Inspection on 13/12/06 for Fairfield View Care Home

This inspection was carried out on 13th December 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.

Other inspections for this house

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Trough House Care Home 88 Manchester Road Audenshaw Tameside M34 5GB Lead Inspector Tracey Rasmussen Unannounced Inspection 13th December 08:55 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 Trough House Care Home DS0000066744.V320294.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. Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trough House Care Home Address 88 Manchester Road Audenshaw Tameside M34 5GB 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) 0161 330 2444 0161 370 8429 Dialmode (301) Limited Christine Plummer Care Home 29 Category(ies) of Dementia (27), Old age, not falling within any registration, with number other category (29), Physical disability (29), of places Physical disability over 65 years of age (29) Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 29 services users to include: *up to 27 service users in the category of DE (Dementia under 65 years of age). *up to 29 service users in the category of OP (Old age not falling within any other category). *up to 29 service users in the category of PD (Physical disability under 65 years of age). *up to 29 service users in the category of PD(E) (Physical disability over 65 years of age). No service user to be admitted to the establishment who is under the age of 55 years. A minimum of 1 registered nurse must be on duty throughout the 24 hour period. The manager must be supernumerary to the above stated staffing levels for a minimum of 20 hours per week. New service 2. 3. 4. Date of last inspection Brief Description of the Service: Trough House is a care home that provides 24 hour residential and nursing care and accommodation to 29 service users over the age of 65. The home has recently been purchased by Dialmode (301) Limited. Trough House is situated on Manchester Road, with bus routes close by for Droylsden, Ashton, Denton and Manchester. Local shops and amenities are close by. The Victorian front of the home faces onto Manchester Road. A purpose built extension has been added at the rear. A ramp is available at the entrance to the building and this provides disabled access into the home. Parking and small garden areas are available. Bedroom accommodation is provided on three levels, including lower ground floor, ground floor and first floor and a passenger lift is available to assist mobility between floors. The home provides 29 single bedrooms. En-suite toilet facilities are available in five of the single rooms. Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 5 Bathing facilities and toilet facilities are provided throughout the home. Two lounges and a dining room provide areas in which service users can socialise and participate in activities and events taking place within the home. A wide variety of adaptations and aids are provided to assist in the nursing of the service users accommodated. A copy of the home’s last inspection report was available from the main entrance area of the home. The current weekly fees range from £355.00 to £503.00 dependent on the package of care required. Further details regarding fees are available from the manager. Additional charges may also be made for hairdressing, chiropody and other personal requirements. Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this unannounced key inspection site visit on the 13th December 2006 The inspection included a review of all available information received by the Commission for Social Care Inspection (CSCI) about the service provided at the home since the last inspection. All key inspection standards were assessed at the site visit and information was taken from various sources which included observing care practices, talking with residents; talking with visitors; interviewing the manager and other members of the staff team. A tour of the home was also undertaken and a sample of care, employment and health and safety records seen. No requirements were made at the last inspection and no requirements have been made following this inspection. This inspection did identify one area that needed addressing and the manager took rapid action to address this. A brief explanation of the inspection process was provided to the manager of the home at the beginning of the visit and time was spent at the end of the visit to provide verbal feedback of the findings from the inspection visit. What the service does well: The home had been purchased recently and this was the first inspection for the new owner. The inspection identified that the home continued to provide a consistent high standard of service and care. This had been enhanced by investment in the home by the new owner. The home was peaceful and offered a relaxed atmosphere. Staff were friendly with residents and went about their duties in a professional manner. Residents were complimentary about the home and comments included ‘I am looked after’; ‘staff are very very nice – when I ask for assistance they will always help me’; ‘I am comfortable’ and ‘I have only good things to say’. Two visitors in the home sought out the inspector to express their satisfaction with the service and their comments included “We can’t praise it highly enough” and “You couldn’t have had any better care”. Another visitor in the home said, ‘the family wouldn’t have her any where else’. The home was welcoming, clean and tidy and had been decorated ready for the festive period. Visitors were welcome into the home and meals and food Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 7 were described as good. Equipment and facilities to meet the different and varied care needs of the residents was available. The new owner has had many areas in the home redecorated and re-carpeted. All bedrooms were now offered as single rooms, one additional en-suite facility had been created for a bedroom and a new shower room had been made. A programme to redecorated and refurbished bedrooms with soft furnishings such as curtains, blinds and bedding was being undertaken.. The manager continued to provide strong leadership, ensuring standards of care were maintained by being part of the team and delivering hands on care. The manager also continued to develop links in the local community with other professional such as the sensory impairment team and the community infection control nurse. The social side of the service provided, continued to be one of the home’s strengths. Activities provided were varied and attempts were made to meet the varied skills and abilities of the residents living in the home. Religious needs were also respected. The home now had access to a mini bus and trips out had been undertaken and arranged. Information about the home and how to comment about the quality of service or complain was readily available at the entrance of the home. Residents were also provided with regular opportunities to comment on the routines in the home through resident meetings. Staff said they liked working in the home and said they were well trained. The majority of staff had had training to ensure residents were safeguarded as far as possible from abuse and staff knew what to do if they suspected abuse. A wide variety of other training had been provided and 65 of the care staff team had a NVQ 2 qualification. Employment recruitment practices were safe so staff who may have posed a risk to residents were not employed. One area of the home’s recruitment practice was noted to be not up to standard and the manager addressed this straight away and at the time of writing this report the matter had been fully addressed. Staffing levels in the home were appropriate to meet the needs and dependency levels of the residents. The new owner had employed additional staff in the home, so that the manager had some administrative support and a maintenance man was employed to ensure repairs and maintenance were attended to. A senior care assistance had also been employed to provide on the job support and supervision to care staff. Resident’s personal monies were not held in the home and safe working practices were promoted. Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 8 What has improved since the last inspection? 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. Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 9 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 Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 10 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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs were assessed before they moved into the home and the home confirmed they could meet the needs of the resident on admission. EVIDENCE: The quality of the information (standard 1) was not assessed at this visit However it was noted that the reception area of the home was welcoming and information about the home was readily available. This included an information guide, a very friendly complaints procedure, previous inspection reports and blank satisfaction questionnaires for care, environment and food. Residents spoken with were positive about the home and comments included; “staff are very very nice – when I ask for assistance they will always help me” and ‘I have only good things to say’ about living in the home. Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 11 Visitors were also very positive and comments included “It’s not like a home; it’s like an extension of your own home” and ‘the family wouldn’t have her any where else’. Three resident care files were seen. These contained detailed information about each of the residents care needs. The care records included information that indicated that the home had made pre-admission assessments or checks on the resident’s care needs before they came into the home. The manager provided a detailed pre-admission assessment she had recently undertaken for a probable new resident. This was detailed and contained relevant information about this ‘new’ person needs. This enabled the manager of the home to assess and confirm whether the new resident’s care needs could be met properly by the services provided in the home Intermediate care (standard 6) is not provided at the home. Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines in place ensure residents are treated with respect and dignity. The care planning documentation was sufficient to enable staff to meet personal and health care needs of residents. The arrangements in place in respect of medication ensured that medication practices within the home promoted the safety and wellbeing of residents. EVIDENCE: The home provides nursing care and support across a range of needs. At this visit the home was caring for mainly older and very dependent people. A number of residents were chatted with and all had good things to say about living in the home. Comments from residents included “staff are respectful and treat me with dignity”; “I am looked after”; “very good people here” and “staff have always been helpful”. Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 13 Visitors were also spoken with. Two visitors purposely sought the inspector out and said, “They are absolutely marvellous” and “We can’t praise it highly enough”. Another relative said “All the family very pleased with her care” The home was calm and peaceful and pleasant music was playing in the lounges. Staff were busy but did not rush with residents and appeared to have good interactions with them. Residents were presentable and dressed according to their preference. The hairdresser called into the home to do two ladies hairs. Staff spoken with were positive about working in the home. Staff said they were trained and supported to do their job and about 65 had achieved a NVQ 2 and the remaining care staff were doing it. Three care planning records were seen. At the last inspection the manager had commenced up grading the care planning record format in the home. At this visit this had been completed. Assessment information was very detailed and person specific which means the care records provided clear information about how to care for the resident in accordance with the resident’s preferences, wishes or known routines. Care plans were available and these were also detailed and relevant to the resident. However some of the information could be developed further by including more person centred information and clearer cross references between the outcomes of formal risk assessment such as a pressure ulcer assessment. The manager did say that this was her next step in the care plan development process. Reviews of the care plans had been undertaken but evaluations about how effective care delivery had been should be developed further. The home also promotes the key-working role, which means that care staff are allocated to be a link person with a number of residents. The home had recently introduced a key workers care review, which is undertaken between the care staff member and the resident. Two records of this key work care review were seen and these provided informal information about how the resident felt about the different areas of care and service. This was informative and is considered good practice. Care plans did include references to promoting privacy, dignity and choice Records of contact with community health services such as GP, chiropody and optical support were available. Medication practices were briefly reviewed. The home has a separate treatment room to store medication. The medication room was clean and tidy Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 14 Storage of medications both in the controlled drug cupboard and refrigerator were appropriate and records maintained accurately. The home uses a monitored dosage system of medication administration which means medication is dispensed by the pharmacist into a blister system. Records in the home indicated that this medication was ‘booked’ into the home when it arrived. Medication administration record sheet were recorded correctly and records of medications disposed of had been recorded until recently. Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Social activities and stimulation was provided to meet the diverse needs of the residents living in the home. Residents were offered a choice of meal at mealtimes and the quality of the food was good and nutritious. Lifestyle preferences were respected and visitors were welcome. EVIDENCE: The home employs and activity person for five afternoons per week. The activity person is very pro-active in providing a wide range of activities to meet the need, skills and preferences of the residents. Brief records were available in a diary which indicated the different activities provided and which resident joined in each activity. These included bingo, painting, exercise, quiz, jigsaw, dominoes and colouring. The activity person was spoken with briefly and she agreed she should keep more detailed records of the activities provided and enjoyed but said that this would reduce the actual time she had providing the activity. Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 16 The manager explained that under the new ownership of the home, the home has access to a minibus which had enabled residents to go out on various trips including trips out to Buxton tea rooms, Blackpool, shopping to Denton and visiting the museum at Portland Place. Four residents had been out for meal at the Stablegate and trips were planned to take residents Christmas shopping to Asda and ten residents with family were going for a Christmas party meal at a local school. A resident said, ‘we went out for a meal last week– it was lovely’. Other comments included ‘I have had a game of bingo – I enjoy it’ and ‘we helped decorate the tree’. At this visit the activity person chaired a resident’s meeting the purpose of which was to find out if residents were happy with the improvements in the laundry service and to explain about all the activities which were planned for the festive period. Resident meetings were held regularly and minutes of these were available. Information was also available which identified that residents who did not wish to or were unable to attend the resident meeting were consulted with. Care plan records contained information about resident’s social history and religious beliefs. One care file indicated that the resident was assisted to continue to worship on a regular basis. The owner had also purchased very large widescreen televisions for both lounges. One resident said ‘the big tvs are a lot better’. Staff were polite and supportive to residents. Routines in the home were flexible and one resident confirmed that her wishes were respected. She said, “I go to bed and get up when I want” and ‘I could have a bath every day if I wanted one’. Visitor confirmed that they were welcomed into the home and were kept informed of all changes in the care of their loved one. The home has a separate dining room and residents were assisted to sit at the table at meal times. Tables were set nicely with table cloths and condiments. A choice of meals were provided and a recent issue identified by residents was the lack of choice for the evening meal. The home had responded to the issue and developed a range of meal options or choices. Residents said, ‘The food is very good’ and ‘food is not bad – I am not hard to please’ Meals were served appropriately and residents were provided with assistance discretely. A staff member was observed in the early afternoon asking residents discretely what he or she would like for their evening meal. The manager said that the home had also introduced offering fresh fruit juice and fresh fruit mid morning to residents and this had proved very popular. Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 17 This also helped the home ensure that residents got some of the ‘five a day’ government recommendation for fruit and vegetables. Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that staff are trained to respond appropriately to suspected abuse. Residents can also be confident that all complaints will be treated seriously. EVIDENCE: The manager has re-written the home’s complaint procedure. This was written in a style, which did not intimidate the reader: it was friendly, clear and written in plain English. This is considered good practice. Since the last inspection visit the manager had received one complaint and this had been responded to according to the home’s complaints procedure. Records were available of the complaint and this included the actions undertaken in response to the complaint. Copies of the official complaint letters sent out by the home were not available in the home and these should ideally held with the home’s complaint record. Residents and visitors spoken with said they wasn’t aware of the specific complaint procedure but said they felt able to speak with the manager if they had any concerns. Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 19 Staff responded appropriately when asked about complaints by indicating they would direct the complainant to a senior person. Staff reported that they had received training in abuse and the protection of vulnerable adults and were able to discuss the content of their training and relate it to the home environment. Records were available of staff training. Staff also confirmed they had undertaken NVQ training and this also included information and training in abuse. Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well maintained home that was clean and odour free. Specialist equipment is available which means the different needs of each resident could be met promptly. EVIDENCE: The main entrance into the home was warm and welcoming. The home had been decorated to celebrate Christmas. The home was clean and all areas were very tidy. The home’s cleaner was very thorough in undertaking her duties and had pride in her work. It was noted that even bedrooms that had not been cleaned and had been tidied up and were very presentable. The new owner of the home has invested in the home. All bedrooms now offer single room accommodation (previously the home was registered for 2 shared Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 21 bedrooms), one room had had en-suite facilities created and a new walk in shower had been fitted. New carpets have been fitted at the entrance to the home and through most hallways, and a programme of bedroom redecoration and soft furnishing replacement was being implemented. Specialist nursing beds had been purchased and outside garden furniture provided. A varied selection of moving and handling equipment was available to meet the varied care needs of the residents. The kitchen and laundry areas of the home were not seen at this visit. The new owner had also employed a maintenance person and their duties included attending to the day to day repairs and general maintenance of the home. Some service reports were available which detailed the on going maintenance in the home and this included fire safety records. Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment vetting practices, staffing levels, training and skill mix were appropriate to meet residents’ needs and promote their health and safety. EVIDENCE: The home had a peaceful atmosphere and all staff spoken with were pleasant. Resident’s said the staff “‘staff are very good with us’ and ‘staff are respectful and treat me with dignity”. Visitor’s comments were also very positive about the home, care and staff. Staff were positive about working in the home. Staff said that they enjoyed working in the home; that they delivered a good quality service and they said they received a good standard of training. The staffing rotas were available and indicated that staffing levels were maintained at appropriate levels to meet resident’s care needs. The new owner had increased the staffing in the home so that the manager had administrative support, a maintenance worker undertook daily maintenance and a senior care assistance was employed to provide on the job support, assistance and supervision to care staff. The manager did say she was Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 23 actively trying to recruit a deputy manager in the home, however this was proving difficult, as the quality and experience of people applying were not sufficient. It is recommended that this recruitment drive continues as it is unlikely the high standards of care and service would be maintained should the manager be absent for any length of time. Three employment files for newer staff to the home were seen. Two staff files had the necessary pre-employment checks such as Criminal Record Bureau (CRB) disclosures and references. However one staff file had evidence that a CRB disclosure had been applied for but had not been received (the worker was a former employee). In such cases the home needs to have a PovaFirst check which if clear allows staff to work supervised in a care setting. This was discussed with the manager who pursued this with the company headquarters and was informed that the home’s umbrella body – which process CRB applications had said they were not able to provide PovaFirst. The manager was not satisfied with this and continued to pursue this and as a result was able to provide a copy of a PovaFirst to the CSCI one week after the inspection. This means that the home has ensured as far as possible that new staff working in the home do not have a history of abusing people. In accordance with the recent amendments of the care home regulations the manager should ensure that all new staff member’s employment are recorded and full working histories are obtained before employment commences. Records were available to indicate that the home did train staff from the start of employment with induction training to on-going training and NVQ. The home’s induction training was in line with Skills for Care requirements. Other staff members detailed various training courses they had attended and these included examination course in health and safety, fire safety, abuse and sensory training such as mini-com training for visual and auditory impairment pressure sore management, challenging behaviour and Understanding dementia. It was reported that 65 of care staff had got their NVQ 2 and the remaining care staff were undertaking this training. Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management of the home promotes the health, safety and wellbeing of the residents. Residents do have a say in how the home is run so they are provided with opportunities to contribute to the daily routines of the home. EVIDENCE: The manager continues to be the driving force in the home, making sure high standards of care and service are provided whilst continuing improve and develop the service. The manager had developed staff handbooks containing information on policy and procedures and this included health and safety. Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 25 She was working with the sensory impairment team to develop an appropriate risk assessment for residents living with sensory impairment in the care home. She had updated the home’s care planning system and developed a new complaints procedure. The manager had also written an infection control booklet for staff to care for someone with MRSA (methicillin resistant Staphylococcus aureus). The community infection control nurse was reviewing the content and it was reported that she was considering sending copies to other care homes. The manager was also up to date about issues around equality and diversity and information was available in the home. The manager is a registered nurse and has completed the Registered Manager’s Award. Discussion with residents, staff and visitors indicate that the manager’s style of management was one of openness. Residents referred to the manager by her name and they said they would speak to her if they had any problems. Staff also said the manager was always available to discuss any concerns. The manager had developed a resident and relative questionnaire covering different aspects of the service provided. Records of responses were available and areas of development noted and acted upon. The owner, manager and maintenance person undertake a monthly audit of the service (as part of the Regulation 26 visit) and action plans to improve the environment or any other areas are discussed and agreed at these visits. Residents benefited from regularly residents meeting where their views, wishes and preferences were respected and the home also had twice-yearly family meeting. Staff also had staff meetings, minutes were available of these, which also included minutes for night staff and trained staff meetings. Records of health and safety and maintenance were available including fire safety records. Records of fire instruction and drills were available and maintained in accordance with the fire officer recommendation. The home does not hold any personal money for residents. Residents or their appointee are billed for all expenses incurred. Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 26 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 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 4 x N/A x x 3 Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 27 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. 1 2 3 4 Refer to Standard OP7 OP16 OP27 OP29 Good Practice Recommendations The registered person should ensure that risk identified in assessments are included in the care plan and detailed evaluations of care delivered are recorded. The registered person should ensure all ‘complaint documentation’ is held together in the home’. The registered person should ensure the recruitment drive to employ a deputy manager continues. The registered person should ensure a full working history is obtained before employment commences and PovaFirsts are diligently obtained before any new worker starts in the home without the receipt of a full CRB. Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Trough House Care Home DS0000066744.V320294.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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