Inspection on 15/12/08 for Evelyn May House

This inspection was carried out on 15th December 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Evelyn May House 18/12/07

Evelyn May House 10/01/07

Evelyn May House 18/10/05

Evelyn May House 03/05/05

Evelyn May House 21/02/05

Evelyn May House 09/08/04

Evelyn May House 25/02/04

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 27/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Evelyn May House Florence Way Langdon Hills Basildon Essex SS16 6AJ     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Michelle Love     Date: 1 5 1 2 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 32 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home Name of care home: Address: Evelyn May House Florence Way Langdon Hills Basildon Essex SS16 6AJ 01268418683 01268543952 evelyn.may@runwoodhomes.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Ms Rumbidzai Mercy Mahupete Type of registration: Number of places registered: Runwood Homes Plc care home 59 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The number of service users for whom personal care is to be provided shall not exceed 59 Date of last inspection Brief description of the care home Evelyn May is a purpose built establishment providing care for up to 59 older people. The registration category permits the home to provide care for those people who have a formal diagnosis of dementia. The home has three floors and each floor is unitised. All bedrooms are for single occupancy and have en suite facilities. Each floor has bathrooms, toilets and lounge/dining areas. The home is situated in the Langdon Hills area of Basildon and is in reasonable distance to/from local community services and amenities. The home has a large adjacent car park. There is limited garden/patio areas surrounding the home. Evelyn May has a statement of purpose and service users guide Care Homes for Older People Page 4 of 32 Over 65 0 59 59 0 Brief description of the care home available. Information about the home and most recent inspection report are available to residents/visitors in the lobby area of the home. Copies of the homes Service Users Guide were also provided in many of the bedrooms around the home The weekly fees are #425.95 to #476.28 for those people funded by a local authority and #590.00 for a private placement. There are additional charges for chiropody, hairdressing, personal items and newspapers/magazines. Care Homes for Older People Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced key inspection. The visit took place over one day by two inspectors and lasted a total of 10 hours, with all key standards inspected. Additionally, the managers progress against previous requirements from the last key inspection was also inspected. Prior to this inspection, the registered provider had submitted an Annual Quality Assurance Assessment. This is a self-assessment document detailing what the home does well, what could be done better and what needs improving. As part of the process a number of records relating to residents, care staff and the general running of the home were examined. Additionally a partial tour of the premises was undertaken, residents and members of staff were spoken with and their comments are used Care Homes for Older People Page 6 of 32 throughout the main text of the report. Surveys for staff, relatives and healthcare professionals were forwarded to the home for distribution. Where surveys have been returned to us, comments have been incorporated into the main text of the report. The manager, deputy manager and other members of the staff team assisted both inspectors on the day of the inspection. Feedback on the inspection findings were given throughout and summarised at the end of the day with both the manager, deputy manager and operations manager. The opportunity for discussion and/or clarification was given. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. Care Homes for Older People Page 8 of 32 The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 32 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective people have the information they need to make an informed choice about where to live. People cannot be assured that their needs will be fully assessed. Evidence: There is a Statement of Purpose and Service Users Guide in place at Evelyn May. This provides specific information about the service so that prospective residents and other interested parties have the information they need to make an informed choice as to whether or not this is the right care home for them. The AQAA details under the heading of what we do well, brochure and comprehensive information leaflet relating to the home is available and the Service Users Guide is given to all residents. It also details that within the next 12 months, more customer satisfaction surveys are to be provided, especially for new people admitted to the care home. This will enable the management team of the home/registered provider to gauge as to whether or not the admission process is appropriate. Surveys returned to us from relatives recorded that Care Homes for Older People Page 11 of 32 Evidence: people felt they had sufficient information about the service. There is a formal pre admission assessment format and procedure in place, so as to ensure that the staff team are able to meet the prospective residents needs. In addition to the formal assessment procedure, supplementary information is sought from the individual residents placing authority and/or hospital. As part of the inspection process, three care files for the newest people to be admitted to Evelyn May were examined. These showed that pre admission assessments were completed prior to the persons admittance to the care home. Pre admission assessments for 2 people were noted to be informative and detailed, however the assessment for one person was observed to be poorly completed with 9 sections of the assessment document not completed. Additionally, care must be taken to ensure that information recorded within the pre admission assessment and placing authority assessment are transferred to the individuals care plan. For example the pre admission assessment and placing authority assessment for one person detailed them as having a poor swallowing reflex and requiring supervision and encouragement to eat. On inspection of the persons care file, no information was recorded in relation to the above requirements. Records showed that the prospective resident and/or their next of kin was offered the opportunity to visit the care home prior to admission and where possible both the resident and/or their representative were involved in the admission process. Evelyn May does not provide intermediate care. Care Homes for Older People Page 12 of 32 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot be fully assured that their assessed needs will be reflected within their individual plan of care. Medication practices and procedures were generally sound. Evidence: As part of this inspection a random sample of 7 care files were examined. Records show there is a formal care planning system in place to help staff identify the care needs of individual residents and to specify how these needs are to be met by care staff. Additionally, formal assessments relating to dependency, manual handling, nutrition, falls, dementia and pressure area care are completed for individual people. Where possible life stories are compiled with the individual person and/or their representative. Care records showed that further development of the care planning and risk assessment process is required as there are some inconsistencies in staff recording. Shortfalls identified, potentially place people at risk of not having all of their care needs met and provides staff with inaccurate and not up to date information about Care Homes for Older People Page 13 of 32 Evidence: individual people. There was evidence to show in some cases that actual delivery of care is not always provided in line with individuals specific care needs. The care file for one person (pre admission assessment/placing authority assessment) recorded them as being at risk of falls and being unsteady on their feet. A formal falls risk assessment had been completed and this recorded the person as being at very high risk. It was positive to note that following recent falls, the person had been formally reassessed. However, the risk assessment did not clearly identify the steps to be taken to minimise the above risk and there was evidence throughout the morning of the inspection that actual care delivery for the resident pertaining to falls was not provided in line with their plan of care. The care plan recorded staff to monitor constantly [name of resident] and give assistance when mobilising. There were several occasions during the morning when the lounge/dining area was left unsupervised by staff, the person was observed to stand up and mobilise within this area without staff support and on two occasions the person was observed to be assisted to walk along the corridor by another resident. Information within the persons care file (placing authority assessment) also recorded them as becoming agitated when having personal hygiene tasks undertaken. This was not recorded as part of their plan of care and no risk assessment was devised. Additionally information was recorded detailing that the person required encouragement to eat, was reluctant to eat and needed supervision as they avoid eating. No plan of care/risk assessment was recorded pertaining to their specific dietary needs and on observing the lunchtime meal, little assistance/verbal encouragement was provided by care staff. The care file for one person recorded them as having prescribed PRN (as and when required) medication administered at times of agitation and anxiety. A detailed plan of care was available pertaining to their agitation/inappropriate behaviours and there was sufficient evidence to show this had been regularly reviewed and updated to reflect their current care needs. However records when cross referenced with Medication Administration Records (MAR), showed no clear rationale in some instances as to why the medication had been administered. Additionally behavioural charts to record behaviours exhibited, actual care delivery by care staff and outcomes were not always available. This was highlighted and discussed with the manager/deputy manager at the time of the inspection. The care file for another person was examined. This made reference to only four areas relating to the individuals memory loss/depression, personal care, social activities and night care plan. No other elements were completed and some of the above areas lacked specific detail. For example the care plan made reference to their memory loss/depression, but there was no specific information recorded as to how this impacts on the persons activities of daily living. Care Homes for Older People Page 14 of 32 Evidence: The AQAA details that care plans within the home are comprehensive and that staff have received training in June 2008 pertaining to care planning. Relatives surveys returned to us generally recorded positive outcomes in relation to Evelyn May meeting their member of familys care needs. Comments included, they have catered for [name of resident] needs in all respects and they are quite happy there. Another relative spoken with confirmed that their member of family was well cared for. Staff surveys returned to us recorded that information about new residents/changes to existing residents needs are passed to staff via the care team leader. Staff interaction with residents was observed within each of the 3 floors. Interactions varied from floor to floor with some positive interactions whereby people were observed to have their rights respected and promoted. In contrast, there were occasions whereby residents were ignored, people were not spoken with and routines within the home were not observed to be flexible and were arranged around care staff and tasks e.g. people were observed to ask for a cup of tea and/or some more toast, however people were advised, youve just had and in a minute (the latter not provided). Another resident was overheard to ask to go to the toilet at 09.45 a.m. and again at 11.00 a.m. The member of staff was heard to say, theres no one to take you, youve just been. The resident was seen to give up and to sit back down. In general terms staff spoken with were able to demonstrate an understanding of individual peoples care needs. When feedback was given to both the manager and deputy manager, we were advised by the management team, that they were aware that some staff were not working well cohesively as a team. People living at the care home have access to a range of healthcare professionals and services, and these include, GP, Chiropodist, District Nurse Services, Community Psychiatric Nurse, Optician etc. One healthcare professional spoken with at the time of the inspection advised that staff are generally proactive in dealing with individuals healthcare issues and where instructions are provided, staff generally follow these. The majority of medication is managed through a monitored dosage system (blister pack). Administration of medication to residents was observed during the morning and lunchtime period within one floor. Actual administration to residents was seen to be satisfactory, however during the morning the trolley was observed to be left open and unattended with medication easily accessible. Whilst we recognise that the care team leader did not leave the lounge/dining area, one resident was observed to go up to the open trolley and to stand next to the open trolley. Medication records were inspected on two floors, and these were seen to be up to date and managed appropriately. Although the room temperatures were seen to be Care Homes for Older People Page 15 of 32 Evidence: appropriate and within recommended levels on both floors, the fridge temperatures on the middle floor were on occasions above the recommended levels. Staff training records showed that all staff who administer medication have up to date training and regular competency assessments. In addition there was evidence to show that weekly medication audits are undertaken. Care Homes for Older People Page 16 of 32 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A range of activities were provided for service users living in the home, both in-house as well as in the local community. However not all of the activities provided were suitable to meet the needs or expectations of all of the service users in residence. The dining experience for some people within the care home needs to be improved so as to ensure positive outcomes. Evidence: The home employs two activities co-ordinators one full -time and one part-time who between them work five days a week. Discussion with the two co-ordinators indicated that they were provided with the necessary equipment to enable them to carry out their roles. They were seen to have access to an activities storage room that was seen to be equipped with a variety of activity equipment, they also both spoke of having access to an activities budget which they were able to use to purchase new equipment and facilitate community based activities. The home was split into three floors with the less able service users being accommodated on the second and top floors. Activity programmes were posted on the notice board in the foyer of the home as well as on the notice boards outside of the Care Homes for Older People Page 17 of 32 Evidence: dining rooms on each floor. The programme for the week commencing 14th December 2008 was seen and indicated the following activities taking place: church visits, church party, manicure and hand rubs, paper debate, carol singing, bingo session, quiz, craft session reminiscence sessions and an Xmas coffee morning. All of the programmes displayed were in both written and pictorial format to assist those who were less able to be able to understand the content. Discussion took place with three service users who were residing on the ground floor (Camellia) all of who spoke positively about the range of activities that were provided by the home. One service user spoken with had an interest in drawing and was keen to show the inspector a mural that they were doing on the wall in their bedroom, the service user said that the home were quite supportive of them doing this and took a real interest in their work. Another service user residing on the same unit was witnessed being supported by one of the activity co-ordinators to have a manicure and spoke of how much they enjoyed their manicure sessions. On the day of the visit a number of service users were seen to be supported to attend a local church party, however most of these people were from the ground floor unit. Being close to the Xmas holiday it was noted that there were a range of activities being provided on each of the units, these included Xmas parties, which had been arranged individually for each unit over a three-day period. It was pleasing to note that different entertainers had been arranged for each individual party and the activity co-ordinator indicated that service users had been involved in the choosing of the entertainer. A shopping trolley goes around the home twice weekly on a Tuesday and Friday morning and provides a variety of items that service users could purchase including: body sprays, bubble bath, cards, razors, sponges, soap, popcorn, tissues, combs, air fresheners, shampoo, chocolate, toothpaste, crisps and biscuits. Activities provided to service users residing on the second floor (Rose) and the top floor (Bluebell) were much more limited than for those people living on the ground floor (Camellia). Observation of a one-hour period just prior to lunch, through lunch and just after indicated that there was very little going on in terms of activity, the environment was very busy and hectic and was task focused. A further period of observation took place on Bluebell following lunch, when service users were observed watching a film and enjoying some chocolates, of twenty service users four to five were actually watching the film, however all of the service users appeared relaxed and at ease. One staff member was observed interacting on a one to one basis with a service user until they were interrupted by another staff member. The Care Homes for Older People Page 18 of 32 Evidence: member of staff left the service user without any explanation, however they did return very soon after to recommence the activity that had been interrupted and apologised to the service user for the interruption. The service user appeared to be genuinely enjoying the company of the member of staff and was clearly benefiting from the interaction. Overall the home was providing a reasonable range of activities to the service users, particularly in respect of the more able people, however the range of activities provided to those service users who were less able was not so good and requires development to ensure that their needs are met. The lunchtime experience for people on Bluebell was observed. The menu displayed within this unit was incorrect and did not correspond with the meal served to people, despite the care team manager advising the inspector earlier during the morning that the menu was incorrect. No staff members were observed to advise people as to the meal being provided and/or the choices available. This is seen as inappropriate as some people may not be able to recall the choices available/chosen. Consideration should be given to devising the menu in both a written (larger print) and pictorial format so as to enable people to make an informed choice. The lunchtime meal was observed to look plentiful and appetising and positive comments relating to food were noted e.g. oh this is nice and I like the food. The lunchtime experience for people was observed to be hectic and in some cases people were not assisted promptly by staff to eat their meal. Some people were noted to be served their meal but not assisted by staff to eat their meal for up to 13-15 minutes later. The most positive interaction with residents, was by an agency member of staff. They were observed to assist one person with due care, dignity and respect and to observe what was happening for other people e.g. getting up from the table and leaving their meal untouched or interfering with other people seated at their table. Other members of staff were observed to be unaware of what was happening, slow to respond to peoples needs and talked exclusively with one another, rather than with residents. Care Homes for Older People Page 19 of 32 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are able to express their concerns, and have access to a robust, effective complaints procedure, and are protected from abuse, and have their rights protected. Evidence: A copy of the homes complaints procedure was posted on the wall in the foyer of the home, and identified to who any compliments or complaints should be referred to, and the timescale within which any complaints received would be responded to following investigation. Also included was the process to be followed for logging a complaint for people whose care was being funded by local authorities. The contact details of the Commission for Social Care Inspection (CSCI) was also included. The home maintains a complaints log for recording any complaints received, sampling of which indicated that from February 2008 fourteen complaints had been received, six of which were care related. All of the complaints received had been logged including details of the name of the complainant, date that the complaint was received, to who the complaint was reported, the category of the complaint, an outline of the complaint, whether or not the complaint constituted abuse and required referring on and a record of the outcome of any investigation. A copy of the homes complaints procedure was posted on the notice board outside of each dining room on each of the units. The three service users spoken with during the Care Homes for Older People Page 20 of 32 Evidence: course of the inspection visit spoke of being aware of who they should speak to if they had any concerns or had the need to make a formal complaint. The home has in place a corporate policy and procedure on safeguarding, which was comprehensively detailed and provided staff with a good level of guidance and information. The home has had one safeguarding referral since the last key inspection; sampling of records relating to this indicated that it had been referred to the appropriate safeguarding team. Discussion with three members of staff indicated that they had received safeguarding training, and had a good level of knowledge and understanding. The home has a staff training matrix, sampling of which evidenced that all staff including carers, cooks, domestics, maintenance staff, activities co-ordinators and the homes administrator had all recently received training in the safeguarding of vulnerable adults. Care Homes for Older People Page 21 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Evelyn May provides a clean, comfortable and safe environment for residents, which meets their needs. Evidence: A partial tour of the premises was undertaken throughout the day by both inspectors. The home is set out on 3 floors and each floor operates as a separate unit, providing care for a set group of residents. On the day of inspection the home was observed to be clean, odour free and no health and safety issues were highlighted. Appropriate signage and picture recognition were available throughout the home to aid orientation for residents within Evelyn May. The care home presents as homely and comfortable for people living there. Of those individual residents bedrooms inspected, all were seen to be individualised and personalised. The communal areas were decorated with Christmas decorations and the main reception area was observed to be welcoming. Comments from residents about the home environment continue to be positive. The home employs a maintenance person 2 days a week. We were advised that their duties include all aspects of routine maintenance e.g. safety checks, fire alarm and hot water checks, emergency lighting tests and maintaining fire escapes. The maintenance schedule for 2008/2009 was noted and this detailed that since the Care Homes for Older People Page 22 of 32 Evidence: last key inspection, the laundry room/ironing area has been repainted and carpets have been replaced in one persons bedroom and other communal areas. The maintenance programme for 2009 showed further plans for redecoration and refurbishment within the care home. A log book was observed, detailing maintenance issues that require addressing. A range of health and safety certificates were sampled and these were found to be satisfactory and in date. A copy of the homes fire plan and procedure to be followed in the event of a fire was displayed. The local fire plan was last reviewed in November 2008. The last fire safety training was provided to 42 members of staff in December 2008. Records also showed that staff participate in regular fire drill practice/training. Care Homes for Older People Page 23 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home are only employed following a robust recruitment process and are trained, skilled and available in sufficient numbers to support the people who use the service. Evidence: Four weeks staff duty rosters were sampled for the period 22/11/2008 to 20/12/2008 inclusive. The rosters showed that the manager is supernumerary Monday to Friday 95 and she is supported by a deputy manager who works 4 days a week in a supernumerary capacity. On the other day we were advised that the deputy manager provides hands on care and support. Additional support is provided by an administrator Monday to Friday. The staffing levels at the care home are 1 care team leader and 1 member of care staff (Camellia), 1 care team leader and 3 members of care staff (Rose) and 1 care team leader and 3 members of care staff (Bluebell). At night there is 1 care team leader and 5 members of care staff to cover all 3 floors. In addition to the above, ancillary staff are employed throughout the week (cook, catering assistant, housekeepers, laundry assistant and a maintenance person). Discussion with staff indicated that they felt these staffing levels were adequate to meet the needs of people within the home. On the day of the site visit, staffing levels on Bluebell were short in the morning, as a Care Homes for Older People Page 24 of 32 Evidence: result of one member of staff accompanying a resident to hospital/appointment. While we recognise this as good practice and steps were taken to provide an additional member of staff (agency), the impact of the staff shortage meant that meeting individuals care needs was fragmented and patchy. Four staff files were sampled of staff who were newly employed. Records showed that all necessary documentation had been sought and that a robust recruitment process had been carried out. Records showed that all newly appointed staff received a comprehensive induction. Discussion with the manager/deputy manager indicated that both were aware of their responsibilities in ensuring that the recruitment process was robust and protected service users. The home has in place a staff training matrix. The matrix evidenced that all staff had up to date training in safeguarding, first aid, moving and handling, dementia awareness, health and safety, food hygiene and fire awareness. Discussion with staff showed that they felt that access to staff training was good. In addition to the above, staff had also received training in care planning, nutrition, infection control, care of the ageing skin and therapeutic activities in dementia. Records relating to NVQ training showed that out of 31 care staff, 21 hold a NVQ Level 2 or higher qualification. The manager and deputy manager have NVQ Level 4 in Care and Management. Care Homes for Older People Page 25 of 32 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst management arrangements in the home are generally sound, shortfalls identified could potentially affect outcomes for people living in the home. Evidence: The manager has been in employed with Runwood Homes PLC for some considerable time, initially as an administrator and then as a care assistant, care team manager and acting home manager. The manager was formally registered with the Commission for Social Care Inspection in 2006. The manager has attained the Registered Managers Award in 2006 and in 2007 completed a Leadership in Dementia course. The manager is supported by a deputy manager. Both advised that the relationship is very good and that they work well together. The manager advised that the main challenges faced by the management team of the home are building up a new staff team, trying to get the best out of them and to nurture them to achieve person centred care that is not task/routine orientated. The Care Homes for Older People Page 26 of 32 Evidence: manager advised that the ethos of the home is to ensure that all people admitted to the care home receive appropriate care and support according to their individual care needs. Staff morale within the care home was reported to be good. Staff spoken with confirmed that they enjoyed working at Evelyn May and felt that the management team of the home were supportive and proactive. The manager sated that she has an open door policy and open surgery, whereby residents, relatives, staff and others can meet with her to discuss any issues. It is evident from this inspection that progress has been made to address previous identified shortfalls in relation to medication practices and procedures, management of complaints and some staffing issues relating to sufficient staff on duty and recruitment procedures. Areas which require further development relate to care planning/risk assessing, ensuring that care staff provide care delivery in line with individuals care needs/plan of care, ensuring that all people within the home receive a varied programme of activities and the dining experience for some people is improved. All sections of the Annual Quality Assurance Assessment were completed and this gives a picture of the current situation within the service. The evidence to support the comments made is satisfactory, however more supporting evidence would have been useful. Records showed that a quality assurance audit was conducted in April 2008. In general positive comments were noted and these included, were very satisfied with the service, marvelous, very helpful and everything is just as I would want it, including all the food that is cooked here. No complaints at all, thank you. Evidence was available detailing that regular staff meetings, managers meetings and resident/relative meetings are held. Regulation 26 visits are undertaken each month by the operations manager or quality development team, with a report compiled. The home holds monies on behalf of residents and records are maintained in the home. On inspection of a random sample of individual residents monies, records and monetary totals were noted to balance with receipts available. A random sample of staff supervision records were examined. Records showed that staff are receiving regular supervision in line with National Minimum Standards recommendations. The home had in place a corporate policy on health safety, which was comprehensive and detailed. Sampling of training records indicated that staff had all received training in health and safety. Care Homes for Older People Page 27 of 32 Evidence: The home had in place a corporate policy on health safety, which was comprehensive and detailed. Sampling of training records indicated that staff had all received training in health and safety. Care Homes for Older People Page 28 of 32 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action 1 7 13(4) Ensure that risk assessments 18/12/2007 are devised for all areas of assessed risk so that these can be minimised and ensure residents wellbeing and safety. Previous timescale of 18/12/07 not fully met. 2 7 15 Ensure that care plans are 18/12/2007 developed further so that these are person centred and fully reflect individual resident?s care needs. Previous requirement of 30.05.06, 1.3.07 and 18/12/07 not fully met. Care Homes for Older People Page 29 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 The needs of prospective people admitted to the care home are assessed. This will determine and enable the management team of the home to make a decision as to whether or not it can meet the persons needs prior to admission. 02/02/2009 2 7 13 Risk assessments must be devised for all areas of assessed risk. So that risks to individual people can be minimised. 02/02/2009 3 7 15 Care planning at the home must identify, and be effective in meeting all residents assessed needs. This will ensure that staff have the necessary information to deliver good care in line with peoples care needs. 02/02/2009 Care Homes for Older People Page 30 of 32 4 9 13 Ensure that where medication requires cold storage, the temperature is within recommended guidelines. This will ensure that medication does not lose its effectiveness. 28/02/2009 5 9 13 Ensure that the medication trolley is not left unattended and medication easily accessible to residents and others. This will ensure unnecessary risks to residents health and wellbeing is prevented. 02/02/2009 6 12 16 Ensure that all people living in the care home are provided with a varied programme of stimulating and interesting activities. So as to ensure that people have their social care needs met. 28/02/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 15 The dining experience for all people within the home should be positive and where people require assistance to eat their meal, this should be provided in a more timely manner. Display the correct menu on any given day so people know what meals are being provided. Consider devising the menu in larger print and/or pictorial format so as to enable people to make an informed choice. The home is run in the best interests of all people living in the care home. 2 3 4 15 15 33 Care Homes for Older People Page 31 of 32 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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