Inspection on 27/09/05 for Davers Court

This inspection was carried out on 27th September 2005.

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

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

Other inspections for this house

Davers Court 06/03/07

Davers Court 20/02/06

Davers Court 06/01/05

Davers Court 08/09/04

Davers Court 22/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Davers Court Shakers Lane Bury St Edmunds Suffolk IP32 7BN Lead Inspector Mary Jeffries Announced Inspection 27th September 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 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. Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Davers Court Address Shakers Lane Bury St Edmunds Suffolk IP32 7BN 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) 01284 352590 01284 352589 Suffolk County Council Mrs Mary Elizabeth Lambert Care Home 34 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (19) of places Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th January 2005 Brief Description of the Service: Davers Court is a purpose built home for older people, situated in a quiet road not far from the centre of Bury St Edmunds in Suffolk. It is a single storey building laid out around a central courtyard and has been completely refurbished and adapted to a high standard to provide care for up to 34 service users. All service users who live at the home have their own spacious bedroom, with en suite shower and toilet. The home is divided into four ‘houses’. Rosewood caters for frail older persons. Rowanwood and Pinewood accommodate older persons who have a diagnosis of dementia and consequently have a high level of dependency. Sandalwood and Barnham are designated for short-term rehabilitation and transitional care. Rehabilitation care is for service users who need a six week fixed period of care to equip them to return home. Transitional care is for service users who need care for a temporary, but unspecified length of time to consider whether a home care package, residential care or returning home is the right option for them. Davers Court is owned and managed by Suffolk County Council. Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during one day in late September, and lasted 7hrs. It was facilitated by the senior team leader, and two team leaders and two care staff contributed. A tour of the home was made, and the majority of service users were met, a group of four service users on the frail elderly unit were spoken with in more depth. Twelve service users and eleven relatives/ visitors returned pre-inspection questionnaires. What the service does well: What has improved since the last inspection? What they could do better: Documentation was not available or not complete in a number of instances. Regular supervision, in line with the standard, needs to be evidenced. Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 6 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. Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 7 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 Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 8 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, 5 Service users can expect to have the necessary information available to determine whether the home will be suitable for them, and to be admitted on the basis of an assessment of their needs. EVIDENCE: The Statement of Purpose and Service User Guides were displayed in reception. The home had confirmed that there had been no changes to the Statement of Purpose since the previous inspection, when it was judged to exceed the standard required. Two service users spoken with advised that their relatives had visited the home before they were admitted. The four service users files inspected all contained single assessments, and where applicable discharge letters from hospitals. Files also contained the homes own preadmission (STARS) assessment: in one instance this had not been summarised and completed. Copies of contracts were on service user’s files, in two of the files seen these were missing. One of these had not yet Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 9 completed the initial 6 weekly period of stay during which it is determined whether the home is suitable for them, but the other one should have been on file. A review is held, with the social worker, after the six weekly period. Records of these were not available on two of the files inspected: in both cases the service user had been admitted in May 2005, one had previously been in the transitional care unit. Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 10 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 Service users can expect to have their needs set out in an individual plan, their health needs to be met, and to be treated with care and respect. EVIDENCE: The care plans and risk assessments were generally well documented and evidenced the care needs of the service users. The files contained good personal information about service users, life histories, personal care preferences and records, other preferences such as diet and daily routines, detailed night care arrangements, leisure preferences. Full care plans based on a commonly adopted care planning format. The care plans were reviewed by key workers on a monthly basis, following a full review six weeks after admission. There was no photograph on two service user’s files inspected. One of these had been recently admitted, but the other had been at the home for several months. One of the files inspected was for a service user who had recently fallen, there was no specific risk assessment for falls on file, and the general risk assessment did not provide sufficient information of actions to be taken to Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 11 reduce risk of falling. The home subsequently advised that this service user had had two falls, and they were awaiting a G.P. visit to ascertain the reason for the fall. Another had a falls risk assessment conducted two months prior to the inspection, and in the absence of the six weekly review record being on file, there was no indication, including on the risk assessment itself, as to whether this had been reviewed. Care plans and discussion with staff indicated that the health needs of service users is carefully assessed and monitored, and appropriate intervention is sought at an early stage when problems arise. Records of GP visits and visits from other healthcare professionals, including District Nurses, and Chiropodist were kept. Each service user’s care records contained a manual handling risk assessment, a nutritional assessment, weight monitoring chart and a continence care assessment. All team leaders and 3 care staff were responsible for medication administration and had received Boots’ training. The senior team leader advised that staff who were responsible for medication were also undertaking a course at West Suffolk College on Self Management of Medications. Receipt, recording and administration practices were scrutinised. No shortfalls were identified or unexplained gaps noted on the medication administration records. There is a separate locked fridge for creams and medications that have to be kept cool. A cream with an active ingredient had, however, been left in the en-suite of a service user with dementia. Regular audits were undertaken by the Pharmacist, and a report of an audit dated 26/08/05 that did not identify any problems was seen. Service users’ medication was kept in locked cupboards in their bedrooms. Inside the cupboard there was a photograph of the service user. The home was using a dossette system for the medication. The lunchtime medication round was conducted by the senior carer attending each service users room, and obtaining the medications to take to the service users who were, with two exceptions, in the dining areas. Two service users were however having their lunch in their rooms. Cupboards were appropriately locked each time they had medication removed. Relationships between service users and staff were seen to be warm and friendly, with carers providing support and assistance in a positive, respectful and sensitive manner. This was the case with the medicine administration, where considerable patience was demonstrated. Some service users appeared to be surprised to be asked to take their medication in front of the carer, and the carer confirmed that those without dementia were not always observed. The reasoning provided was that some service users did not like to interrupt their eating to take tablets, and this did not seem unreasonable, however it is not acceptable to sign for medications until they have been observed to be Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 12 taken. The carer checked that the service user had sufficient to drink when medication was administered. Service users were very appreciative of the kindness of staff. Staff and service users confirmed that carers knock on bedroom doors and wait for an answer before entering. Keys are available for bedroom doors where service users wish. One service user said, “ you can’t find fault, you can’t. You are waited on hand and foot; if you can do things, you do them, but I get puffed and they help me.” Another said, “I don’t think you’ll find much wrong.” Relatives returning pre – inspection questionnaires indicated a high degree of satisfaction. Comments provided included: “ Fantastic place, staffed by genuine people who can’t do enough for residents and visitors alike. Should be more places run and staffed to this standard”; “ As far as my husband and I are concerned everything is A1 at all times”; “Excellent overall caring facility with exceptional attentive staff”; “ I am very happy with the way the home is run and the care my mother receives. The staff are patient and caring”. Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 13 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 Service users can be confident that their relatives and visitors will be made to feel welcome at the home, and involved appropriately in their care. Service users can also expect to enjoy a very good diet, to have their views elicited regarding the meals provided, and to enjoy themed dinners on special occasions. Some service users would benefit from more activities. EVIDENCE: Service users confirmed that entertainments and activities took place within the home. An activities worker provides activities one day a week, at other times care staff are responsible for activities on the units. They advised that they try to do something every day, but felt they could do more with additional staffing. An activities log was kept at the home. Other activities included meals and celebrations to mark special dates in the year, which the kitchen staff played an important part in, videos, reading a book with a service user. A church service is held monthly by the local Baptist church, and a communion is held fortnightly at the home. Service users returning pre – inspection questionnaires indicated that the provision of suitable activities was one the area they were not totally satisfied with. Three of the twelve indicated that Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 14 there were sometimes, but not always suitable activities, one replied that there are no activities, and another noted not sure. One recently admitted service user said that so far they felt there was enough going on, but also that on most days the TV was the main entertainment. Another service user said “ we would like more if we could have it”. All relatives/ visitors providing a pre-inspection questionnaire confirmed that they were welcome at the home, could visit their friend or relative in private, were kept informed of important matters affecting their relative / friend, and were consulted about the service user’s care if their friend or relative was not able to make decisions for themselves. Service users spoken with confirmed that they are able to receive visitors at any reasonable time, and that visitors are welcomed and may use the facilities to make themselves a cup of tea. Service users spoken with confirmed that routines are relaxed and individual choice is encouraged and supported. A specific smoking area was available for service users who wished to smoke. The main midday meal served on the day of the inspection was ham, pineapple, and fresh vegetables. Service users confirmed that it was enjoyable, and that they had a range of other choices which the kitchen staff had discussed with them. Meals are delivered from the kitchen in heated trolleys, and kitchen staff are on hand to serve the food and hear first hand any comments service users may have. Serving dishes are placed on the table to allow service users to serve themselves, and presentation is good. Service users described a range of choices that they have for breakfast: one noted that one service user likes to have a fry-up. They also spoke about how birthdays are celebrated with a cake and a buffet tea. The catering staff showed that there was a choice of 4 birthday tea menus for the person celebrating their birthday to choose from. Snacks were available at all times, including fresh fruit. Full hairdressing facilities were available for service users who wished to have their hair done on site. Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 15 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, 17, 18 Service users can be confident that their rights will be protected and that their views and complaints will be listened to and acted on. Service users can be confident that the home’s practices and training offers protection from abuse. EVIDENCE: The home uses the Social Care Services complaints procedure, and copies of this were available in the entrance hall. Four service users returning preinspection questionnaires noted that they would not know who to speak to if they were unhappy with their care, but one of these noted that they would find out if this arose. All but one of the relatives / visitors responding confirmed that they were aware of the procedure. The home keeps a log of complaints, but had not received any since the previous inspection. Service users spoken with felt that it was most unlikely that they would have to complain. One said that things get dealt with as they go along, anything that bothered them, with the carers. Service users also stated that they would have no difficulty in raising concerns with the manager, who was “very nice”. The service users spoken with confirmed that they had received postal votes for the recent general election. Information regarding a service providing free advice and guidance on all financial matters was displayed in reception. The home uses the Social Care Services Protection of Vulnerable Adults (PoVA) policy. Care staff spoken with were aware of the policy, and steps they would Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 16 need to take if they suspected abuse. Protection of Vulnerable Adults training had been part of NVQs, and had also been provided in house. Copies of CRB certificates had been obtained for the Social care team based within the home. Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 17 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 Service users can expect to live in a very clean, homely and suitable environment that they are likely to feel proud of and happy with. EVIDENCE: The entrance to the home is very well kept and attractive, and had information available for service users. Within the home there is an office for a team of workers who provide a “keeping well unit” for service users in the community. This team also uses a large communal area in the home, the function room, which has its own a toilet within the facility, 2-3 days a week to offer a service for older people who are in their own homes. This area has been separated off from the corridor by large doors, so that the impact to the residents of Daver’s Court is minimised. The home provided more than double the recommended communal space per service user. Communal space consisted of at least one lounge and one dining room on each house as well as a choice of conservatories and other general Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 18 communal areas. There would be no difficulty finding an attractive spot for service users to entertain guests in private at any given time. All bedrooms at the home were provided with en suite toilets and assisted showers. The provision of assisted showers in all en suites was in excess of National Minimum Standards. Two communal assisted bathrooms and one communal assisted shower room were available in addition to the private facilities. There were also separate assisted lavatories near to communal areas. The hoist in one of the bathrooms was not working at the time of the inspection: a new part had been ordered. Radiators are the low surface temperature type, and the temperature of hot water is carefully controlled to ensure no risk to service users. All hot water outlets within the home were fitted with thermostatic mixing valves to ensure the water was delivered at close to 43°C. A spot check of hot water temperatures at two outlets was made, and found to be satisfactory. Over half of the rooms are larger than 12 square metres, all are over 10 square metres. A large number were seen and were well furnished and personalised. Two separate lockable storage facilities were provided in each of the bedrooms, one for medications and one for personal effects. All doors were fitted the facility to be opened outwards, which would be useful if a service user was to fall against the door. A fully operational call bell system was in place with different rings for a standard call for assistance and an emergency. Floor lights were fitted in the corridors to ensure lighting levels could be kept low, yet safe at night. These had been regularly tested. The unit for people with special needs had alarms on the doors to alert staff to when service users left the unit, but were not locked. Individualised nameplates for bedroom doors incorporate meaningful visual aids, reflecting the interests of the service users. During the day, none of the service users on the unit were seen to be in any distress, though they were alert to their surroundings. There was one small smoking room, for service users – only - which had lots of green plants in it. The home was very clean, and odour free on the day of the inspection. The group of service users spoken with confirmed that the home was always very clean. Appropriate sluice and laundry facilities were in place. The home’s infection control policy did not detail laundry arrangements, although these were detailed in a generic risk assessment, and a senior spoken with was able to advise on these procedures. Several well tended and pleasant secure gardens were available for the use of service users. These gardens included water features, tables, chairs and Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 19 summerhouses. A central garden was less well tended, and some of the flagstones had gaps between them where the mortar had eroded. Plans were in place to landscape this area, using a fund awarded to the home for performance. Service users spoken to expressed much satisfaction with the home, its cleanliness and its comfort. Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Service users can expect to be cared for by a stable, motivated, and competent staff group who have received appropriate training to meet their needs. Activities provision may suffer as a consequence of the care staff being one down at times. EVIDENCE: Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 21 Scrutiny of staffing rosters and discussion with staff and service users indicated that the staffing levels at the home were based on five care staff being on duty at all times during the day, with each care staff member specifically designated to each house. The staffing structure was that each of the five units had one carer between 7.00 am and 10pm, and that a floating worker was employed between the two units catering for service users with dementia, between 7.30 am and 10 pm, with a half hour overlap between these two shifts at mid day. There was also provision for another float between one of the units for service users with dementia and a unit for frail elderly on the same basis, but this was not available on the day of the inspection, and the Inspector was advised that it had not always been possible to have a seventh worker on duty, due to long term staff sickness and a three vacancies. Three team leaders were on duty on the day of the inspection, and the Inspector was advised that there are three “most days”, to support the care staff. When there are six care staff on duty, as on the day of the inspection, this means that 15 service users with dementia have 3 carers. Staffing appeared adequate on the day of the inspection, particularly given the support provided by ancillary workers. An activities co-ordinator was employed for one day per week. Staffing levels at night were two care staff and one team leader. Ancillary staff were employed to attend to domestic, kitchen and maintenance duties, with a housekeeper designated for each unit, plus an additional one. The manager was supernumerary to all of these staff. Four personnel files for staff most recently recruited to the home. These files contained two written references, Criminal Records Bureau (CRB) Disclosure checks and photographs. Proof of identification was not on file. Records showed that in addition to all staff employed at the home, the hairdresser, chiropodist and volunteers had undertaken a CRB Disclosure checks, as had a team of Social Care workers recently based within the home. Personnel records contained evidence that new staff had attended appropriate induction and foundation training courses locally. A written record of workforce planning was provided, which showed over 50 of care staff held National Vocational Qualifications. A range of training was provided within the home, and this was evidenced by the homes diary, but no analysis of who had received this was available, with the exception of fire training. The fire training schedule showed that a number of staff, including night staff were overdue for fire safety training. The list was subsequently checked against the staff list provided in the home’s pre-inspection documentation and it was found that six members of staff detailed there were not on the fire-training schedule, and at least one of these was a night carer. Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 37, 38 The home is generally very well managed and this is evident in the interest and commitment of staff and the satisfaction of service users. Staff supervision does not currently meet the standard; the only indication that this is having an impact on service users is the lack of some completed documentation. Documentation was not in all cases complete and correct, and this presents some risks. EVIDENCE: Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 23 The manager originally trained as a nurse before moving into the care of older people in residential settings. After working as a deputy manager she became the manager of a care home in 1985 and has been the manager of Davers Court since 1996. She gained the CSS qualification in 1991, later completed the Diploma in the Management of Care Services and has also qualified as a NVQ assessor and manual handling co-ordinator. Excellent pre-inspection information was provided. A member of staff who said they had worked in a number of places over the years said that the management style was excellent “ very fair, everyone is developed. If there is something wrong it is brought up but you know where you stand, no mixed messages.” The home enjoys a relaxed and friendly atmosphere, and staff demonstrated a very positive and inclusive approach to caring for residents. Two members of care staff spoken to separately both said that they loved their jobs, and looked forward to coming to work. Staff confirmed that they had staff meetings once a month, and were able to put items of the agenda, which was posted before the meeting. Two surveys had been carried out by the home in 2005, one of relatives and one of professionals. The results of both had been collated, and an action plan devised. The home had an up to date business plan. Staff recruitment and general care records were stored securely in the manager’s office. The working care plan for each service user was kept in their private bedroom. Four staff files were inspected. Files did not contain proof of identity of staff. Records for Induction, Training, and Supervision were in place on staff files. Staff receive individual supervision, with each Team Leader taking responsibility for a group of staff. The home’s supervision policy states that “supervision may need to occur in groups, in such a case managers should ensure that individual sessions are held every 6 months.” Four staff files inspected contained supervision agreements, but three did not have sufficient records of formal supervision to meet the standard. One had 3 formal supervisions in six months, but the last was at the end of May 2005, i.e. four months prior to the inspection, another had a supervision record for April 2005 and May 2005, but again, not thereafter, a third had three in an eight month period, the most recent was up to date in this instance. The fourth file inspected had three recorded sessions in five months and was acceptable. A service user advised that they have meetings on their unit every three months or so, and that they heard what was going on in the home, for example the intention to build a special garden. Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 24 A current, up to date certificate demonstrating appropriate Employers Liability Insurance for the business was on display outside the main office. The home’s Registration Certificate and notice of the Inspection were displayed. The Statement of Purpose, Service User’s Guide and last Inspection report were available in reception. Daily records were kept of refrigerator temperatures, freezer temperatures and the temperatures of hot food. These records indicated appropriate temperatures. Food in the fridge was covered and labelled, with the exception of jellies for that evening’s puddings, which were in the process of setting. The Control of Hazardous Substances hazardous to health (CoSHH) cupboard was locked, and product sheets available. Manual handling training was evidenced on the staff files inspected. The home’s fire risk assessment had been reviewed on 3/08/05, however under fire training it stated that this was completed, which was not the case. Fire extinguishers had been serviced recently. Staff confirmed regular fire drills took place. Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 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 4 2 2 2 3 X 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 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 3 3 x x 2 2 2 Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 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 OP4OP37 Regulation 14(1) Requirement Documentation used to assess the homes ability to provide for the service users needs should be fully completed. 6 weekly reviews should be available on file in a timely manner. Evidence that risk assessments have been reviewed, as part of the monthly care plan review must be on file. Creams with active ingredients must be appropriately stored. Medication must be seen to be taken before being signed for. Staff files must contain proof of identification. Regular formal supervision must carried out and recorded, in line with the standard. Care plans must all contain a photograph of the resident. Fire training updates must be completed, with priority to night staff. The fire risk assessment must be reviewed. DS0000037636.V253355.R01.S.doc Timescale for action 31/10/05 2 3 OP5OP7OP 37 OP7 15(2) 15(2) 31/10/05 31/10/05 4 5 6 7 8 9 10 OP9OP38 OP9 OP29OP37 OP36 OP37 OP38 OP38 13(4) 13(2) 19 (1)(a) Schedule 2 18(2) 17(1)(a) Schedule 3 23(4)(d) 23(4) 27/09/05 27/09/05 31/10/05 31/12/05 31/10/05 05/10/05 31/10/05 Davers Court Version 5.0 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 3 4 5 Refer to Standard OP2 OP9 OP12 OP26 OP30 Good Practice Recommendations Residents must have a signed contract on file once their place is confirmed. The timing of the lunch time medication round should be reviewed so that service users are not required to take medications during their meals. Regular activities provided should be reviewed. The infection control policy must be developed to include domestic and laundry procedures. A training analysis and plan should be produced for all training other than NVQs. Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 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 Davers Court DS0000037636.V253355.R01.S.doc Version 5.0 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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