Inspection on 18/04/08 for Dalkeith

This inspection was carried out on 18th April 2008.

CSCI found this care home to be providing an Good service.

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

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Dalkeith 285 Gloucester Road Cheltenham Glos GL51 7AD Lead Inspector Mrs Kate Silvey Unannounced Inspection 18th April 2008 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 DS0000070646.V362513.R02.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. DS0000070646.V362513.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dalkeith Address 285 Gloucester Road Cheltenham Glos GL51 7AD 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) 01242 522209 01242 522209 Camelot Healthcare Ltd Alison Faith Smith Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places DS0000070646.V362513.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 22. Date of last inspection Brief Description of the Service: Since October 2007 Camelot Healthcare Limited are the new providers. Dalkeith is an adapted older property, which has retained a number of its period features. It is located in the St Marks area of Cheltenham. There is a post office/newsagent about 500 metres along the road, which is one of the main roads into the town. Buses pass the front door and the railway station is close by. The accommodation is on four floors with a shaft lift providing access between the ground floor and the first floor and a stair lift from the basement bedroom to the ground floor. The communal rooms consist of four lounge areas, two of which also have a dining area and one lounge area is on the first floor. Sixteen bedrooms have en-suite facilities. Two of these have a bath and shower respectively. Four bedrooms have wash hand basins only. There are three bathrooms two of which are assisted. Of these, one has a bath hoist and the other is a ‘walk in’ bath. There are large gardens, and seating areas at the rear of the home. Parking for several cars is available at the front of the home. The accommodation fees range from approximately £475.00 to £600.00 based on facilities/room size and additional charges include hairdressing, chiropody, escort duties and newspapers. Information regarding how fees are calculated and the criteria for when local authority funded places are available is in the homes Service User Guide. DS0000070646.V362513.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. One inspector undertook this unannounced key inspection in one day. Nineteen people were accommodated and most were seen and spoken to. Four people had a conversation with the inspector in their own rooms. We spoke to people in the communal rooms and a relative who was visiting in the home. There was direct contact with the home’s registered manager, the company’s operations manager, the assistant manager and two members of staff. Two directors from Camelot Care Limited visited the home during the inspection and spoke to us. A number of records were looked at including care plans, risk assessments, health and medication records. The care records of three people accommodated were looked at, two of them in more detail. The environment was inspected and staff were observed engaging with people living in the home. The surveys we sent to the manager arrived on the day of the inspection and were to be distributed to people living in the home, the care staff and any relatives that visited the home. The surveys had not been returned to us during the following four weeks therefore any comments could not be included in this report. The registered manager did not return the Commissions Annual Quality Assurance Assessment to us, which was due on the 13 May 2008, this is a selfassessment about the home and is a legal requirement. Subsequently a reminder was sent to the home, for this to be returned to us as soon as possible, when the AQAA is received the information provided will be reviewed. What the service does well: People are treated with dignity and respect and their care plan details their needs, which includes healthcare professionals when required. People told us; ‘They look after me well’, and ‘I am very happy here’. DS0000070646.V362513.R02.S.doc Version 5.2 Page 6 A relative told us the staff were ‘excellent’. People are provided with the complaints procedure and the manager asks for their views through the homes quality assurance surveys and individually. Care staff have had Safeguarding training which helps them to know what abuse is, how to recognise it and what to do should there be any suspicion of abuse to the vulnerable people accommodated. The homes recruitment procedure meets statutory requirements and the National Minimum Standards to help ensure people living in the home are protected. Staff receive a good induction and many have completed NVQ level two training or are working towards it. Mandatory training is completed which includes manual handling and first aid training. What has improved since the last inspection? What they could do better: The homes Statement of Purpose and Service User Guide require updating to ensure people have the correct information. Pre-admission assessments could be more detailed and healthcare professionals contacted before admission to help ensure that peoples need can be met in the home. Daily records and monthly reviews could be more meaningful to help ensure people’s care plans are helping them and their needs are being met. Medication administration records could be improved to ensure safe handling and administration at all times. An update to staff medication training was planned for all staff who administer medication. DS0000070646.V362513.R02.S.doc Version 5.2 Page 7 People are generally satisfied that the care they receive meets their needs, but there are times when they may need to wait a short time for staff support. This can be at peak times of activity in the morning and at the weekends when less staff are available, that is any management staff that can answer the telephone and door bell, compared to the weekdays. People living in the home were spoken to individually and made the following comments; ‘The staff are very busy’, ‘they are on the go all the time, I don’t think there is enough staff here, but my needs are met and the staff are respectful and jolly’, ‘the home is sometimes short staffed but they seem to cope’, and ‘the staff are very very busy and have a job to answer the bell but they treat me with respect. The manager should ensure that all information required for an inspection is provided for us to help ensure a balanced view of the home is provided. 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. DS0000070646.V362513.R02.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 DS0000070646.V362513.R02.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 & 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are admitted to the home after an initial assessment to find out what their needs are and that they can be met in the home. Information was not consistently detailed to ensure that people are adequately assessed. The Statement of Purpose and the Service User Guide required updating. EVIDENCE: We looked at the homes Statement of Purpose, which will soon be updated with the recent training staff have completed, and equality and diversity issues will be included in more depth. The information regarding the fees payable for accommodation and how they are calculated should be included in the Service User Guide for prospective people to see, in line with the Fees and Frequency Regulations. Intermediate care is not provided in the home. DS0000070646.V362513.R02.S.doc Version 5.2 Page 10 Two pre-admission assessments were looked at for recent admissions to the home. The new registered manager and the assistant manager usually complete the assessment together and contact any healthcare professionals involved in the persons care directly, with their consent. One assessment could have been more detailed and referred to a Community Psychiatric Nurse being involved but unfortunately they were not contacted until after the person was admitted. The other assessment was more detailed and appropriate healthcare professionals had been alerted and were visiting, which helps to ensure that care needs are well met. An additional adaptation to help with eating had been ordered for this person. A record had been made to contact their preferred religious group and find out where they meet locally. DS0000070646.V362513.R02.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 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All people have a care plan to help staff know what to do, more meaningful daily records and monthly reviews would help staff know the plans are working well. People were seen being treated with dignity and respect. Medication could be managed more safely as some administration records were incomplete, which had also been identified by the homes monthly audit system. EVIDENCE: We looked at three care plans, two in detail and spoke to people about their care. The plans seen had good assessments, but there was little social history, which can be particularly useful for people with mental health needs. All areas of care needs had been identified and there was good actions for staff to follow which included night care and exactly what people like during the night e.g. the light on low and hourly checks. DS0000070646.V362513.R02.S.doc Version 5.2 Page 12 People’s diets had been recorded and their weight had been charted on a graph to easily identify any changes in the monthly weight assessment. The daily records could be more meaningful to provide information for a more comprehensive monthly review of the care plan to help ensure the actions are working well. Risk assessments had been completed and the manager was completing an additional assessment for one person who required support from the district nurse. People that require nutritional screening have a care plan to identify their needs, an example seen was a person with diabetes. The protocol for this person’s diabetes required changing with regard to blood tests. We saw evidence that equality and diversity issues are addressed as a person who was partially sighted had his meals described to him so he knew where each food was on his plate in relation to the clock hands/hours. People told us; ‘They look after me well’, ‘I am very happy here’, ‘ the laundry here is good’, ‘ staff don’t have the time to spend with you if you are well’ There was evidence that healthcare professionals support people and the records clearly state the reason and outcome. The records indicated that a Community Psychiatric Nurse visited one person in April. People told us they had regular health checks with their doctor, optician, dentist and chiropodist. We looked at the medication storage and records. We saw the homes medication procedure, which was dated March 2002 and we were informed by the manager that it was currently being updated. There was a monitored dosage procedure given by the supplying pharmacist and a copy of The Royal Pharmaceuticals Society’s medication guidance. All medication had been signed as received into the home and we saw a returns book completed for when medication was sent back to the pharmacy. The homes medication reference book was dated March 2008. The controlled drugs record was complete. We saw the last three medication audits completed monthly where there had been signatures missing from the records. The manager informed us the supplying pharmacist was coming to complete an update on medication training to all staff. We looked at the administration records and transcribed records had not been signed and the dosage in milligrams was not always completed correctly. The correct procedure was recorded for covert administration of medication with relevant healthcare professionals involved and following an enhanced Care Programme Approach from the psychiatrist and the Community Mental Health nurse and ‘Best Interests’ guidance was followed. There was a good protocol for when to administer ‘as required’ medication for angina, which had been laminated. We also saw some good information about administering eye drops. Two people were self-administering their own medication and staff said they checked storage and amounts daily to help ensure compliance. We found one DS0000070646.V362513.R02.S.doc Version 5.2 Page 13 person with paracetamol tablets not locked in the bedroom drawer. Staff must ensure people store medication safely to protect others. Not all people administered medication ‘as required’ had a written protocol to ensure staff are consistent and safe with administration, this must be completed. We did a spot check of the monitored dosage system, which was correct, and medication not on the monitored dosage system had been dated when opened. It is recommended that when cream is administered the amount should be recorded e.g. pea size. The medication was stored safely and the medication fridge temperature was recorded. We were informed that all staff administering medication were appropriately trained and supervised to ensure they remained competent. DS0000070646.V362513.R02.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 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home organises different activities and tries to ensure people’s needs are met, more trips out would improve this for some people. People have regular contact with their relatives and decide what they want to join in with. Most people enjoy the food provided and people are able to influence what is provided. EVIDENCE: We met the person providing fortnightly exercise classes and people living in the home were taking part. A musical entertainer is also provided fortnightly, and has been coming to the home for many years. A newsletter informs people about what is taking place and in May there were afternoons for a ‘pampering’ session, plant potting and bingo. Film nights in the home were also planned and the aim is to take people out locally in the afternoons. A relative spoken to said the ‘exotic fruit tasting’ one afternoon was a success with her relative joining in and she also said the staff were excellent. There are plans for a summer ball where people can meet others in the four group DS0000070646.V362513.R02.S.doc Version 5.2 Page 15 homes. The activity funds are small and the home has fund raising events, the monies raised may be used for trips out. Some people go out alone and are taken out by relatives. People told us their relatives and friends visit regularly and take them out. One person said that they don’t join in with the activities but would like to do some gardening. Another person commented that the home does not organise outings, as there is insufficient staff. We spoke to one person who was glad the staff found time to take him downstairs to smoke outside, as physical disabilities did not allow this to be done alone. One person attends local clubs and also receives a taped newsletter from Gloucester Association for the Blind, talking books and a taped newspaper the Cotswold Listener. Another person who is registered blind did not have access to any taped books or papers yet, but was relatively new to the home. The new manager told us that they were planning more improvements in the activities provided. The manager told us the menus had been the same for a while and now a new one was being planned including requests from people living in the home. A meeting with people had resulted in curry and savoury rice, spaghetti Bolognese and garlic bread being added to the menu by request. The new menu had not been fully implemented yet by the new cook, but some requests had already been included and we saw this on the day of the inspection. People told us about the food provided; and said • The food here is excellent we have alternatives for lunch and supper and a cooked breakfast • the food is ok we have a choice • the food is not too bad, a bit repetitious though • the food is good, I have porridge for breakfast. Afternoon care staff prepare the supper menu, which can be time consuming and sometimes people have to wait as there are only two staff on duty at this time. We looked in the kitchen, which was clean and organised, and the manager said she did not think there were any requirements outstanding from the last Environmental Health Officer’s visit. DS0000070646.V362513.R02.S.doc Version 5.2 Page 16 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 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People know how to complain and have a copy of the homes procedure. There were no recorded complaints, however, it is recommended that concerns and how they are dealt with are recorded as good practice. The care staff help to safeguard people from abuse as they are trained to recognise abuse and know what to do. EVIDENCE: The manager told us that all people living in the home have a Service User Guide with the complaints procedure in it and some have the new updated guide. A new person who is registered blind had the Service User Guide read to him by the staff. There had not been any complaints recorded since the last inspection. It is recommended that any concerns and how they are dealt with are also recorded. Four people told us there was not enough staff but they may not have told staff in the home. All the care staff have had Adult Protection (safeguarding) training, one carer told us she would like to do an update on safeguarding. We spoke to staff who knew what to do if they suspected abuse or witnessed it and they had read the homes procedures relating to the protection from abuse and ‘whistle blowing’. DS0000070646.V362513.R02.S.doc Version 5.2 Page 17 The assistant manager told us she had completed part 1 of the Protection of Vulnerable Adults training and was waiting to complete part 2. DS0000070646.V362513.R02.S.doc Version 5.2 Page 18 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, 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a well maintained environment for people and there are further plans to improve the facilities. The recent staff recruitment to provide dedicated cleaning hours will improve the overall cleanliness of the home. EVIDENCE: We looked at the communal rooms and most of the bedrooms and the bathrooms. The assistant manager told us the home has some new carpets, new curtains, new chairs and new bedspreads and both dining areas have new flooring. There are plans to provide an additional table in the main dining room at the front of the home. All bathrooms will be upgraded when the homes plans for refurbishment takes place, and the top floor bathroom will be changed into a shower room for easier access. The bath hoist was serviced on 15 April 2008. DS0000070646.V362513.R02.S.doc Version 5.2 Page 19 People are able to regulate the temperature of the radiators in their bedrooms, which are protected to prevent burn injuries. Most rooms looked clean but the home had been without a cleaner recently and the care staff had been doing extra shifts to complete these tasks. One person told us that the ensuite toilet was not cleaned as often as it should be. We saw two bedside tables that were dirty, but staff cleaned them when it was brought to their attention. The records indicated that a person living in the home continually broke a window restrictor. It was recommended that a sturdier model be used to provide a safe environment. We looked in the laundry room and infection control information was available, a member of staff spoken to knew how to prevent cross infection. The gardens are well maintained and people enjoy using them. DS0000070646.V362513.R02.S.doc Version 5.2 Page 20 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 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are generally satisfied that the care they receive meets their needs, but there are times when they may need to wait a short time for staff support. The homes recruitment procedure meets statutory requirements and the National Minimum Standards to help ensure people living in the home are protected. Many of the care staff have completed NVQ level 2 or above training, which helps to ensure they can meet the needs of the people accommodated. EVIDENCE: There were nineteen people accommodated and many seen were highly dependant, some had dementia care needs that required a lot of attention. The manager told us fifty percent of the people accommodated were highly dependant. The rota indicated that there are usually two care staff and the manager on until 16:00 hrs each weekday then two staff in the evenings, and during the night one carer is on duty and one is asleep and is woken when required. During the weekend there are two staff on duty all day. The manager told us that sometimes the home has an extra carer when activities require it, a recent example was when the activity for people to sample ‘exotic fruit’. This is usually a staff member described as a ‘floater’ DS0000070646.V362513.R02.S.doc Version 5.2 Page 21 between all four homes used in particular when regular staff are sick or on holiday. Four people living in the home were spoken to individually and made the following comments; • ‘The staff are very busy as a lot of people here suffer from dementia and they are on the go all the time, I don’t think there is enough staff here, but my needs are met and the staff are respectful and jolly’ ‘the home is sometimes short staffed but they seem to cope’ the staff are very very busy and have a job to answer the bell but they treat me with respect. the staff are very busy night and day, there is pressure on staff and sometimes I have to wait and sometimes I wet myself. • • • We spoke to three staff and all of them said there was not enough staff, particularly in the morning when they were run off their feet and had little time to spend with people. They told us that there was hardly time to communicate with people as the medication round in the morning took at least an hour to complete. Two people have a bath and the remaining seventeen have a shower each week. One carer told us weekends can be difficult as there are more visitors and less staff to answer the door bell and telephone and record all calls. It is essential that the registered manager is the third person caring in the morning as previously agreed. A review of staffing levels/dependency levels should be regularly recorded to monitor that people’s needs are met appropriately. People are accommodated over four floors and during the inspection a person with dementia went missing, whilst it is appreciated that a visitor may have left the front door on the latch adequate staff should be available to supervise/engage with people who have dementia. We looked at three recruitment records. Application forms had been completed and we saw interview notes for one member of staff. Two staff records had two references and one had only one reference. Criminal Records Bureau and protection of Vulnerable Adults checks were complete. One record had a copy of a certificate previously gained. It is recommended that interviews are recorded to include reasons for any gaps in employment. We looked at an induction record for a new carer, it was comprehensive and included the six areas identified by Skills for Care as important. The manager told us the staff induction usually takes three months to complete then staff begin NVQ level 2 in care training. The operations manager agreed to send us the homes staff training record and completed AQAA. DS0000070646.V362513.R02.S.doc Version 5.2 Page 22 The registered manager told us that four staff have recently started NVQ level 2 training and that when they had completed it all staff will have completed NVQ level 2 or 3. The manager informed us that recently Gloucestershire Older Peoples Project team have provided staff training in person centred care planning and completing records, with training in the prevention of falls to follow. Staff told us all mandatory training to include manual handling and first aid had been completed, and dementia care awareness training and nutritional training had also been achieved. Staff said they were supported by the manager, but only one of the three staff we spoke to had received formal supervision. The home is currently advertising for a cook and was interviewing the following week. Meanwhile care staff who are able to cook were covering some shifts. The vacancy for a cleaner had just been filled and the person was due to start the following week for twelve hours each week. When the cleaner is not on duty the care staff complete cleaning duties as required. The care staff complete the laundry during the day and night shifts. DS0000070646.V362513.R02.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, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The new manager is well qualified and experienced, but is new to the home and had not been able to provide all the information needed for the inspection process. Quality assurance systems are in place to find out what people think about the service, and there was evidence that peoples comments are acted upon to improve the service. People have the facilities to manage their own monies, and the home also has a safe system for managing peoples personal monies for them. EVIDENCE: We met the homes recently registered new manager who has an NVQ level 4 in care and has completed the Registered Managers Award. The manager has many years care experience and was a deputy manager at a home for people DS0000070646.V362513.R02.S.doc Version 5.2 Page 24 with learning disabilities for three years. She is supported be the company’s operations manager and an experienced assistant manager in the home. It was disappointing that no surveys were returned to us after we sent them to the manager to distribute, this would have helped with the inspection process. The Annual Quality Assurance Assessment was not returned to us either, and various information promised to us on the day of the inspection has not been received. The AQAA is a legal requirement to help us assess the quality of the home and should have a lot of information about management systems, which have not been included in this report. We discussed quality assurance with the manager who said she meets with people living in the home individually and as a group. The recent discussions have highlighted that people want an alternative menu to choose from in addition to the main menu. They also wanted more foods that can be chewed and more chips on the menu. The menus were being changed to include people’s preferences. The manager has also started producing newsletters to inform people about what is happening and planned in the home. Quality assurance surveys are given to new people when they move into the home and at other times, the manager agreed to send us their most recent quality assurance results. Some people manager their own monies and have a lockable facility in their bedrooms. We looked at the homes management of people’s personal monies and a spot check of two records the monies were correct. There is a good system with clear records to include an invoice from the hairdresser, and all receipts are kept. The manager told us she had completed health and safety training and when we receive the AQAA we can check that all the correct maintenance and servicing have been completed for the home and that procedures are in place. We found that two bedroom doors that lead onto the stairs were wedged open, an alternative agreed by the fire officer should be used as these stairs are the main means of escape. The manager told us that the homes fire risk assessment has been completed and the fire safety officer wants an additional action plan, which is in progress. The home does weekly fire safety checks to ensure the fire alarms and the emergency lights work. The manager told us staff fire training was up-to-date and that only the new staff required training. We discussed equality and diversity issues briefly with the registered manager and the operations manager. It was agreed that there should be more information and staff training to address the six principle areas, disability, sexuality, race, religion or beliefs, age and gender to help ensure that all peoples needs are met. DS0000070646.V362513.R02.S.doc Version 5.2 Page 25 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 X 3 X 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 3 3 X X X X X 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 4 X X 3 DS0000070646.V362513.R02.S.doc Version 5.2 Page 26 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 OP9 Regulation 13 (2) Requirement The registered manager must ensure that the medication is managed correctly to ensure safe administration; • Sign transcribed medication and ensure the information is correct. Ensure people selfadministering store their medication correctly. All ‘as required’ medication has a protocol to help ensure consistent and safe administration. 04/07/08 Timescale for action 30/06/08 • • 2 OP27 18 The registered person must ensure that there are sufficient care staff on duty at peak periods of activity to help meet people’s needs. DS0000070646.V362513.R02.S.doc Version 5.2 Page 27 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 OP3 OP7 Good Practice Recommendations Healthcare professionals should be contacted before a person is admitted where appropriate. The daily records could be more meaningful to provide information for a more comprehensive monthly review of the care plan to help ensure the actions are working well. It is recommended that the amount of any cream applied should be described. It is recommended that any concerns and how they are dealt with are recorded. It was recommended that a more sturdy window restrictor is used where indicated to the manager, to provide a safe environment. 3 4 5 OP9 OP16 OP19 DS0000070646.V362513.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 DS0000070646.V362513.R02.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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