Inspection on 29/01/07 for Faithfull House

This inspection was carried out on 29th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Faithfull House 25/01/10

Faithfull House 13/03/06

Faithfull House 22/09/05

Faithfull House 03/03/05

Faithfull House 19/10/04

Faithfull House 17/02/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Faithfull House Suffolk Square Cheltenham Glos GL50 2DT Lead Inspector Mrs Helen James Key Unannounced Inspection 29th January 2007 09:30 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 Faithfull House DS0000016436.V316873.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. Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Faithfull House Address Suffolk Square Cheltenham Glos GL50 2DT 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) 01242 514319 01242 578392 Cheltenham Old People’s Housing Society Limited (The Lilian Faithfull Homes) Mrs Suzanne Dawn Booker Care Home 72 Category(ies) of Old age, not falling within any other category registration, with number (72) of places Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th March 2006 Brief Description of the Service: Faithfull House is a substantial attractive property, originally three Regency Houses, which have been converted to provide accommodation for 72 elderly residents who require personal care. The fees range from £450 to £ 550 per week. The home is owned and managed by a charitable organisation (Cheltenham Old People’s Housing Society Ltd) and is one of the Lilian Faithfull Homes. It is situated in the Montpellier area of Cheltenham, within easy access of shops and local amenities. Accommodation is provided on five floors of the home; all of which are served by two shaft lifts. Currently, access to other areas is provided by a number of stair lifts. In addition, a variety of aids and adaptations have been provided throughout the property to assist the service users. The majority of bedrooms have been equipped with en-suite facilities and assisted baths and toilets have been installed throughout the home. The communal areas on the ground floor consist of several lounges, a dining room and a conservatory. There is also a library and Chapel located on the lower ground floor. The residents have the benefit of well-maintained enclosed gardens at the rear of the property. Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key Unannounced inspection took place over nine hours on one day in January 2007 and was completed by two inspectors. Thirty-three Care Standards for Older People including all the twenty-two Key standards were assessed on this occasion. Of these thirteen exceeded the standard, nineteen met the standard and one was not applicable. Time during the inspection was spent speaking with the Manager Mrs Booker, Chief Executive Mr Bennett, staff, residents and visitors, examining documentation, management records and the environment. Those residents/visitors who were able to converse with the inspectors discussed the admission process, care, food, lifestyle, activities and relationships with the staff at the home. The information in relation to care and welfare gained from these discussions and observations was then cross-referenced with residents’ individual care records and other appropriate documentation. Questionnaires were sent out prior to the inspection and analysed prior to the site visit. The nine responses from residents were all very positive about the care, food, activities and staff. One resident even commenting, “that Mrs Booker was very professional, efficient and an amazing person as are all the staff.’ The six responses received from relatives/visitors were again very positive about the management of the home, care, food and attitude of the staff. One relative commented that they were never asked who they were; no one ever introduced themselves when they answered the door and they did not feel satisfied with the care. But the inspectors could find no evidence to support any of this at the inspection. The five responses from the staff were very positive about the home, support, training and management they receive whilst at work. What the service does well: The Home has the benefit of an experienced Manager who is greatly involved in the home on a day-to-day basis. There appears to be an open, friendly approach to the running of the home, where resident’s needs are paramount and this is reinforced in the training and example given to staff. This results in Faithfull House being run safely and efficiently with residents’ rights, independence and choice being safeguarded and protected whilst involving them in how things are run. It was evident through discussion with residents/relatives who were able to talk to the inspectors that they felt their views were always taken into account. They found the Manager and staff approachable and friendly. Residents spoken with all confirmed that they are very happy with the home and they had no concerns. They felt they were kept well informed and feel Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 6 that there is appropriate stimulation in the home and the ability ‘to do what you like when’, ‘to go out as you please’ and ‘to stay involved in the local community’. There was confirmation that residents were given choice in what they do and that independence is promoted. All the comments made by residents, relatives/representatives in conversation and via questionnaires were very positive about the home, staff, care, activities and the food. Interactions and communication between staff and residents was observed during the inspection and it was noted that tasks were undertaken diligently, respectfully and compassionately. Staff engaged with individuals during all interactions, the atmosphere was calm and unhurried and all interactions retained resident’s dignity, privacy and respect. Lifestyle and hobbies are well recorded and social activities cater for individual interests. The activities are varied (group as well as individual) and are well attended by residents who enjoy the activity and outing programme. Three staff were seen fully engaging with five residents in a game of skittles. Really positive interactions were witnessed. They spoke to them respectfully, provided explanations for why they were doing things and supported them throughout the activity. Many residents still go out alone or with friends or relatives. Management records relating to health and safety issues and regular checks were in place. There was evidence that if any action had been necessary that it had been completed. All incidents and accidents that require reporting under regulation 37 are completed and sent to the Commission. Quality Assurance systems are implemented well within the home. What has improved since the last inspection? What they could do better: The Manager has a comprehensive array of documented auditing tools in place to examine quality and effectiveness of systems in the home. To enhance the quality systems in place the accident audit needs to be formalised and auditing tools for care practice developed further. The home also needs to seek and evidence the views of its community stakeholders to give a holistic assessment Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 7 of the quality of service provided to residents by the home. An annual Quality Assurance report needs to be produced to evidence the review of the effectiveness of the quality systems in the home and must include stakeholders’ views and future developments for the home. In conclusion Faithfull House provides excellent standards of care in a comfortable environment for its residents who in the main are quite independent. The inspectors found a warm, relaxed and welcoming atmosphere that felt homely and comfortable for residents and visitors. The home felt quite embedded in the local community with residents going to local venues to participate in community activities or to the local shop to do some shopping. The Manager provides leadership by example to the staff team, which motivates and enthuses staff to work to high standards. The management are committed to an ethos of ‘continuous improvement’ for the service they provide for residents. This is reflected in their approach to the inspection process, their willingness to engage with the residents to improve things and the commitment to implement appropriate changes / improvements that are bought to their attention by the Commission. 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. Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 & 6. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users and their relatives are well informed about the home prior to admission. Arrangements are in place to ensure that each prospective resident is fully assessed prior to admission. This is reassessed on admission, to ensure that all their specific care needs can be met by the Home. Residents or their relatives have the opportunity to visit the home. Intermediate care is not provided. EVIDENCE: The home has a Statement of Purpose and a Service User’s Guide, this has been reviewed and a copy is to be sent to the Commission as soon as it is available. A yearly review is carried out to ensure that residents and their families receive accurate information about the home and services provided. Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 10 Residents/relatives spoken with confirmed that there was an assessment by the Manager of the home prior to admission and that they were reassessed once they arrived at the home. They confirmed they are involved in the process with their relatives/representatives on admission and at the monthly reviews about their care. Documentary evidence of the assessment process was available to demonstrate this with residents / representative signature. There is a formal review of the placement and contract at three months with family/resident/ staff and all those involved with the individual by the Manager. Residents confirmed that they or their relatives visited the home prior to the admission. Residents had contracts but it was not always the resident who was involved with this, some left it to their relatives /representative or Social Services; and some said they did not want the worry of this (a sample were seen). The contract contained all the required details and has been examined by the organisations solicitors to ensure compliance with the Office of Fair Trading Standards. The issue relating to the £5000 capitation charge on residency for private residents was discussed. It is quite explicit in the contract and residents and their relatives are fully aware of this payment when they make enquiries for residency. Discussions relating to this charge were held with Mr Bennett, Chief Executive and arrangements are being made for further examination by the solicitors in light of the Office of Fair Trading guidance to ensure it meets legislative requirements. Relatives/representatives of people recently admitted were spoken with and all confirmed that they are very happy with the home and they had no concerns. They felt they were kept well informed and feel that there is appropriate stimulation in the home and the ability to do what you like when, to go out as you please and to stay involved in the local community. There was confirmation that residents were given choice in what they do whilst independence is maintained. All the comments made by residents, relatives/representatives in conversation and via questionnaires were very positive about the home, staff, care, activities and the food. Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 11 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, 10 & 11 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. All of the service user’s health, personal and social care needs are set out in an individual plan of care. Health care needs are fully met. Service users are protected by the home’s policies and procedures for dealing with medicines. Medicines are managed and given to residents in a safe way. Service users feel they are treated with respect and their right to privacy is respected. EVIDENCE: Care records seen included a photo of the resident; an assessment of the residents needs prior to admission or on admission and diagnosis. The assessment was based on general information and on the activities of daily living in order to ascertain that the residents needs could be met. Residents may also receive an assessment from a mental health advisor employed by company if required. A plan of care is then written based on the residents Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 12 needs in conjunction with the resident, who then agrees to the care by signing the documentation. Care records seen had the relevant documentation in and care plans related to the identified needs. Risk assessments were appropriate to individual needs and all had moving and handling assessments recorded. Where residents were self-medicating a documented risk assessment was present, this is reviewed each month with the resident when the new medication is ordered. Consent is recorded where necessary and where a resident requests not to have something done then this is recorded and signed by them: for example when they do not wish to be checked hourly at night. Weight is monitored and recorded where necessary but a baseline is always taken on admission. Bathing records were also available. The past lifestyle, activity, hobby interests is recorded and records of attendance at activities are recorded. The Manager is in the process of putting all the care records into resident’s rooms except for the daily careplan and daily records, these will be kept at the care office due to the layout of the home and its 72 rooms. This will ensure that all the information required is kept in one file. Some minor amendments were discussed with the manager during the inspection relating to the fact that there should be more written detail in the care interventions in respect of how the carer provides assistance. Care and interactions of staff were observed as sensitive, approachable, respectful they were observed dealing with residents with dignity and privacy and facilitating choice. Where they were not able to make a choice due to an inability to communicate this to staff, staff were diligent in their communication, guiding and reassuring residents appropriately and respectfully. Medication: Residents have their own lockable medication cupboards in their room; this contains their monthly supply of medication. Two staff are allocated medication as part of their duties each day on the allocation sheet. When staff dispense medication for the resident two staff go to the residents room with the Medication chart, give the medication and then the record is signed at this time. Except at lunchtime, the lunchtime MDS is kept separately and these are given to residents whilst they have lunch, as most of the residents will be in the dining room. The deputy Manager is responsible for ordering the monthly medication from Boots through the Monitored Dose System (MDS). Returns are dealt with appropriately and all medication is signed in and out of the home. Each resident who self-administers his or her own medication is reassessed using a medication risk assessment each month when the new order is being requested, this entails assessing the residents capabilities and compliance with taking the medication prescribed. The Pharmacist Inspector for the Commission has reviewed the medication policy and procedure in 2005. Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 13 Boots do a medication audit and provide the Manager with a copy; they also provide a medication training session for staff dispensing the MDS. All staff who dispense medication in the home have attended accredited training as well as this. The Organisations training department is to run accredited training alongside the NVQ Medication training for all staff. Health care needs are well met by the Community Healthcare team. There is a GP’s surgery at the home each Friday. District Nurses from the St Catherine’s practice deal with all the nursing needs of the residents and supply all the nursing equipment the resident/ home may need to care for the individual. Several residents have the district nurse for dressings, continence and injections at this time. District Nursing (DN) records are kept in the resident room. One resident has a leg dressing following a Haematoma to the leg following a fall in October and one has a pressure sore on the sacrum following a fall to the floor 6 weeks ago both are being treated by the DN. The Community Continence service has been good but over the past few months the provision has deteriorated with delays in the nurse advisor visiting for assessment and not providing residents with enough or appropriate aids. The Manager is to speak with the Primary Care Trust about this issue. The home has been buying aids as necessary to ensure residents get assistance with continence needs until the assessment is made. There is good support from the newly established Mental Health Community based team although there is no –one receiving visits from them at the present time. The Home has the benefit of being able to gain support from the Mental Health Nurse employed by the organisation who is based at St Faiths, another home in the group. Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 14 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, & 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents experience a stimulating and varied life at the home with visitors and community links encouraged. There is a full activity programme available to suit all abilities within the home. Residents continue to have the option for a varied lifestyle. Residents continue to be able to exercise choice and control over their lives within the individual ability to do so and maintain contact with family and friends. The meals at the home are wholesome and nutritious with choice at each meal. EVIDENCE: The past lifestyle, activity, hobby interests are documented and kept by the activity coordinator. There is also a record of all the activities that residents participate in within the home. The activity coordinator meets with residents when they start to live at the home and lets them know about the activities available and talks to them about the things they would like to do. She has coffee mornings, sees residents at the meal table to talk to them about Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 15 suggestions they have for activities, trips or outings they would like. The activity coordinator is on maternity leave at the present time but one of the carers is doing this role, planning the activity programme. She also arranges the associated resources for all activities and transport and arranges holidays for the residents with them. The home has a ‘Soiree’ every six weeks, music and a three-course meal, which is enjoyed by residents and their relatives. Tea - dances are arranged and there is good attendance at these and several residents come from the other homes within the company Four residents attend mothers union. There are trips out in the mini bus every Tuesday and Thursday and a group of residents play skittles regularly at the local pubs. Several residents were seen taking themselves out into the local community to meet friends, have coffee or to go shopping. People were seen coming and going in the home during the inspection. There is a church service at the home every week and some residents go out to church. There is a chapel at the home but this is not currently used. Staff were seen fully engaging with five residents in a game of skittles. Really positive interactions were witnessed. They spoke to residents respectfully, provided them with explanations for why they were doing things. Supported them throughout the activity. All five residents were actively involved. From the Questionnaires, whilst there is choice with food, many respondents commented that food could be improved, these were obviously personal opinions but the inspectors could find no evidence to substantiate this at the visit. However there was evidence to demonstrate that the Manager and Catering Manager take the issue with food seriously. There are monthly catering audits, reports and meetings with residents to discuss food issues, from the minutes of these meetings, it is evident that the management support changes that the residents would like. Specialist diets can be provided and where residents are deemed as at risk from malnourishment due to medical conditions and/or are losing weight they are monitored monthly and this is recorded. Appropriate intervention would be implemented such as nourishment drinks, extra snacks between meals and added supervision when eating. Fluid intake is also monitored where necessary. There are thematic lunches and dinners at the home pertaining to the time of year for example a remembrance day lunch was held. The home has a contract with the catering company Eurest who keep all the required records. The catering manager audits the provision and shares this information with the Home Manager at their monthly meeting. They meet with residents at the six monthly residents catering meeting where catering issues are discussed. The home has achieved the Cheltenham Borough Council Spa Award for excellent standards of food hygiene, no smoking areas and healthy eating choices. Faithfull House DS0000016436.V316873.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): 16, 17 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives and friends are confident that their concerns and complaints will be listened to, taken seriously and acted upon. Service users legal rights are protected and service users are protected from abuse. EVIDENCE: The home has a complaints procedure that all spoken with were aware of. Residents spoken with stated that ‘they have no concerns about the care or the home and they always feel confident to discuss concerns with the Manager or staff’. This was also evidenced from questionnaires received from relatives and residents. The Manager keeps a log of complaints/concerns and minutes of meetings demonstrated that concerns are acted upon as soon as they are made aware to the Manager. The Manager is to look into ways of collating compliments about the service that is provided at the home. The home has its own policy on abuse and adults at risk file. The Manager has attended enhanced adults at risk training in the last three months. All staff have training on ‘abuse awareness/adult protection and whistleblowing’ on induction and this is updated regularly. Staff spoken with confirmed they had received this and in discussion they knew what they would do if they saw abusive practice or saw anything that bothered them. On admission to the home all residents are required to have an Enduring Power of Attorney as part of the contract process. Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of décor within this home is good residents live in a safe wellmaintained environment that is in the process of redecoration. Residents live in a pleasant, clean, warm and homely environment. EVIDENCE: The organisation has made great progress with refurbishment and maintenance work in the last year. A new lift, new call bell system and bathroom/shower refurbishment has been undertaken and has contributed to making life in the home even better. There is a process of redecoration ‘floor by floor’ being undertaken at the present time; the floors that have been completed are done extremely well and brighten and lighten the ambience of the home in these areas. Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 18 The on-site maintenance team deal with all decorating, building, electrical and maintenance work. All, except three rooms in the home have been decorated. All maintenance issues are recorded in the maintenance book on a daily basis and these are addressed each day by the team and signed off when they are completed to ensure an audit trail. Gardens to the side of the home are safe, accessible, attractive and well maintained and are used by the residents in the better weather. All radiators and pipework are guarded and provide low surface temperature for residents. Radiators can be regulated. Windows are restricted but do allow for natural ventilation of the rooms. Water is stored at appropriate temperatures and yearly Legionella testing is completed certificated evidence was seen. Monthly testing of hot water outlet thermostatic devices is undertaken and recorded by the maintenance staff with action taken, records were seen. There is a domestic team that keeps the home clean, tidy and odour free. The laundry in the basement has good hygienic facilities for the laundering of clothes, which complies with infection control standards. Although two issues require addressing as they potentially present a hazard: • Remove the chest of drawers that contains the clean underwear, as this has chipped surfaces and cannot be cleaned properly and is permeable. • The wooden beading on the storage shelves requires resealing as it is chipped and cannot be cleaned properly and is permeable. The inspector also discussed the flooring of the laundry whilst it is acceptable at the moment but there needs to be a plan in place to reseal or replace the flooring in the future as it becomes more worn. Hand washing and hand drying facilities are in place throughout the home and protective clothing is supplied and used appropriately. All staff are instructed in the Control Of Substances Hazardous to Health (COSHH) on induction and updated regularly. The Manager reported that a monthly audit of the home is done to check whether any work needs to be completed and to look for any health and safety issues. During the inspection no urgent maintenance issues were noted only ones that are being addressed through the redecoration process. The new bathroom where the waterproof wall covering is coming off was discussed with the Manager and this is being addressed; the company is visiting next week to re-hang the wall covering. Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 19 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 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are employed in sufficient numbers to meet the residents needs and care observed was appropriate. Morale remains high with a very low staff turnover so there is consistency in the staff team for the residents. There appears to be a good leadership of the care practice in each area by senior care staff and from the Manager. This ensures consistency of care practice in the home. The procedures for the recruitment of staff are good and protect the people living in the home. There is a full staff-training programme from the internal training department that covers all mandatory training for all staff and care issues. EVIDENCE: The number of staff on duty appeared more than adequate to meet the needs of residents in the home at the time of the inspection. Not one resident or relatives made any comments relating to ‘not enough staff’ on the questionnaires. All comments from relatives and residents were that staff were kind, considerate and always available to do things or spend time with you, they were polite, pleasant and friendly. Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 20 Staff spoken with felt that staffing was sufficient to meet the needs of residents and that they had time to do their job. There are support staff that deal with domestic chores, catering staff and maintenance staff therefore care staff are free to deal with residents and care issues. The care staff feel they receive good support from the Manager, deputy Manager and senior carers. Completion of National Vocational Qualification (NVQ) is related to a pay reward structure to encourage completion and motivate staff. There is also a performance management system in place that rewards staff through pay and bonus incentives based on attendance at work, performance and reliability. Fifteen of the twenty-six care staff have now completed their National Vocational Qualification (NVQ) level 2 or 3. The Manager has NVQ level 4 as has the deputy Manager. This exceeds the minimum ratio of 50 of care staff to be trained to NVQ level 2. Three staff who have learning difficulties are to begin their NVQ level 2 with support from the Manager and Training department in the Summer (2007). The Manager and her deputy are both NVQ assessors. General Team meetings occur every three months and these have an agenda and minutes. A verbal handover is given at each shift change for all staff and the Manager talks to staff about a wide range of issues at these meetings. Recruitment practice was examined CRB checks for three new staff with their POVA first check were seen these were all satisfactory. It is now required that these are shredded and only those of new starters are kept for the next inspection, to comply with data protection and confidentiality. The Manager was advised during the inspection that should she employ a member of staff with a previous criminal record that there must be a risk assessment completed and kept on the personnel file. There has been no experience of this to date at this home. New starters files were seen for three care staff. One member of staff who was employed from January 2006 was found to have an incomplete work history (10yrs missing) and the Manager was asked to complete this and confirm in writing to the inspector the missing years. Two applicants files were found not to have two written references; one reference was verbal. The Manager must ensure that the organisations Human Resources department takes two written references and puts evidence on file that they have requested these, where there is difficulty getting the reference then alternatives must be obtained. The Manager reported that the Managers now oversee the recruitment process with HR due to errors like this occurring last year. The carer recruited in November 2006 had all the required paperwork in place to comply with Regulation 19. All new starters undertake three days of paid induction training, which complies with the NTO induction standards; this includes adult abuse and Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 21 whistleblowing training. They then have two weeks working alongside experienced carers at the home and they are supervised from the day they start. They have a three-month review and if all is satisfactory they will be appointed on a permanent contract. All staff complete updating in all the mandatory training and the training matrix for this was seen. Staff all receive more than three days paid training a year. All staff have dementia awareness training and a variety of other care training pertinent to their jobs. Training planned for this Year includes Death ands Dying, Medication, communication skills, dining with dignity, keyworking, first aid and updating in all the mandatory training. Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 & 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 is excellent and the Manager provides leadership, guidance and direction to staff on a ‘day to day’ basis. The systems for service user consultation and Quality assurance are well developed in the home and could be enhanced further by stakeholder consultation and an annual Quality report. There are processes in place to safeguard the financial interests of residents. The health, safety and welfare of the people using the service are protected and safeguarded. Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 23 EVIDENCE: Policies and Procedures are reviewed and updated yearly or on an as and when needed basis. It is recommended that when policies and procedures are updated that the date of updating is put on the bottom of the page. The staff reported that the Manager is approachable and has an open door policy so is accessible at all times. They feel they have good support from her and have had their annual appraisal with her. The Manager reports that supervision for all staff is in place as required and it happens in variable forms i.e.: team, individual, group and as issues arise, this is satisfactory as long as the Manager can evidence to the CSCI Inspector that all staff receive supervision at least six times a year and records kept.. Generally these documents are being sent to the HR department for filing on personal files this was discussed with the Manager and it was suggested that these remain at the home, the Manager will consider this. Yearly appraisals are undertaken and staff complete a self-assessment questionnaire prior to their appraisal and then this is discussed during the session both parties sign this record and any action agreed from this meeting. Staff pay incentives have been introduced and these are linked to statutory training completion, performance and attendance at work and this is reported to work well in motivating staff. Evidence was available to demonstrate that staff receive mandatory training and other training pertinent to their needs. This is implemented through the ‘in-house’ training department and includes fire, health and safety, moving and handling, food hygiene and first aid training etc, the training records for some staff were seen. The Manager meets domestic staff every six months and they are supervised by the Manager and the deputy. Maintenance staff are supervised by the Maintenance Supervisor and catering staff by the Catering Manager. There are a variety of regular minuted meetings for the home, a Home Managers meeting every month; Coffee mornings (Residents meetings) every three months to gain feedback from the residents about the running of the home etc and these are very well attended, minutes were seen. There is also a Faithfull House visitors committee meeting three times a year where the voluntary visitors meet with the Manager and talk through concerns /issues. These volunteers act as a support network for residents and visit residents as and when they wish them too or act for them if there is a concern. The Manager has completed the Fire risk assessment of the home and this is documented. She audits the Homes Environmental Risk Assessments that are in place. Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 24 The Lilian Faithful Homes have Quality Assurance systems in place and the home has accreditation for Investors in People and ISO 9001. The Manager has a comprehensive array of documented auditing tools in place; every three months a management audit is undertaken on a specific area of management. These are done throughout the year to examine quality and effectiveness of systems in the home. It was recommended that these audits be kept at the home to demonstrate the outcome of the audits and the action implemented for continuous improvement. Some of these audits were seen during the inspection; the accident audit is informal and requires formalisation. Auditing tools for care practice need to be formalised and developed further. Whilst the home audits residents and relatives views it is essential that views be sought from GPs, chiropodists, hairdresser, Community Nurses and other community stakeholders to give a holistic assessment of the quality of service provided to residents by the home. All of this information should then be drawn together to form an internal quality audit that is published in the home to demonstrate the strengths and improvement areas for the home to benefit the people living there. This information would then inform the annual development plan for the home and demonstrate the cycle of continuous improvement and quality of service that the home strives for. All financial dealings are completed through the invoicing system except for personal monies. Most residents manage their own personal monies and lockable facilities are available. Residents cash cheques with head office and the Manager has an accounting system for this with written records of transactions and it is auditable. All the required documentation is in place and is stored securely. The organisation is not registered under the Data Protection Act 1998 due to it being a ‘not for profit company’. The home has recently had its computer system networked with the head office of the organisation and information systems should be fully functional by April 2007 with all relevant information readily available to the Manager. All the required Health and Safety checks were in place in the home and documentary evidence was available pertaining to this including suitable insurance cover. Faithfull House DS0000016436.V316873.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 4 3 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X 3 3 3 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 3 3 3 3 4 Faithfull House DS0000016436.V316873.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. 1. 2. Standard OP1 OP26 Regulation 4(1 &2) 13(3) Requirement Timescale for action 20/07/07 3. OP33 24(1) Revised Statement of purpose and service user guide to be sent to the Commission To prevent an infection control 20/07/07 hazard in the laundry the Registered person must: • Remove the chest of drawers that has chipped surfaces and cannot be cleaned properly. • Reseal the wooden beading on the storage shelves, as it is chipped and potentially permeable. The Registered person must 20/07/07 ensure that: • Management audits are kept at the home to evidence outcomes of audits and action implemented for continuous improvement. • A formal documented accident auditing system is put in place to evidence the informal auditing that takes place. • That auditing tools for DS0000016436.V316873.R01.S.doc Version 5.2 Faithfull House Page 27 4. OP33 24(2) care practice are developed and formalised further. The Registered person must produce an annual quality assurance report to evidence the review of the quality systems in the home. This must include stakeholders’ views and future developments in the home. 20/07/07 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. Refer to Standard OP33 OP33 Good Practice Recommendations When policies and procedures are updated the date of updating should be put on the bottom of the page. A quality assurance policy and procedure should be devised to detail how the systems are used within the home and how this affects the development of the service. Whatever the means of supervision there must be a record for each staff member to evidence its occurrence for the CSCI Inspector. 3. OP36 Faithfull House DS0000016436.V316873.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 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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