 33 service users living in the main residential area, in single bedrooms. The other 16 service users, who require support due to dementia, live in a separate self-contained residential area known as Cedar and Oaks (referred to as Cedar Oaks). This area of the home provides specialist residential care for people with dementia and is supported by a nurse from Somerset Mental Health and Social Care Partnership. Although the home provides two residential areas the service users get together for social events and the supervisor on duty supervises both areas. Critchill Court DS0000016011.V299916.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over the course of one day in July 2006. It was undertaken by two inspectors. The inspectors spoke to some residents, some staff, visitors to the home and the manager during the inspection. Selected resident and staff files were checked and documents related to the running of the home including policies and procedures were examined. A tour of the building took place and the communal areas and some residents’ rooms were viewed. Mrs Carol Mohide is the registered manager and she is supported by Mrs Sue Steeds, her deputy manager. Surveys were sent out to residents, relatives and medical and health care professionals. Eighteen surveys were received from residents and six from health, social and medical care professionals. All the comments received from residents on the day the inspection and through anonymous surveys were complimentary about the home and included comments such as ‘all is fine’, ‘excellent’ and that the home ‘is very nice’. The current fee levels are between £361 and £430 per week. What the service does well:
The home provides a statement of purpose, brochure and service user guide that clearly sets out the objectives and philosophy of the service. Prospective residents are given the opportunity to spend time in the home. Admissions are not made to the home until a full needs assessment has been undertaken. Each resident is provided with a clear statement of terms and conditions that sets out the terms and conditions of residency. The care planning, policies and procedures include comprehensive person centred policies and procedures for the end stages of residents lives. Each resident has a plan of care that includes risk assessments that are comprehensive and give staff sufficient information to meet individuals physical, mental and social needs. The policies and practice within the home mean that residents are supported to access appropriate external medical and health care professionals. Attention is given to ensuring privacy and dignity
Critchill Court DS0000016011.V299916.R01.S.doc Version 5.2 Page 6 when delivering personal care. One health care professional stated that ‘ for the managers and staff at Critchill worked very hard to ensure that residents are respected and well cared for’. Residents’ privacy and dignity was maintained and on the day of the inspection it was noted that discussion with visiting healthcare professionals took place in the privacy of their own room. Residents are encouraged to retain life skills and supported to help within the home, for example at lunchtimes if they wish to, and one resident collects used cups on a trolley throughout the home. The routines of the home are planned around residents and needs and wishes. Residents are seen as individuals and care plans tailored to meet their needs including those from a different culture. The residents are encouraged to personalise their rooms. The home takes residents opinions seriously and makes changes where possible. One resident commented that ‘everyone is very kind, they always help when needed, but if I want to be on my own they leave me to my own space’. Appropriate activities are available throughout the home which residents are able to choose whether to participate in. The home ensures that residents and their relatives have access to advocacy services. The residents are satisfied with the meals served the home. Visitors to the home feel welcome and know they can visit the home at any time. The service has a complaints procedure that generally meets the national minimum standards and regulations. Residents were confident that they could raise complaints or concerns with senior staff. The home has policies and procedures in place to ensure the protection of residents living at Critchill Court. The home has a robust recruitment procedure that is followed by the manager. Residents have confidence in the staff that cares for them. Staff are encouraged and supported to undertake training and gain appropriate qualifications to ensure that they have the skills and experience to care for the residents in the home. The manager has the required qualifications, skills and experience and is competent to run the home. One professional commented that there had been ‘all-round development of the home since Mrs Mohide took over’. The home has clear health and safety policies and regular checks take place to ensure that the home is a safe environment.
Critchill Court DS0000016011.V299916.R01.S.doc Version 5.2 Page 7 Residents are able to take responsibility for their own finances but if they are not able to do so robust systems are in place to safeguard their financial interests. What has improved since the last inspection? What they could do better:
Opening and discard dates should be clearly written on all creams, ointments and liquids. The registered manager should ensure that staff sign the MAR sheet for all medication administered. Any complementary therapies such as Evening Primrose Oil should be clearly labelled. Staff must ensure that all medication given to residents is taken as prescribed. The complaints policy should make clear that complainants are able to contact Commission for Social Care Inspection at any stage for complaint. All references to regulation of the home should refer to CSCI. The information in the statement of purpose regarding the action to be taken by the home should a serious allegation be received should be updated to reflect current good practice advice. The bed rail policy should be reviewed to make clear to staff that residents should be involved in decision making as afar as they are able to. Consideration should be given to replacing the hallway carpets that are worn through wear and tear. Critchill Court DS0000016011.V299916.R01.S.doc Version 5.2 Page 8 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. Critchill Court DS0000016011.V299916.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 Critchill Court DS0000016011.V299916.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3. Standard 6 is not applicable to this service. The quality of this outcome group is good. The home provides a statement of purpose, brochure and service user guide that clearly sets out the objectives and philosophy of the service. Perspective residents are given the opportunity to spend time in the home. Admissions are not made to the home until a full needs assessment has been undertaken. Each resident is provided with a clear statement of terms and conditions that sets out the terms and conditions of residency. EVIDENCE: The home has a corporate style Statement of Purpose, adjusted to reflect Critchill Court, a coloured brochure and service user guide that is given to prospective residents and their families. The documents are informative and
Critchill Court DS0000016011.V299916.R01.S.doc Version 5.2 Page 11 clear about the services offered at the home and the homes culture and values. The documents are available in various formats including audiocassette. The manager told the inspectors that the statement of purpose was currently being updated. Information provided by the home makes it clear that prospective residents and their families/representatives are encouraged and supported to visit and spend time in the home on more than one occasion if necessary, before they make a decision about residency. A visit by the manager or deputy to the prospective residents home or wherever they are staying is made to undertake a pre admission assessment to make sure that the home is able to meet the prospective residents needs. All admissions are on a trial basis and followed by a formal review with the resident and their families to assess the suitability of placement. Residents spoken to during the inspection confirmed that they or their families had visited and spent time in the home before admission. The manager obtains information from the funding authority prior to admission and the inspectors saw that this was taken into account when drawing up initial care plans and assessments. The inspectors checked the personal files of some new residents admitted to the home and saw the completed pre admission assessments and initial care plans. The home has a contract of the terms of conditions of residency that meets the national minimum standards. The contract makes clear what is included in the fees and what separate expenses residents are responsible for. Copies of the contract were seen on selected residents files and residents surveyed were aware of the terms and conditions of residency. Critchill Court DS0000016011.V299916.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. The quality of this outcome group is good. Each resident has a plan of care that includes risk assessments that are comprehensive and give staff sufficient information to meet individuals physical, mental and social needs. The policies and practice within the home mean that residents are supported to access appropriate external medical and health care professionals. Attention is given to ensuring privacy and dignity when delivering personal care. EVIDENCE: The inspectors examined selected residents personal files. They contained up to date care plans, risk assessments in relation to falls, nutrition and skin integrity, records of residents weights and contact that residents had with appropriate healthcare professionals such as chiropodist, audiologists, optician
Critchill Court DS0000016011.V299916.R01.S.doc Version 5.2 Page 13 and dentists. Evidence was seen of regular view and updating of records where necessary. A daily record was on each file that gave details of how residents were and noted any changes in their physical or mental health or circumstances. These were generally up to date in the majority of files checked but one record had not been completed since the 4th July 2006. Changes in residents’ physical or mental health were recorded and any contact or referrals to health or medical professionals were noted. One file noted that a resident’s health had been given cause for concern and that they had been referred to the G.P who had recommended a change in medication. The residents had chosen not to accept this advice and their decision was respected and recorded on their file. The manager informed the inspectors that the philosophy of the home was to provide person centred care and that ongoing training and changes in the dayto-day routines of the home were taking place to make sure that this happened. All the residents spoken to were clear that staff treated them with respect and the day-to-day routines in the home respected their dignity. This was confirmed by all but two of the residents surveys returned which stated that they received the care and support from staff that they needed. The inspectors observed staff interacting with residents and visitors to the home in a friendly, professional and respectful manner. The bed rail policy did not make clear to staff that residents should be involved in decision making as afar as they are able to. The home has comprehensive policies and procedures in place to support residents and their relatives at the end stages of their life and if a terminal illness was diagnosed. This would involved the resents and their relatives making decisions about their care and would include any necessary medical and healthcare professional such as G.P’s and McMillan nurses. Records checked contained details of specific medical conditions and how staff needed to support residents to manage these in conjunction with health and medical professionals if necessary. Records were seen on individual files of the homely remedies in use and that this had been agreed with individual residents GPs. The manager has carried out monthly medication audits throughout the year to ensure that the management of medication is sound. Two signatures supported all hand-written entries on the MAR sheets. Photographic identification of residents was kept with the MAR sheets. A sample signature list was seen and a list of all staff designated to administer medication. The manager informed the inspectors that all staff that administered medication had undertaken training in how to do so safely. Whilst the medication procedures were generally satisfactory the following issues were identified,
Critchill Court DS0000016011.V299916.R01.S.doc Version 5.2 Page 14 gaps were seen on some MAR sheets, a complementary therapy was not clearly labelled who it was for, a liquid was seen with no open or discard date and tablets were left with some residents at lunchtime and no check was made as to whether they had been taken. Critchill Court DS0000016011.V299916.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. The quality of this outcome group is good. The routines of the home are planned around residents and needs and wishes. The residents are encouraged to personalise their rooms. The home takes residents opinions seriously and makes changes where possible. Appropriate activities are available throughout the home. The home ensures that residents and their relatives have access to advocacy services. The residents are satisfied with the meals served the home. Visitors to the home feel welcome and know they can visit the home at any time. EVIDENCE: The routines of the home were seen to be flexible to meet individuals’ choices and preferences as far as possible and residents spoken to confirm that they
Critchill Court DS0000016011.V299916.R01.S.doc Version 5.2 Page 16 were able to choose what time they call up and went to bed. The manager stated that they were striving to work towards person centred care and staff spoken to confirm that the routines of the home had changed to become more individualised. Two residents spoken to those said that they’ liked living here and that they were well looked after’. Residents’ files contained background information and social histories that included details of individuals’ ethnicity, culture and religious preferences and how the home and staff met these needs on an individual basis. The home has a recreation and leisure policy and sexuality /relationship policy that gives clear information to staff on how residents social and cultural needs can be met whilst living in the home. The policy makes it clear that residents are able to continue with their existing relationships and to form new ones if they choose to do so and are able to make an informed decision, this includes same-sex relationships. There was environmental, documentary, and first hand evidence of good practice around establishing communication with a person of a different language and of efforts made to make people from different backgrounds and cultures feel at home. Activities were on offer including in Cedar Oaks and were tailored to the preferences, choices and abilities of residents. Doll therapy has been introduced in Cedar Oaks and has been very popular with some residents. Records were seen of activities provided and planned for. It was recorded in residents care files if they had participated in activities or if they had been offered opportunities but chosen not to do so. A display board informed residents of planned activities and the days that they would take place on. The gardens and all service users areas are accessible to all residents. The courtyard garden is well maintained with shade offered in hot weather and provides an attractive amenity that was valued by service users spoken with and seen to be used on the day of the inspection. One resident spoken to say that they enjoyed helping in the garden and that staff supported them to do so when necessary. Throughout the inspection there was a relaxed atmosphere as service users, who were able, moved around the home freely and bedrooms seen reflected the individual residents choices and preferences. Visitors to the home confirmed that they were able to visit at any time and were made to feel welcome. All residents spoken to were satisfied with the quality and quantity of food served at the home. Residents said they enjoyed the homemade cakes and that staff were familiar with their likes and dislikes. The menu on display did not reflect the actual meal served and there had been a mix-up on the day of the inspection and residents had been misinformed about what they were eating but the manager assured the inspectors that this was a one-off incident
Critchill Court DS0000016011.V299916.R01.S.doc Version 5.2 Page 17 and would not reoccur. The inspectors observed lunch and saw that it was relaxed and unhurried and that residents were offered discreet assistance if they needed it. The menu was varied and offered seasonal changes. Special diets including diabetic, ethnic, soft or vegetarian were catered for according to individual needs. One resident said that the ‘food was lovely’. The home provides residents and their relatives/representatives information on how to contact independent people who will act as advocates on the residents’ behalf. Critchill Court DS0000016011.V299916.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. The quality of this outcome group is adequate. The service has a complaints procedure that generally meets the national minimum standards and regulations. Residents were confident that they could raise complaints or concerns with senior staff. The home has policies and procedures in place to ensure the protection of residents living at Critchill Court. EVIDENCE: The home has not received any complaints since the last inspection. The home has a corporate complaints procedure that is made available. People are invited to make their views known in the corporate leaflet displayed by the main entrance. The information about complaints in the statement of purpose needs updating and the leaflet ‘Seeking Your Views’ should make clear that complainants are able to contact the Commission for Social Care Inspection at any stage of a complaint. None of the residents spoken to had any complaints about the home and all were clear that should they have any complaints or concerns they would speak to the manager of another senior member of staff and that they would sort any
Critchill Court DS0000016011.V299916.R01.S.doc Version 5.2 Page 19 problems out. Staff spoken to were clear that they would pass on any concerns or complaints to the manager or a senior member of staff. The home has a policy and procedure on the protection of vulnerable adults and this is available to all staff. The information on action to be taken by the manager should a serious allegation be received needs to reflect the advice given in Safeguarding Vulnerable Adults Adult Protection in Somerset Multi Agency Policy and Practice Guidance. Appropriate recruitment checks of undertaken of new staff to ensure the protection of people living at the home. The home has up-to-date policies giving staff advice on how to manage physical and verbal aggression by residents. The homes policies make it clear to staff that they cannot accept gifts from residents and cannot assist with or benefit from residents wills. Critchill Court DS0000016011.V299916.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26. The quality of this outcome group is good. The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the residents. The shared areas provide a choice of communal with opportunities to meet relatives and friends in privacy or in their own rooms. Appropriate laundry facilities are provided and infection control policies and procedures are in place. EVIDENCE: The home was clean, tidy with no unpleasant odours on the day of the inspection. A tour of the premises was undertaken and the inspectors viewed
Critchill Court DS0000016011.V299916.R01.S.doc Version 5.2 Page 21 all the communal areas and some of the residents’ private bedrooms. All the residents’ rooms seen had been personalised to reflect individuals’ choices and preferences. Residents are able to being in personal items including small items of furniture within the space constraints of their room and in agreement with the manager. Some vinyl flooring and carpeting within the home has been replaced since the last inspection. The inspectors noted that some carpets in hallways showed signs of wear and tear and had been joined in some areas with tape and were frayed. A fireplace has recently been installed in Cedar Oaks to further increase the homely atmosphere. Some new furniture has been provided including a sideboard in the dining room and some new chairs. The hairdresser’s room has been updated to make it a more comfortable environment. There has been no change in the physical layout of the home, a comment was received from a professional visiting the home that the internal space on Cedar Oaks is not very spacious and would benefit from extra communal space, particularly in winter when residents are not able to use the outdoor areas. The kitchen has been refurbished since the last inspection and offers an improved working environment for staff. Residents in Cedar Oaks have a safe garden that they can use and do so in the warmer months. A summerhouse has just been erected in the Cedar Oaks garden. The courtyard garden provides an accessible and attractive amenity for all residents in the main house. Residents are encouraged and supported by staff to look after the garden if they wish to. Planting in the courtyard area is being raised beds to facilitate this. There are sufficient and suitable toilet and bathing facilities available throughout the home. Specialist equipment was observed in use during the tour of the home. In addition to bathroom and WC adaptations, they included, mobile hoists, air mattresses and cushions for the prevention of pressure sores. The home has appropriate laundry facilities with clear instructions available for staff and residents spoke to confirm that their clothes were well laundered and that they received their own clothes back from the laundry. Appropriate handwashing facilities, such as liquid soap and paper towels, are available in all staff and communal washing facilities. They are also provided in bedrooms if anyone suffers from an infection. In addition to hand washing, staff members use a bacteriological hand gel and visitors are also encouraged to do so. Infection control policies, procedures and training are in place for staff. Critchill Court DS0000016011.V299916.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. The quality of this outcome group is good. The home has a good recruitment procedure that protects residents. Residents have confidence in the staff that care for them. Staff are encouraged and supported to undertake training and gain appropriate qualifications. EVIDENCE: The home was fully staffed on the day of the inspection and the manager informed the Inspectors that all vacancies have now been filled. Residents spoken to were very satisfied with the care they receive from staff and the response when they needed attention. The inspectors checked selected staff files for three new members of staff, all contained the appropriate documentation and relevant checks such as CRB and POVA had been undertaken before the staff started work. The home has good access to NVQ training through the company and aims to have all care staff achieving NVQ qualifications. Training records seen
Critchill Court DS0000016011.V299916.R01.S.doc Version 5.2 Page 23 evidence that 66 of the care staff is trained to NVQ Level 2 in care or above; others are working towards gaining this qualification. Staff undertake an induction programme to Skills for Care standards. Supervisors undergo an induction programme whether recruited internally or externally and all staff are encouraged to develop their role. The manager submitted an annual training plan that shows that staff have received a range of training. A visiting professional commented that staff were ‘always helpful and well organised’ and that instructions left for staff are always followed. Staff were observed throughout the inspection to be professional, friendly and respectful towards residents and visitors to the home. Critchill Court DS0000016011.V299916.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. The quality of this outcome group is good. The manager has the required qualifications, skills and experience and is competent to run the home. Residents and staff are kept informed and involved in the running of the home. The home has clear health and safety policies and regular checks take place to ensure that the home is a safe environment. Residents are able to take responsibility for their own finances but if they are not able to do so robust systems are in place to safeguard their financial interests. EVIDENCE:
Critchill Court DS0000016011.V299916.R01.S.doc Version 5.2 Page 25 The registered manager since 2005 has been Mrs Carol Mohide who has worked in care for many years and has held a senior role in another home within the company. Mrs Mohide has NVQ4 in Care and the registered manager’s award and undertakes ongoing training is required. A visiting professional, residents and relatives spoken with confirmed that Mrs Mohide is open and approachable and has had a positive impact on the home. Senior staff have designated roles and Mrs Mohide appears well supported by her deputy. Staff spoken to were confident that they could approach the manager and that they were supported and encouraged in their role by Mrs Mohide. Regular staff meetings to discuss the operation of the home take place and minutes circulated. Evdidence was seen that recent discussions had taken place between the manager and staff on the theory of person centred care for residents, its importance in providing care and how the staff group could achieve this. Regular residents meetings are held with all welcome to attend. Topics discussed included menus, activities and any changes planned for the home for example the recent refurbishment of the kitchen. The home does not maintain bank accounts on behalf of residents but do keep cash and cheques for those who cannot or do not wish to hold their own money. The inspectors checked selected the residents’ financial records and found them to be well maintained, with appropriate receipts kept of all expenditure and with inputs and balances agreed with the signatures of staff and residents or relatives. A tour of the premises was made and areas seen were free from hazards and it was noted that a recommendation made in the last report that uncovered radiators should be guarded had been addressed. Records were seen that showed that all equipment including bathing equipment, fire equipment, hoists, and electrical equipment were subject to regular checks and had been serviced. Records in relation to the health and safety of residents such as temperature checks of food served were seen to be kept by staff. The training record provided, showed that that staff had received mandatory training and updates and also a range of specialist training. A training record was maintained to evidence that all staff had undertaken mandatory training is recommended in the last report. Critchill Court DS0000016011.V299916.R01.S.doc Version 5.2 Page 26 The accident book was available to staff and selected residents personal files were cross-referenced and found to be correctly recorded in both documents and CSCI had been notified of any serious incidents at the home. Critchill Court DS0000016011.V299916.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 14 15 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X 3 X X 3 Critchill Court DS0000016011.V299916.R01.S.doc Version 5.2 Page 28 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 OP8 OP9 Good Practice Recommendations The bed rail policy should be reviewed to make clear to staff that residents should be involved in decision making as afar as they are able to. Opening and discard dates should be clearly written on all creams, ointments and liquids. The registered manager should ensure that staff sign the MAR sheet for all medication administered. Any complementary therapies such as Evening Primrose Oil should be clearly labelled. Staff must ensure that all medication administered is taken. The complaints policy should make clear that complainants are able to contact Commission for Social Care Inspection at any stage for complaint. All references to regulation of the home should refer to CSCI. The information in the Statement of Purpose regarding the action to be taken by the home should a serious allegation be received should be updated to reflect current good
DS0000016011.V299916.R01.S.doc Version 5.2 Page 29 3 OP16 4 OP1 OP18 Critchill Court 5 OP19 practice advice. Consideration should be given to replacing carpets in hallways worn through wear and tear. Critchill Court DS0000016011.V299916.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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