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Inspection on 06/09/06 for Denewood House Care Home

Also see our care home review for Denewood House Care Home for more information

This inspection was carried out on 6th September 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Although not directly assessed during this visit, previous inspection have evidenced that appropriate information is provided to residents prior to admission ion order that they can make an informed decision about moving to the home, all residents have an assessment of need before making this decision so the home can be sure it has the staff and services to meet specific, individual need. Following assessment, a care plan is written with the resident and their representative to ensure that staff at the home have sufficient instruction in order that those needs can be met. Visiting GP`s, district nurses, chiropodists etc meet resident`s health care needs. Medication is well managed although one error needs to be dealt with, the registered manager and deputy confirmed that the staff member responsible would be spoken with. The error noted did not have detrimental effect to any resident and generally, residents can be assured that good medication systems are in place. Organised social activity is limited although it was evident through discussion with residents that they were generally content in being able to organise their own leisure time with books, newspapers and television and friends and family are able to visit freely. Meals provided for residents are good and a variety of dishes are served from a set menu which is subject to regular changes and seasonal variations. Should any resident or their relative have any concerns or complaints they can be confident these will be managed effectively as a written complaints procedure outlines the procedure for making a complaint and the way in which it will be resolved and responded to. The correct policy is in place informing staff of procedures necessary should any allegations of abuse or neglect be suspected or reported, some revisions are needed to the internal procedure to ensure conflicting information is not provided, staff have received training in adult protection and abuse issues. Denewood House provides a good standard of accommodation that is clean and well maintained and residents` benefit from private rooms where they can have some of their own belongings around them, well presented communal areas and satisfactory bathroom and toilet facilities. Enough staff are employed and on duty at any given time to meet residents needs and provide the expected level of support. Staff are safely recruited ensuring appropriate vetting procedures so the registered persons can be satisfied that they are suitable for working with older people and various optional and mandatory training is provided. Caroline Bleach manages the home well with the support of a competent deputy. Good procedures are in place to assist residents with the management of their personal finances if they choose. Health and safety process in the home ensure the safety of residents, staff and the premises

What has improved since the last inspection?

One requirement of the last inspection has been addressed concerning fire safety training for staff. Five good practice recommendations were also made at the last inspection, of these, one has been repeated and four have been addressed.

CARE HOMES FOR OLDER PEOPLE Denewood House Care Home 12-14 Denewood Road West Moors Ferndown Dorset BH22 0LX Lead Inspector Jo Palmer Key Unannounced Inspection 10:00 6 September 2006 th 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 DS0000061333.V310853.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. DS0000061333.V310853.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Denewood House Care Home Address 12-14 Denewood Road West Moors Ferndown Dorset BH22 0LX 01202 892008 01258 841255 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) Samily Care Ltd Mrs Caroline Anne Bleach Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places DS0000061333.V310853.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th November 2005 Brief Description of the Service: Denewood House is a detached house in a residential area of West Moors, local shops, churches, pubs and a library are available close by following a level walk. The home is registered with the Commission for Social Care Inspection to accommodate a maximum of 21 older people. It is privately owned by Samily Care Ltd and managed by Mrs Bleach. The bedrooms are located on the ground and first floors. There are two double bedrooms and 17 single rooms. The home does not have a passenger lift but a stair lift operates to the first floor. Due to the layout of the home the service users are assessed on admission to determine that they are independently mobile. Public transport is available from outside the premises. The rear garden has seating available for service users; some of the rooms have patio doors opening out to the garden. DS0000061333.V310853.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection on 6th September 2006 lasted for five hours. Caroline Bleach, Registered Manager was not on duty although arrived for the second half of the inspection; the assistant manager was present throughout and competently assisted with the inspection. The inspector spoke with five residents and three members of staff, examined relevant records and took a tour of the premises. This was a ‘key’ inspection where the home’s performance against the key National Minimum Standards was assessed along with progress in meeting the one requirement of the last inspection. A pre-inspection questionnaire was sent to the manager in order that certain information could be provided, questionnaires were also sent to the home prior to the inspection to be distributed to residents, relatives and visiting health care professionals. The pre-inspection questionnaire had not been returned to inform the inspection. At the time of writing the report, fifteen questionnaires had been received from residents, three from GP’s, five from health care professionals and fourteen from relatives; their comments are included as relevant throughout this report. What the service does well: Although not directly assessed during this visit, previous inspection have evidenced that appropriate information is provided to residents prior to admission ion order that they can make an informed decision about moving to the home, all residents have an assessment of need before making this decision so the home can be sure it has the staff and services to meet specific, individual need. Following assessment, a care plan is written with the resident and their representative to ensure that staff at the home have sufficient instruction in order that those needs can be met. Visiting GP’s, district nurses, chiropodists etc meet resident’s health care needs. Medication is well managed although one error needs to be dealt with, the registered manager and deputy confirmed that the staff member responsible would be spoken with. The error noted did not have detrimental effect to any resident and generally, residents can be assured that good medication systems are in place. Organised social activity is limited although it was evident through discussion with residents that they were generally content in being able to organise their own leisure time with books, newspapers and television and friends and family are able to visit freely. DS0000061333.V310853.R01.S.doc Version 5.2 Page 6 Meals provided for residents are good and a variety of dishes are served from a set menu which is subject to regular changes and seasonal variations. Should any resident or their relative have any concerns or complaints they can be confident these will be managed effectively as a written complaints procedure outlines the procedure for making a complaint and the way in which it will be resolved and responded to. The correct policy is in place informing staff of procedures necessary should any allegations of abuse or neglect be suspected or reported, some revisions are needed to the internal procedure to ensure conflicting information is not provided, staff have received training in adult protection and abuse issues. Denewood House provides a good standard of accommodation that is clean and well maintained and residents’ benefit from private rooms where they can have some of their own belongings around them, well presented communal areas and satisfactory bathroom and toilet facilities. Enough staff are employed and on duty at any given time to meet residents needs and provide the expected level of support. Staff are safely recruited ensuring appropriate vetting procedures so the registered persons can be satisfied that they are suitable for working with older people and various optional and mandatory training is provided. Caroline Bleach manages the home well with the support of a competent deputy. Good procedures are in place to assist residents with the management of their personal finances if they choose. Health and safety process in the home ensure the safety of residents, staff and the premises What has improved since the last inspection? What they could do better: There are no statutory requirements as a result of this inspection, Denewood House has developed good systems to ensure the health, welfare and safety of residents. Two good practice recommendations have been made, one repeated from the last inspection. It remains a recommendation that hot surfaces are guarded to prevent accidental scalding. The second recommendation concerns care planning and ensuring that staff have clear instruction regarding specific health care procedures and that these instruction should be based on good advice from the district nursing team. Please contact the provider for advice of actions taken in response to this DS0000061333.V310853.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000061333.V310853.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 DS0000061333.V310853.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 is not applicable) Quality in this outcome area is good; this judgement is made using available evidence. The admissions process is such that it ensures resident’s needs are assessed prior to admission to ensure the home is able to meet their needs and provide the services they require. EVIDENCE: Three resident care files were examined, two for recent admissions to the home. It was evident that each person’s care needs had been assessed prior to him or her moving to the home. Either the manager or senior staff member will visit the resident prior to admission for the purpose of this assessment and will identify, with the help of the resident and their representative, what the persons needs are and whether Denewood House has sufficient resources to meet them. Assessments examined detailed each person’s personal care needs, physical needs including continence, mobility, diet and skin care and psychological and emotional needs including communication and mental state. Either the resident or their representative signs assessments where possible to indicate they agree with the identified care outcomes. DS0000061333.V310853.R01.S.doc Version 5.2 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 Quality in this outcome area is good; this judgement is made using available evidence. Care plans provide sufficient detail for staff to be aware of resident’s health and welfare needs and how to meet them although some need developing with regard to specific care routines to ensure the best interests of residents are safeguarded. Most medicines were being given as prescribed and recorded appropriately although attention is needed to ensure all records are accurately maintained to enable effective audit of medication usage in the interests of residents. Resident’s rights to privacy are supported through care delivery, relationships with staff and confidential record keeping practices. EVIDENCE: Care plans examined detailed how needs are to be met in relation to personal care, physical and mental health and social care. It was evident that resident’s needs are considered individually and care plans reflect personal choices such as their preferred time of waking, daily routines, likes and dislikes. Based on a DS0000061333.V310853.R01.S.doc Version 5.2 Page 11 pre-admission assessment, the care plan is drawn up along with an appropriate risk assessment where necessary. Care plans and risk assessments identify the action needed by staff to meet needs and reduce risks. The deputy manager has spent considerable time and effort in developing an effective care planning system although must now work to ensure all reviews are undertaken at appropriate intervals. Where residents have specific health needs, the care plans need to be developed to ensure staff are aware of the action to be taken to maintain good health and welfare, for example: where residents have catheter care needs, the care plan needs to instruct on care and cleaning of the catheter site. Similarly, where residents are receiving wound care from the district nursing service, staff at the home need to be aware, through written instruction, of management of the wound site between the nurses visits to prevent the introduction of infection to the wound; these instructions must be referenced to care tasks for bathing and personal care to ensure the dressings do not become damaged during everyday care routines. Care records detailed that resident’s health care needs were being met by community based health care professionals, records indicate when GP’s, chiropodist, district nurses etc. have been involved with residents. Five comment cards were returned from visiting health care professionals and all had positive comments about the conduct of the home although four returned cards responded with comments stating that the staff were sometimes a bit ‘over zealous’ in calling for a district nurse to attend a resident for what was considered a ‘minor’ ailment. Medication in the home is generally well managed although some anomalies were noted with regard to one specific date where the evening does of medication for resident’s were omitted. The registered persons are strongly advised to ensure that the member of staff on duty that day (as identified from the staff rota) is spoken with to ensure the error does not reoccur and that all medication continues to be given as prescribed. Five residents were spoken with all of whom confirmed they are treated respectfully by a caring staff group who are able to meet their needs in the manner to which they expect. Residents confirmed that their privacy is respected in their rooms and when receiving assistance with personal care routines. All 14 relatives who responded to questionnaires confirmed that they are able to see their relative in private and additional comments received from residents on returned questionnaires included: ‘Staff are very attentive, always cooperative and understanding, treated with respect, …it is a happy place to be’. ‘Generally happy with the home and most staff are kind and helpful’. ‘Some staff are a bit bossy’. DS0000061333.V310853.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is good, this judgement is made using available evidence including a visit to this service. Social care assessments provide staff with basic information concerning individual social and leisure choices and residents were content with the homes social arrangements. Residents are supported in maintaining contact with their friends and family and in making decisions about their lives in the home. Residents are provided with a varied menu and choices of meals that meet their dietary needs. EVIDENCE: A written schedule of activities, or ‘activities programme’ was not examined although it was evident from discussion with residents that they were generally satisfied with the level of activity in the home although on returned questionnaires, in answer to the question ‘Are there activities arranged in the home that you can take part in?’ 4 said ‘always’, 3 said ‘usually’ and 8 said ‘sometimes’. However, those spoken with were happy with the arrangements and were able to enjoy books, magazines and newspapers and visits from friends and family. DS0000061333.V310853.R01.S.doc Version 5.2 Page 13 Assessments and care plans demonstrate the extent to which residents individual social and leisure preferences have been taken into account, it was also evident from care documentation the extent of family involvement and residents confirmed they are able to receive visitors freely. Some residents confirmed that they are able to get out with the support of their families to visit local places of interest and to socialise. Residents confirmed that they are able to make decisions and choices and retain some control over their lives confirming that they can get up and go to bed when they please, move freely about the home, form and maintain friendships and are involved in decisions about their care. Discussion with residents confirmed that a variety of appetising meals are provided, those residents not wanting the set midday meal are at liberty to have an alternative and this was confirmed by the cook who said a variety of alternatives are available; Breakfasts are served by individual choice and the evening meal consists of a lighter dish such as sandwiches, soup, salad etc. The cook confirmed that menus are changed regularly in accordance with seasonal variations. The cook confirmed that there are plentiful supplies from which to prepare meals and that the registered providers are very good at buying in what is necessary and extras if residents want something special. Of 15 questionnaires returned from residents 6 confirmed that they ‘always’ like the meals, 6 ‘usually’ like them and one does ‘sometimes’. Comments received from residents on questionnaires included ‘Bored with brown bread sandwiches for breakfast, would like a change, more choices – porridge’, and ‘meals are sometimes not to my taste’. Although residents spoken with confirmed that they enjoyed the meals, the deputy manager said that as a result of these comments she would speak to residents to ensure their views, tastes and preferences are taken into consideration when preparing menus. DS0000061333.V310853.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good, this judgement is made using available evidence including a visit to this service. Any person wishing to complain is directed through a written procedure detailing how their concerns will be addressed, they can therefore be confident that their complaints will be listened to and taken seriously. Procedures for responding to suspicions of abuse are held in accordance with Department of Health guidance, meaning that any allegations of abuse can be managed effectively. EVIDENCE: The homes Statement of Purpose and Service User Guide (standard 1) were not reviewed at this inspection although the last inspection reported that information was provided as required; Mrs Bleach confirmed that this has not changed since the last inspection. The Service User Guide contains the home’s complaints procedure, which is available to all residents and their representatives; of 14 questionnaires returned from relatives 11 indicated that they knew how to make a complaint should they need to. Mrs Bleach confirmed that one minor complaint had been received since the last inspection; this had been appropriately logged detailing how the complaint had been resolved. Mrs Bleach confirmed that the policy referring to adult protection procedures is available, as reported at the last inspection, no revisions or amendments have been made to this policy which was satisfactory. Staff receive training in adult protection related issues during their induction training. DS0000061333.V310853.R01.S.doc Version 5.2 Page 15 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, 21, 23, 24, 25 & 26 Quality in this outcome area is good. This judgement is made using available evidence including a visit to this service. Accommodation at Denewood House is safe and well maintained. Residents are able to benefit from comfortable, well furnished, clean and hygienic surroundings with some of their own belongings around them. EVIDENCE: There was evidence of regular servicing of equipment (see standard 38). There are sufficient bathing and toilet facilities sited around the home which are provided with appropriate aids and adaptations to meet residents needs. The home is reasonable decorated although one area of the first floor corridor is in the process of redecoration with the walls currently striped to the plaster. Resident’s rooms are comfortable and furnished appropriately and residents are able to benefit from having some of their own belongings around them. The lounge and dining areas of the home provide a sociable meeting place for residents. DS0000061333.V310853.R01.S.doc Version 5.2 Page 16 The home was appropriately ventilated and a reasonable temperature, Radiators and exposed pipe-work are not all guarded to prevent accidental scalding although risk assessments are in place for individual residents to identify any necessary control measures needed to secure against the risk of accidental scalding when the heating is on in colder weather. All areas of the home visited were clean and free from offensive odours, questionnaires returned from relatives included the comment that the ‘general cleanliness, often have to ask for the floor to be cleaned, toilet likewise, table top to be wiped of sticky marks, rooms do not appear to be cleaned on a daily basis’. Of 15 questionnaires returned from residents, 10 confirmed that eh home is ‘always’ fresh and clean, 3 that it is ‘usually’ and 1 that it is ‘sometimes’ fresh and clean. Other comments included ‘it is very much a homely home’ and ‘very homely, comfortable and clean’. Staff are provided with appropriate hand washing facilities including antibacterial soap, disposable towels and an alcohol based hand sanitizer. The laundry room was not inspected although it was evident from observations of residents dress and bedding that the laundry service is effective, residents spoken with confirmed that their laundry is done quickly and is returned in good condition. Standard 22 was not assessed although Mrs Bleach confirmed that following a recommendation of the last inspection, an assessment of the premises by a qualified occupational therapist was being carried out on 11th September, this will be examined at the next inspection of Denewood House. DS0000061333.V310853.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement is made using available evidence including a visit to this service. There are sufficient numbers of staff on duty in the home each day and night to provide the level of care and support needed by residents. Staff training programmes are developing to ensure that the staff group develop their skills and knowledge to meet resident’s needs. Staff recruitment practices are good and ensure resident’s safety with all staff being appropriately screened prior to taking up employment. EVIDENCE: There are sufficient numbers of staff on duty for each shift with between 4 and 5 carers on each morning, three each afternoon and 2 each night. Additionally, the registered manager and deputy manager are available in the home at varying times throughout the week, if both are off duty, one is always on call as shown on the rota. 14 questionnaires were retuned from relatives 13 of whom confirmed that they felt there were sufficient numbers of staff on duty, 1 declined to comment. Of 15 residents who responded to questionnaires, 11 said they ‘always’ receive the support and care that they need and 4 said they ‘usually’ do, 9 said staff are always available when needed, 5 said staff are ‘usually’ available and 1 said staff are ‘sometimes’. DS0000061333.V310853.R01.S.doc Version 5.2 Page 18 Four members of care staff have attained NVQ level 2 in care, all staff attend various training courses relevant to their roles including infection control, moving and handling, food hygiene and care specific course as they become available. Two staff files were examined, both staff had been recruited following the homes procedure. On each staff file was an application form detailing previous employment and qualifications and providing referees. Each staff had made a declaration of health and each file held two satisfactory references, one form the applicant’s last employer. Both applicants had applied for and received, satisfactory CRB* and POVA* certificates. Evidence of the applicants identification were held on each file. Mrs Bleach confirmed that the home’s induction programme is being revised, two recent employees have attained certificates of induction from their previous employer with confirmation that the training met the National Training Organisation (NTO) workforce training targets for care staff, both staff received a basic in-house induction and orientation at Denewood House. Mrs Bleach said she was looking into the possibility of buying in training for the home’s own NTO standard induction training. * Criminal Records Bureau and Protection Of Vulnerable Adults - The CRB check includes a check against the POVA list to ensure the person applying for the position has not been excluded from working with vulnerable people. DS0000061333.V310853.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement is made using available evidence including a visit to this service. Denewood House is managed effectively and in the best interests of residents. Quality assurance processes are developing although to ensure controlled measurement of care and services provided these need further development. Residents are safeguarded by good procedures for managing their personal financial affairs with support of the home and their families. The health and safety of residents is protected by procedures ensuring that equipment is checked and maintained. EVIDENCE: Caroline Bleach is registered with the Commission to manage the home on a daily basis for Samily Care Ltd, Mr & Mrs Bleach are owners of Samily Care Ltd. Mrs Bleach hands much of the management responsibility over to her deputy DS0000061333.V310853.R01.S.doc Version 5.2 Page 20 manager who has nearly finished the NVQ level 4 in care and the Registered Managers Award, although Mrs Bleach maintains a daily oversight of the running of the home. Staff and residents spoken with confirmed that the home is well managed and either Mrs Bleach or her deputy is always available for support and advice. One questionnaire returned from a relative stated that: ‘Caroline especially was very professional when we first enquired and is always friendly’. Quality assurance plans were not reviewed although discussion with the deputy manager informed that questionnaires have been sent to residents and relatives although responses have not lead to a thorough quality review or development plan. On 1st April 2006 a change in the regulation introduces a legal requirement for registered providers to produce an Annual Quality Assurance Assessment (AQAA), this will be introduced to care homes in autumn 2006. Although the Commission will introduce a set proforma it would be considered good practice for the registered persons to consider in a development plan, how well in their estimation, they deliver good outcomes for residents at Denewood House including where improvements can be made and what action will be taken to respond to any requirements and recommendations of inspection. Denewood House assists some of the residents with the management of their personal finances with the support of their families or representatives. Records seen demonstrate any money received on behalf of the resident, expenses and the balance of funds held. Records audited accurately with balances, which are held securely, and individually for each resident. No excessive amounts of cash are held. Examination of records of testing and maintenance of alarm system, fire doors and exits, smoke detectors, emergency lighting and fire fighting equipment demonstrated that these are being undertaken at the required intervals. A service contract is in place demonstrating the required level of maintenance of the fire warning system, emergency lighting and fire fighting equipment. A contracted engineer has carried out a fire risk assessment. A requirement of the last inspection dated November 2005 that staff receive fire safety/awareness training within the given time-scales had been addressed with all staff receiving appropriate training in February and March 2006. However, at the date of this inspection, seven months since February 2006, again, staff training had lapsed. Mrs bleach confirmed that training was arranged for the following week and all staff would attend. Between the dates of inspection and writing the report, written confirmation has been received from Mrs Bleach that all staff are now up to date with the required level of fire training. DS0000061333.V310853.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 X 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 DS0000061333.V310853.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard OP7 OP25 Good Practice Recommendations Care plans referring to wound care and catheter care should be developed and cross referenced to other care plans detailing how personal care needs are to be met in respect of these. It is recommended that all radiators and hot surfaces are guarded to prevent against accidental scalding. 1. 2. DS0000061333.V310853.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000061333.V310853.R01.S.doc Version 5.2 Page 24 - 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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