Inspection on 16/07/07 for Dane House

This inspection was carried out on 16th July 2007.

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

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

Other inspections for this house

Dane House 29/05/06

Dane House 14/12/05

Dane House 18/07/05

Dane House 06/12/04

Dane House 01/06/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Dane House 52 Dyke Road Avenue Brighton East Sussex BN1 5LE Lead Inspector Melanie Freeman Key Unannounced Inspection 16th July 2007 10:30 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 Dane House DS0000013976.V338994.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. Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dane House Address 52 Dyke Road Avenue Brighton East Sussex BN1 5LE 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) 01273-564851 01273 507161 dane.house@fshc.co.uk www.fshc.co.uk Ringdane Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Tracey Fiona Davis Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability (5) of places Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is twenty-five (25). That service users should be aged sixty-five (65) or over on admission. That a maximum of five (5) service users may have a physical disability and be aged between forty-five (45) years and sixty-five (65) years on admission. 29 May 2006 Date of last inspection Brief Description of the Service: Dane House is a converted family house situated in a residential area of Hove. The home is registered to provide nursing care for twenty-five service users in the category of old age. A variation to the category has enabled the home to provide care for up to five service users with a physical disability. Intermediate care is not provided at Dane House. Dane House is a large detached property, with a conservatory to the rear of the house leading to a pleasant rear garden with an attractive pond and quality garden furniture. The accommodation offered consists of nineteen single bedrooms, ten with en suite facilities and three double bedrooms, two with en suite bathrooms. There are ample communal bathrooms with adaptations for the disabled. The lounge area is large with comfortable furniture, which leads into a conservatory, which is used as a dining and seating area. There are other quiet areas on the ground floor with comfortable chairs, which can be used by the residents. Fees charged as from 1 April 2007 range from £690 to £790 depending on the room to be occupied. Additional charges are made for hairdressing, individual toiletries, chiropody, newspapers and outside activities such as visits to the theatre. Within the homes philosophy of care it identifies one of its main aims is to ‘care for every individual in a holistic humane and sensitive way’. Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Dane House will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting health care professionals. The unannounced assessment visit was facilitated by the registered manager who was working in the home. On the day of the home assessment the inspector was able to spend much of her time meeting with residents and their visitors and observing practice, and noting how residents needs are being met. Resident’s lifestyles within the care home were also looked at along with measures taken to promote residents individuality. A tour of the premises was undertaken and a range of documentation was reviewed including the homes statement of purpose, service users guide, duty rotas, medication records, and recruitment files. The care documentation pertaining to three residents were reviewed in depth along with a number of records relating to health and safety. Discussions with the registered manager looked at progress since the last inspection and how the requirements and recommendations had been addressed. Staffing arrangements reviewed included the management structure and measures put in place to monitor the quality of care and services in the home. The inspector was able to eat a midday meal with the residents in the communal dining room and review the arrangements for providing suitable diets. During the inspection visit four visitors were spoken to and were able to provide their views on the home and how their relatives were being cared for. Following the visit one residents representatives were contacted by telephone along with four health care professionals. What the service does well: Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 6 The atmosphere at the home was relaxed, with communication between staff, residents and visitors being positive open and friendly. A good standard of care is maintained with one relative saying ‘Staff treat my father as if it is their own father or grandfather which is good to see’ visiting professionals confirmed that the home contacts them appropriately and responds to the advice they provide. All parts of the home were generally clean and comfortable, the home has pleasant communal areas and residents are encouraged to have personal items in their rooms to help them feel at home. The quality and choice of meals remain good and all service users spoken with confirmed this. The new activities co-ordinater has been well received by everyone and her high motivation has provided the home with a variety of entertainment and activity. The staff and management of the home are welcoming to all visitors and visiting is unrestricted. Feedback from all sources was complimentary about the staff working in the home with one resident calling them ‘cracking’. What has improved since the last inspection? What they could do better: Further attention needs to be focussed on meeting residents needs documented to ensure all care needs are attended to fully. The medication practices in the home for the ordering of medication need to improve to ensure the health needs of the residents are met and supported. The procedure for recording and responding to complaints needs to be improved to demonstrate complaints are recorded thoroughly and any investigation is clear. Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 7 The laundry facilities and service needs to be reviewed to ensure good infection control is followed at all times and that residents receive a good service. The recruitment practice needs to be improved with an appropriate record of two references, identification of each staff member to ensure residents are safeguarded. Systems for quality auditing need to be developed with the questionnaires received being reported on and responded to and for interested parties being made aware of the findings. Staff supervision was not maintained and should be developed to ensure staff feel valued and are being monitored. Robust Health and Safety systems need to be adopted and recorded to ensure staff and residents safety. 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. Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although the home has assimilated a good level of information about the home, its facilities, services and the costs involved this needs to be made readily available to prospective residents and other interested parties. The admission procedures allow for the needs of prospective residents to be assessed by a competent person before admission although people are not assured in writing that their needs will be met. EVIDENCE: On arrival at the home it was noted that the registration certificate was displayed in the front entrance area of the home. The statement of purpose and service users guide however was not available at request and the registered manager was able to demonstrate that the service users guide was being updated and would once finalised provide Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 10 comprehensive information to people about the home and the services it is able to provide. This updating should also include the registering authority’s change of address from Eastbourne to Maidstone. In conversation a visiting relative confirmed that he received in depth information about the home before his father was admitted to the home. He was also able to confirm that the contract arrangements were clear. A further review of a recently admitted resident’s records confirmed that a contract agreement had been completed. A review of the admission process included the review of the last two admissions to the home. This demonstrated that a full admission assessment is completed prior to anyone being accepted. Although it would be useful for the assessment tool to clearly record where the assessment was completed and who else was present. Once the assessed person is admitted to the home the assessment documentation is incorporated into the care documentation. Residents and relatives spoken to during the inspection visit to the home said that they were able to come to the home to look around before an assessment was completed, one relative was impressed with the atmosphere at the home saying. “The home provided a pleasant feel and look and I liked the home when I visited”. A trial period at the home is also offered. Although prospective residents are written to with information about their admission to Dane House the home does not confirm having regard to the assessment that the home can meet the assessed needs of any prospective resident. This was discussed with the manager who was advised that this should be completed in writing in accordance with the required documentation. Intermediate care is not provided at Dane House. Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Individual plans of care provided set out a framework for the delivery of care and the home was found on the whole to be meeting resident’s health and general needs with accessed additional community support when needed. However further attention to detail to ensure a high quality care is delivered is needed. The management of the medicines do not ensure the health care needs of residents are met at all times. EVIDENCE: The care documentation pertaining to three residents were reviewed as part of the inspection process and each of these residents were met with, during the inspection visit to the home. Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 12 The documentation used has been changed since the last inspection and now provides a clear and structured system for recording residents care needs. As this new documentation has been recently implemented there was evidence that all residents had had their care needs reviewed over the last month. It was clear that the trained nursing staff had worked hard on improving the care documentation to ensure it provides appropriate guidance on resident’s health care needs and recent training had facilitated this process. It was however noted that the social and psychological needs of residents are not routinely assessed and included in the plan of care. There was also evidence within the care documentation that residents or their representatives are aware of the care plans and the content of them. Regular contact with specialist health care professionals was clearly recorded within the documentation and professionals spoken to all commented on the way that the home used the resource that they provide appropriately. A variety of risk assessments are used to inform the care provided and included an assessment of moving and handling, pressure sore development, nutritional and risk of falls. It was however noted that records relating to residents fluid intake and output and repositioning charts were not completed in accordance with the plan of care, either indicating that the resident was not receiving the planned care or staff were not vigilant in completing the care documentation. Two relatives spoken to also indicated that staff did not always attend to the detail in respect to residents care for example resident’s mouth care. The management of the home was made aware of these issues. It was good to note that the care documentation was now available within the ground floor office and that the ‘key workers’ were making regular entries. In addition residents spoken to knew who their ‘key worker’ was and commented on how they liked them. During the visit it was noted that the registered nurse on duty always administers the medicines and that a trolley is used to transport medicines to the resident. Records seen were accurate and up to date, however it was again noted that two prescribed medicines were not available as they were out of stock. This concern was again raised with the registered manager who said she was unaware of this problem and assured that she would resolve the issue the next day. Contact with a relative also confirmed that prescribed medicines have at times not been available. This is an ongoing problem in the home that the manager is working to resolve with the supplying pharmacy and the registered nurses. Residents and visitors were complimentary about the standard of care provided in the home and comments made included ‘We are happy with the care provided we could not wish for better’ ‘I would thoroughly recommend this home. Observation confirmed that staff were very kind to residents treating them with respect and dealing with some difficult situations sympathetically and Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 13 appropriately. Privacy doors were in place in all areas and although net curtains had not been provided to the first floor bedrooms the bus stop had been moved from outside the home, so the possibility of people looking into the home has been reduced. The manager agreed to discuss with the individual residents concerned regarding the provision of net curtains as discussion with one relative indicated that her mother would not want these, as they would obscure her view. Documentation held within individual residents files indicated that end of life care is discussed and planned for in an appropriate manner. Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Links with friends, relatives and the community are encouraged and choices made are respected. Resident’s opportunities for stimulation through leisure and recreational activities have been developed and meals provided promote variety and choice. EVIDENCE: Since the last inspection a new activities co-ordinator has been employed and it was evident that she has made a positive impact on the home. She was seen to be engaging with residents and providing meaningful activities that included a group of ladies making sun hats for the forthcoming summer fete to be held in the garden, residents were enjoying the preparation for this event. The activities co-ordinator works in the home 15 hours weekly and had a good knowledge of all residents spending time with them individually she also recorded any contact or participation in events in their care records. As she is new to her role in the home the position is developing with opportunity to ensure a varied provision to suit individual preferences and needs. Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 15 Residents spoken to said that they are able to have visitors at any time and some continue to attend local church services. Visitors were also positive about the visiting arrangements with one saying that ‘I can pop in late at night just to say good night to my father’ all visitors to the home said that they were received positively. Choices were seen to be responded to in the home with an emphasis on meal choices. Catering staff have a close contact with residents talking to them daily and receiving direct feed back on the food provided. Resident’s rooms seen were found to be personalised. The meal eaten with the residents was very good and residents were able to eat communally or in their own rooms. The dining area is in the conservatory and is set up attractively with each table having condiments flowers and serviettes. The food was varied and one resident who is a vegan confirmed that his needs are attended to. Another resident with a small appetite confirmed that the ‘staff try hard to get things that he can eat’. Staff were available if needed and helped residents in an unrushed manner. The afternoon coffee/tea was accompanied with a homemade cake that residents enjoyed and a bowl of fresh fruit was available in the lounge area. Dane House DS0000013976.V338994.R01.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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are confident that complaints made would be taken seriously and responded to appropriately; procedures are in place to ensure residents are protected from abuse. EVIDENCE: Discussion with the manager confirmed that the complaints procedure has been up dated recently and is to be made available within the service users guide. The manager was reminded to ensure the correct address for the CSCI is recorded. Although a system is in place for recording complaints it did not clearly evidence the investigation completed in addition complaints raised verbally are not being recorded although they are being resolved. For example missing clothing is being replaced however the lack of recording does not provide an audit trail or information on an evolving issue. The registered manager confirmed that one unresolved complaint has been referred to the senior management team in accordance with the complaints procedure. She also confirmed that she has made a complaint about a community service that did not meet her and the home’s staff expectation. Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 17 All residents and relatives spoken to said that they would be happy to approach the manager with any concerns, as she was ‘approachable’ and they thought that she would act on any concerns in a positive way. Discussion with the registered manager and other staff confirmed that there was a good understanding of what constitutes abuse and how this should be responded to. The home has an adult protection (safeguarding adults) and whistle blowing procedure. Records indicated that some staff have received training on adult protection but further up to date training is needed, the registered manager had recognised this shortfall and said that this matter was to be addressed. Dane House DS0000013976.V338994.R01.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, 20, 24, 25 and 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 comfortable, clean and safe environment for those living in the home and visiting. Residents are enabled and encouraged to personalise their room, and rooms are homely and reflect the resident’s preferences. EVIDENCE: Dane House is a converted premise that has retained a home like environment. Accommodation for residents is provided on the ground and first floor with disabled access being provided via a passenger shaft lift. A tour of the home confirmed that a good standard of decoration is maintained throughout along with a satisfactory standard of cleanliness. Stained carpets in the lounge area are to be replaced in the near future. The garden is very attractive and well maintained and provides alternative seating areas. Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 19 The home provides attractive and versatile communal areas, which include a lounge and large conservatory that is used as a dining and provides additional seating. Although the lounge has blinds the registered manager and a visitor said that it still gets very hot. Air conditioning is to be fitted to improve the temperature control of this room. Although three rooms are registered as shared rooms all rooms are being used as singles. The residents are encouraged and enabled to personalise their rooms with furniture and pictures, and this was evident during the visit. All personal items are listed in the individual care documentation. Seven adjustable beds have been provided since the last inspection and the registered manager was able to advise that all residents that need variable height bed have one to ensure both staff and resident safety. During the inspection visit staff were seen to be following good infection control practice although the sluice room was unclean and the urine bottles looked stained/dirty. The registered manager said that this room would be cleaned and urine bottles replaced. Care staff complete all laundry duties and it was noted that this room is small and does not allow for a good separation of clean and dirty laundry. A number of residents and relatives said that there was some problems with the laundry and the misplacing of residents clothing. Dane House DS0000013976.V338994.R01.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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is sufficient staff that are suitably trained on duty to ensure that residents receive the level of care they need. The recruitment practice was found to be inconsistent with robust procedures not being followed. EVIDENCE: At the time of this inspection visit 20 residents were living at Dane House. Staff residents and relatives spoken to said that the staffing was satisfactory although there was ‘some shortages when staff were sick or on holiday’ it was however noted that in most cases agency staff are used to cover any shortfalls. The registered manager confirmed that recruitment was taking place as staff turnover had increased and this would provide a stability in the staffing provision. Since the last inspection the staffing levels have been reviewed with an increase to the staffing over the night shift. It was however noted that the care staff working during the day shifts are expected to complete all laundry duties and some domestic/catering duties. Staffing levels must be kept under review to ensure quality care and service provision in the home. Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 21 The duty rotas examined confirmed that staffing arrangements are maintained throughout the week, the manager works Monday to Friday although this is not recorded on the duty sheet it was also discussed the need to record staff full names and qualifications on this document including the agency staff provided. Feedback about the staff was positive with comments including ‘the staff are cracking’ ‘I have always found the staff to approach and speak to residents in an appropriate way’ ‘the staff are always welcoming and they engage with the residents in good way’. The recruitment files pertaining to three staff were reviewed as part of the inspection process and identified that the recruitment practice was not consistent; the following shortfalls were identified; • • • • One carer did not have a record of any references; another catering staff member only had one reference. There was no evidence that staff were given a copy of the General Social Care Code of Conduct. One staff member did not have a record of her identification. Although Criminal Record Bureau checks are completed evidence that a POVA check is also completed is not recorded in all cases. Although staff spoken to said that the staff training in the home had improved and that they were receiving more regular and interesting training the registered manager said that her own audit had identified the need for improved staff training. She is aware that health and safety and safeguarding vulnerable adults training is needed and is addressing these areas. Induction training is structured and recorded in a handbook signed off by the registered manager. The use of a training matrix would improve the way training is evidenced and planned for. Some staff have completed a National Vocational Qualification in care at level 2 or above and the registered manager is working towards more carers completing this training. Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home are receptive to residents and relatives views although systems for quality monitoring in the home need to show how the home ensures that quality is maintained and improved. Staff are not well supervised or consulted with. The health, safety and welfare of residents and staff are not well protected in all areas. Resident’s financial interests are safeguarded. EVIDENCE: Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 23 The manager is suitably qualified and experienced to run Dane House. She takes responsibility for the day-to-day running of the home and is supernumery to the staff providing direct care; she is also on call for any emergencies when she is not working. The residents and relatives are aware of who the manager is and her role in the home. She is supported by a deputy manager and an administrator who works in the home 25 hours a week. Relatives and residents said that they found the registered manager approachable, available and responsive to their views. Although staff spoken to were happy working in the home and acknowledged that staff meetings were held they felt that they were not listened to and it was noted that staff supervision is not being maintained in accordance with the standards. Some staff supervision has been completed however this has not been formalised and structured to ensure all staff receive it in an appropriate manner it was also noted that staff do not have a personal development plan. Contact with visiting professionals identified that the home is working with them to provide appropriate specialist care to residents. There are systems in place to monitor the quality in the home and these include a clinical governance audit completed by the registered manager and regular monthly visits by the allocated regional manager, which generate a written report. Questionnaires are also sent out by head office who in turn audit the results from these and provide a report to the home. Following discussion with the registered manager it was unclear how this report was used and shared with interested parties. It was also recommended that the use of questionnaires be expanded to include staff and visiting professionals. It was confirmed that the home does hold small amounts of money for most residents. This is known as their ‘personal allowances’ and is used to pay for extras like hairdressing. An account record is supplied on a monthly basis to each resident or his or her representative. During the inspection visit two of these accounts were checked and found to be accurate. Records relating to Health and Safety in the home were reviewed and on the whole were found to be satisfactory although it was noted that; • • • • Internal and external environmental risk assessments are not completed routinely. Staff training was limited. Hot water checks on baths were not evidenced Some health and safety checks were not being maintained as often as the home said that they should be. e.g. Checks on windows. Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 24 Following the inspection visit the registered manager confirmed in writing that all hot water supplied to baths in the home had been checked the next day and found to be supplying hot water at a safe temperature. Observation during the visit to the home confirmed that residents were wearing safe foot wear and that wheelchairs had footplates in place. Dane House DS0000013976.V338994.R01.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 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 X X X 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1) Requirement That registered person if wanting to admit someone confirms in writing that having regard to the assessment made on the prospective resident that the home can meet those needs. That all documentation in respect of residents health needs are kept up to date, reviewed regularly and assessable to all staff as per schedule 3. In particular the fluid and turning charts of the frail residents. (Previous timescales of 30/09/05 & 01/04/06 & 29/05/06 not met.) Staff need to ensure all care needs are attended to in accordance with the care documentation. 3. OP9 13(2) That medication is ordered in sufficient time to ensure that the medication is administered consistently. (Previous timescale 29/05/06 not met) 01/08/07 Timescale for action 01/08/07 2. OP8 13(1)(b) 01/08/07 Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 27 4. OP18 22 5. OP26 13(3) 6. OP29 19(1) That the registered person 01/08/07 ensures that all complaints are recorded and dealt with effectively and appropriate and that records are maintained to demonstrate a thorough and robust investigation and provide enough information to be audited. That the laundry arrangements 01/10/07 are reviewed to ensure appropriate infection procedures are followed, that the staffing arrangements do not impact on resident care, and that it provides a good laundry service where clothes are not mislaid. That the registered person 01/08/07 operates a thorough recruitment procedure that includes the appropriate checks being completed including 2 references and evidence that a POVA check has been completed. Evidence that each employees ID has been checked also needs to be retained in the home. That the information gathered 01/10/07 for quality monitoring is reported on made available to interested parties with recorded evidence of action taken in response to demonstrate ongoing review and improvement to the quality of care and services in the home. That all staff receive formal 01/10/07 supervision at least six times a year. (Previous timescale 29/08/06 not met) That these sessions are used to ensure staff feel listened to and valued and to develop a personal development plan for each staff member. 7. OP33 24 8. OP36 18 (1)(2) Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 28 9. OP38 12 (1) 13 (5) That robust health and safety practice is adopted to include thorough environmental risk assessments. (Previous timescale 29/05/06 not met) All staff must receive appropriate health and safety training. 01/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP27 OP33 Good Practice Recommendations That further emphasis is given to the assessment and planning of care to reflect the residents social and psychological care needs. That the duty rota clearly records who is working and in what capacity. That questionnaires are provided to staff and visiting professionals as part of the quality assurance monitoring programme. Dane House DS0000013976.V338994.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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