Inspection on 24/06/08 for Emsworth House

This inspection was carried out on 24th June 2008.

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

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

Other inspections for this house

Emsworth House 29/06/07

Emsworth House 15/11/06

Emsworth House 27/09/05

Emsworth House 24/05/05

Emsworth House 15/02/05

Emsworth House 26/10/04

Emsworth House 09/03/04

Emsworth House 18/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Emsworth House Emsworth House Close Havant Road Emsworth Hampshire PO10 7JR Lead Inspector Laurie Stride Unannounced Inspection 24th June 2008 09:15 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 Emsworth House DS0000037245.V365321.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. Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Emsworth House Address Emsworth House Close Havant Road Emsworth Hampshire PO10 7JR 01243 373016 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) Hampshire County Council Mrs Melanie Jane Brodison Care Home 79 Category(ies) of Dementia (79), Dementia - over 65 years of age registration, with number (79), Old age, not falling within any other of places category (79) Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users must be over 60 years of age on admission. Date of last inspection 29th June 2007 Brief Description of the Service: Emsworth House is a local authority care home, under the management of Hampshire County Council. The home is registered to accommodate up to seventy-nine older people, providing long stay residential or nursing care for older people as well as those with a diagnosis of dementia. The home is situated in a residential area of Emsworth, within easy access of local community and health care facilities and was renovated and refurbished in January 2007. The home is separated into two wings and the accommodation is on two floors, which are accessible by passenger lift. There are lounge/diners on each floor as well as small sitting areas in different parts of the home and there is a courtyard garden in the centre of the home. All bedrooms are single, the rooms in the nursing wing have en-suite facilities, but not those in the residential wing, there are sufficient bathrooms and lavatories on each floor. The residential wing is connected to the nursing wing on the ground floor. The fees charged range from £413.00 to £556.00 per week, with extra charges for hairdressing and personal toiletries. This information was obtained at the time of the inspection visit. Members of the public may wish to obtain more up-to-date information from the care home. Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This unannounced visit took place as part of a key inspection of this service. The visit lasted approximately seven hours during which, we (the commission), spoke with one of the people who use the service, two members of staff, the registered manager and two other members of the management team. We received survey questionnaires from five people who use the service, who had been supported to complete the survey by relatives or carers. We also received two survey questionnaires from members of staff. We also looked at samples of the records kept in the home and undertook a tour of the communal areas of the premises. Further evidence used in this report was obtained from the home’s annual quality assurance assessment (AQAA) and the previous inspection report. What the service does well: What has improved since the last inspection? Medication administration records are being properly maintained, which better protects people who use the service. Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 Page 6 Care planning is being continually improved and these now reflect the current needs of people who use the service. Files have been streamlined, making it easier for staff to access and record information. What they could do better: 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. Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 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 Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home has good systems in place to ensure that people who use the service have their needs assessed prior to moving into the home. The home does not provide intermediate care and therefore standard 6 is not applicable. EVIDENCE: The home’s annual quality assurance assessment (AQAA) states that all new residents are admitted by referral from a Care Manager whether funded or self-funding. The Registered Unit manager receives a copy of the preadmission assessment and all new residents are admitted for a six-week trial period. During this visit we looked at pre-admission assessments for two people who began using the service since the last inspection. This confirmed that potential Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 Page 9 residents’ needs are assessed by the registered manager or a senior member of staff, so that the home can be sure of meeting the person’s needs. The assessments were detailed and there was evidence that people who use the service and their relatives were encouraged to be involved in the assessment process to ensure that all relevant information is obtained. We saw that care management assessments are also asked for, or a joint assessment visit takes place. The sample of files also contained signed and dated copies of the terms and conditions of residence for each individual. Five people who use the service, who returned survey questionnaires, said they received enough information about the home before they moved in so they could decide if it was the right place for them. Emsworth House DS0000037245.V365321.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Continuing improvements in the home ensure that the health and personal care needs of people who use the service are reflected in their care plans. The home has good procedures for managing medication and the principles of respect, dignity and privacy are put into practice. EVIDENCE: The home’s Statement of Purpose states that each resident has an individual plan of care and risk assessment. The care plan is jointly agreed between the resident (and a relative, if the resident agrees) and the home. This identifies the needs of the resident and how care can be delivered to meet those individual needs. The home’s annual quality assurance assessment (AQAA) states that care plans are reviewed and, where necessary, updated on a monthly basis. A Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 Page 11 named member of the management team is responsible for checking the relevance and suitability of the current care plan. The AQAA also told us that the service is currently reviewing and revising the care planning format, to take into consideration the changing needs of people who live in the home and development of the service. During this visit we looked at samples of records from the files of six people who use the service. Day and night care plans contained information about the personal histories, strengths and abilities of each person, their social and healthcare needs. Risk assessments and care notes covering aspects of their care, such as nutrition, mobility, risk of falls and moving and handling assessments were also on file. Information in the daily records indicated that care was given in line with the individuals’ assessed needs. Visits from healthcare professionals such as the GP or chiropodist are recorded on the ‘contact’ sheets that are in each care plan. The previous inspection report identified a requirement that all care plans must reflect the current needs of people who use the service and be kept under regular review. The sample of care records we saw during this visit showed that senior staff now carry out monthly audits of care plans and the home has streamlined the current working files, making it easier to access and record information. The registered manager showed us work is in progress to update and improve the format used for care planning. Recent reviews of people’s care showed that relatives are invited to attend, where appropriate, and referrals to healthcare specialists take place as and when necessary. This meets the previous requirement. Two members of staff who completed survey questionnaires indicated that they are always given up-to-date information about the needs of the people they support or care for (for example, in the care plan). Four residents who returned survey questionnaires indicated that they usually receive the care and support they need. Four said that they always receive the medical support they need. Another said they usually do. One person who uses the service said that ‘staff are available most of the time when I need them, but on occasions due to staff shortages, (I) have had to wait a little longer than usual.’ Another two people also indicated that the staff are usually available when they need them. One said ‘sometimes’ and another said ‘always’. Two people commented that ‘ the staff here are very good.’ The manager told us that staff recruitment has recently improved. Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 Page 12 We saw that medication is stored securely and observed procedures being carried out for ordering and recording stocks of medication. Previous inspection reports had identified a requirement that records of all medication administered are maintained. During this visit we saw a sample of medication administration records in both the residential and nursing wings of the home. These showed that staff members had signed the record each time a medication had been administered. Care staff we spoke with said that they receive training about medication but do not administer, this is done by senior staff members. All medications we saw were labelled with the individuals’ name and dosages of medication given and signed for had been given as prescribed. This meets the requirement. A person who uses the service told us how staff had supported and encouraged them to regain their confidence and previous level of mobility and independence when they left hospital. This person also confirmed that staff treat people with respect and throughout the visit we observed the manager and staff treating people respectfully and in a friendly manner, and saw that individuals’ privacy is upheld. Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who use the service benefit from the structured activities in the home, which will be further enhanced by the deployment of an activities co-ordinator. The home supports people to keep in contact with their relatives. The meals offered are varied and nutritious and promote individual choice. EVIDENCE: The home’s Statement of Purpose states that regular residents meetings take place, where people who use the service are encouraged to be involved in the running of the home. This provides the opportunity to discuss what food they would like to be included on the menu and what activities they would like to be involved in. The home’s annual quality assurance assessment (AQAA) states that three full and three snack meals per day are provided, with seasonal menu planning and rotation. Fluids of choice are available on demand and residents may keep drinks and snacks in their rooms if they wish to do so. The AQAA also told us Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 Page 14 that there are plans in next 12 months to employ an activities co-ordinator, build a sensory room and purchase more activity equipment. Three residents who returned survey questionnaires said there are usually activities arranged by the home that they can take part in. One of these also commented that ‘activities are arranged but sometimes do not take place because of lack of staff.’ Another person said there are sometimes activities. Another resident indicated that there are always activities arranged ‘but I only attend the Church service.’ Two members of staff we spoke with on the residential wing confirmed that activities take place and that staff encourage individuals who want to take part. Both gave examples of how they support people to exercise choice and control over their lives. For example, involving people in planning their care and support, working to individuals’ chosen routines for getting up and having their meals in their rooms if they wish. Activities on offer in the home are detailed on the notice boards near the communal areas. People who use the service have participated with staff in putting up pictures and posters to advertise events. Activities on offer included musicians, singers and entertainers who visit the home, hair and nail care, games, raffles and discussions. There is a relatives support group who help to organise events and fund-raising for activities. The activities programme is more developed and formalised in the residential wing. The manager told us that staffing recruitment has recently improved and an activity co-ordinator is being recruited to undertake this role in the nursing wing. The manager said there are also plans to use one of the lounges specifically for activities. We saw that work has begun on a sensory room. A garden party was arranged for the coming weekend. A person who uses the service told us that their visitors are made to feel welcome in the home. They also told us that “there’s no restriction here, you can come and go as you like.” We observed other people moving around freely or choosing to spend time in their rooms, alone or with visitors. There are several sitting rooms and areas available around the home where people can go and meet their visitors in relative privacy if they did not want to talk in their bedrooms or the communal lounges. Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 Page 15 The nursing wing is divided between two floors, with people who have dementia occupying the upper floor. (The previous report identified that people living in the home have said that they feel uncomfortable about other residents wandering into their rooms during the day and at night. The manager has offered them the opportunity to move to rooms in other parts of the home, but they have declined as they like the rooms they are in. People are able to lock their doors, but choose not to, many keep them open during the day as they like to see what is happening within the home). The registered manager said that this situation is not ideal and she would prefer it if people with dementia occupied the ground floor, from where they could access the enclosed garden areas freely. However the majority of overhead tracking hoists are installed on the ground floor to assist people with limited mobility, so this is currently not an option. We observed the lunchtime meal in the residential wing and on the first floor of the nursing wing. There was a choice of meals, which were well-presented and individually served in adequate portions and included fresh vegetables. Information about individual dietary needs and preferences was available. The meal that was observed was a sociable occasion, the dining room in the residential wing is large, light and airy, with people who use the service sitting in small groups at separate tables around the room. The dining area on the other floor also provided a pleasant place to eat for those who used it, while others chose to eat in their rooms and were supported there if this was needed. Staff support was available throughout the mealtime for people who needed it and this support was provided in a discreet, respectful and sensitive manner. A person who uses the service told us that the meals are good. Three residents who returned survey questionnaires indicated that they usually like the meals at the home. One person said they always like the meals and another said they sometimes do. Emsworth House DS0000037245.V365321.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): Standards 16 & 18 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who use the service can be confident that any concerns they have will be taken seriously and acted upon. The home’s policies and procedures, backed up by regular staff training, protect people who live in the home from abuse. EVIDENCE: The home’s annual quality assurance assessment (AQAA) states that the home provides all new residents with written information on how to make a complaint. Easy access to written information on the complaints procedure is provided for family and other visitors. The service has a robust safeguarding procedure which encompasses all people who use the service and is shared with adjacent local authority services. All staff members are trained on the issues relating to safeguarding. The procedure has been reviewed and relaunched in March 2008 to take into consideration changes in legislation. We saw that the home has a complaints policy and procedure, which is displayed in the home and is also contained in the Service Users’ Guide to the service. The AQAA told us that there had been twelve complaints in the last twelve months. The registered manager keeps a record of when a complaint has been made and the details. Through looking at this and discussing some Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 Page 17 of the complaints with the manager, it was evident that peoples’ complaints are taken seriously and action is taken to address them. Three residents who returned survey questionnaires said they always know who to speak to if they are not happy. Another two said they usually know who to speak to. All confirmed that they know how to make a complaint. Four residents confirmed that staff listen and act on what they say. Another said they sometimes do. Two staff members said that they know what to do if someone has concerns about the home. A person who uses the service told us that they knew what to do if they wanted to make a complaint but has not needed to. They also confirmed that they feel safe in the home. The home has policies and procedures for safeguarding adults from abuse. We spoke to two members of staff who both confirmed they had received training in safeguarding issues, were aware of the home’s policy in this respect and would report any suspected abuse to the manager. Training records demonstrated that all staff received training on abuse issues as part of their induction as well as further, ongoing training throughout their employment. The home had informed us of an ongoing safeguarding issue, which it had reported to the appropriate authority who are jointly investigating the matter with the home’s management. Emsworth House DS0000037245.V365321.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): Standards 19 & 26 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who use the service benefit from having a clean, pleasant and comfortable environment to live in, which meets their individual needs. EVIDENCE: We undertook a tour of the communal areas of the home and were also invited to speak to one person in their private room. The decoration of the home and the furniture provided in the home are of good quality and contributed to the comfortable, homely feel in the building. On the day of the visit the home was clean and tidy. The care staff team in the home is supported by cleaners, laundry, housekeeping and kitchen staff. All bedrooms in the home provide single accommodation, the forty-eight rooms on the nursing wing have en-suite facilities and the thirty-one rooms on the Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 Page 19 residential wing have sinks, with lavatories and bathrooms in each corridor. Twenty of the bedrooms have overhead hoists in place, which makes moving those residents much easier and is more comfortable for them. The accommodation is over two floors and there is a lift to enable staff and people who use the service to move easily between the two floors. The lift is maintained regularly and was spacious enough for staff to push wheelchairs in and out of it comfortably. We spoke to one person in their room, who confirmed they had been able to bring some of their own furniture with them and also expressed how pleased they were with the room and furniture provided. The home has seven dining areas, some of which are lounge diners, and people can choose where they would like to have their meals. There are also ten lounge areas in the home, some of which are quiet rooms and do not have a television. There are also two visitors rooms, which are not used frequently and so one of these is being converted into a sensory room. The garden has several different areas for people who live in the home to use. There is a central courtyard garden that is enclosed and secure for the people who live in the home and like to wander around, it contains seating areas, flowers, shrubs and bird feeders and is visited by the local wildlife. The laundry is suitably equipped with washing machines and dryers and is well managed, with staff on duty from 8am – 8pm. Hygiene standards are maintained in order to decrease the spread of infection. There is a separate washbasin for staff to wash their hands and plastic gloves and aprons, which are also available throughout the home. There are labelled plastic baskets for people’s clothing, to reduce the risk of the wrong items being given back to individuals. Five residents who returned survey questionnaires confirmed that the home is always fresh and clean. Emsworth House DS0000037245.V365321.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): Standards 27, 28, 29 & 30 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home provides staff with training to meet the needs of people who use the service. People who live in the home are protected by the homes’ staff recruitment procedures. EVIDENCE: Two members of staff who completed survey questionnaires said there are sometimes enough staff to meet the individual needs of all the people who use the service. The registered manager confirmed the current staffing rota in place to meet people’s needs. The residential wing has an assistant duty manager with four care staff during the mornings, three care staff in the afternoons and two care staff at night. The nursing wing, lower floor, has one nurse with the same number of care staff during the day as the residential wing and two care staff with a nurse at night. The nursing wing, upper floor, has two nurses with five care staff during the mornings, four care staff in the afternoons and two care staff with a nurse at night. The manager told us that staffing recruitment has recently improved, including the employment of a cook and an activities co-ordinator. Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 Page 21 We observed staff interacting with people who live in the home in a friendly and respectful manner. A person who uses the service told us “all the staff are wonderful. Nothing is too much.” The homes’ annual quality assurance assessment (AQAA) stated that all staff had satisfactory pre-employment checks. Further evidence of this was seen at the time of our visit through inspecting a sample of two staff members’ recruitment records. These files contained the required information, such as dates of employment and completed job application forms, two written references and evidence of satisfactory Protection of Vulnerable Adults (POVA) and Criminal Records Bureau (CRB) checks. One of these staff members had been recruited very recently and the rota clearly showed that they were working on a supernumerary and supervised basis while awaiting the clearance of their CRB check. This demonstrates that people who use the service are being protected. The two members of staff who completed survey questionnaires confirmed that their employer carried out checks, such as their CRB and references, before they started work. One said that their induction covered mostly everything they needed to know to do the job when they started. The other said the induction covered everything very well. Both said that they are being given training which is relevant to their role, helps them to understand and meet people’s individual needs, and keeps them up to date with new ways of working. We saw that the home has a training programme and structured induction process and two staff members we spoke to during our visit expressed the view that the training provided is good. The sample of training records we saw indicated that all staff had attended or were scheduled to attend mandatory training such as moving and handling, fire safety, first aid, food hygiene and infection control. Other training included medication, safeguarding and National Vocational Qualifications (NVQ). The AQAA informed us that the home had also recently introduced training in end of life planning. Due to movement within the staff team, not all relevant staff members currently have received dementia training and the manager said plans were in place to improve on this. The manager is also working on improving the planning for the induction of new staff, as access to the local authority programme can be affected depending on the dates when new staff members start work. We saw records showing that staff members receive regular formal one-to-one supervision, which was further confirmed by talking with two of the staff team. Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 Page 22 Two staff members who completed the survey also said that their manager meets with them regularly or often to give them support and discuss how they are working. Both staff members said that they usually feel they have the right support, experience and knowledge to meet the different needs of people who use the service. Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 & 38 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People using the service benefit through the good management of the service. The home is run in the best interests of the people who use the service and their health and welfare are protected. EVIDENCE: The registered manager is well qualified and has many years experience of nursing and management in nursing and residential homes. Mrs Melanie Brodison is supported by 4 assistant unit managers in the residential wing and 3 senior nurses in the nursing unit, who in turn supervise the nursing and care staff. Throughout our inspection visit, the manager was open and responsive to people who use the service, visitors and staff. Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 Page 24 The home’s annual quality assurance assessment (AQAA) states that by use of a 12 monthly questionnaire, the service seek the views of residents regarding the facilities within the home and their level of satisfaction with the service provided. Questionnaires are completed anonymously wherever possible, analysed within house and results are posted on the residents notice board. Results are also provided to residents individually if required. The AQAA also tells us that there are plans within the next 12 months to increase the frequency of service user surveys to 6 monthly to improve service response time to any issues that arise. We saw that a report had been made available in relation to the results of the previous years quality survey. The manager informed us that managers working groups are currently developing improved questionnaires, including a staff survey tool. We saw that records were kept of residents’ meetings and those for the relatives support group meetings. A person who uses the service told us that they could attend monthly residents’ meetings and that they felt free to speak openly. We also saw records showing that representatives of the service provider carry out Regulation 26 quality monitoring visits. The manager informed us that the majority of people who use the service deal with their own finances, assisted by their relatives and representatives. The home keeps records of personal monies it looks after in relation to two individuals. We saw that the storage arrangements are secure and that the records are clear and up-to-date. We saw evidence that safe working practices are promoted and maintained within the home. Staff members receive regular health and safety related training and workplace risk assessments were in place and kept up-to-date. Records showed that equipment such as gas appliances, lifts, hoists and fire safety systems are regularly checked and serviced. Emsworth House DS0000037245.V365321.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 X X X X X 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 Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 Good Practice Recommendations Emsworth House DS0000037245.V365321.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone 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. 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