Inspection on 21/07/08 for Favorita House

This inspection was carried out on 21st July 2008.

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

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

Other inspections for this house

Favorita House 23/10/06

Favorita House 09/11/04

Favorita House 29/06/04

Similar services:

Springfield House

Southfields

The Shelley

Thorndene

Sutton Lodge Nursing Home

Insight - Eastchurch

Magenta

Seabourne House

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

CARE HOMES FOR OLDER PEOPLE Favorita House 28 Canterbury Road Herne Bay Kent CT6 5DJ Lead Inspector Chris Woolf Unannounced Inspection 21st July 2008 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Favorita House DS0000023411.V367454.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. Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Favorita House Address 28 Canterbury Road Herne Bay Kent CT6 5DJ 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) 01227 374166 admin@favorita.co.uk Mr Kevin Gordon Post Mr Peter Post, Mrs Teresa Post Mrs Pauline Anne Gough Care Home 16 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (15) of places Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 person has a learning disability has a d.o.b of 16/11/44 Date of last inspection 23rd October 2006 Brief Description of the Service: Favorita House is registered to provide care for up to 16 older people. There is a condition of registration which enables them to care for one service user with learning disabilities. The home is located on the main road into Herne Bay. Local shops and the sea front are all close by and local transport is easily accessible. Although there is on street parking outside the home this is time restricted. There are 14 bedrooms including 2 that are registered for double occupancy but which are currently used as singles. The home is laid out over 2 floors and there are stair lifts available to access the two levels of the upper floor. Communal facilities include a main lounge, a dining room, a smaller lounge/dining room, and a small conservatory. The current fees for the service at the time of the visit range from £320.63 to £539.25 per week. Information on the Home’s services and the CSCI reports for prospective clients will be detailed in the Statement of Purpose and Service User Guide. The e-mail address of the home is admin@favorita.co.uk, and the web site address is www.favorita.co.uk Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Key Lines of Regulatory Assessment (KLORA) have informed the judgements made based on records viewed, observations made and written and verbal responses received. KLORA are guidelines that enable the Commission for Social Care Inspection (CSCI) to make an informed decision about each outcome area. The information for this report has been gained from an Annual Quality Assurance Assessment (AQAA) completed by the service; notifications of significant events submitted by the home since the last inspection; comment cards received from 6 clients or their representatives, 6 members of staff, 4 care managers, and 3 health care professionals; and a site visit to the service that lasted 6 hours and 55 minutes. The site visit was unannounced. This means that neither the staff nor the clients knew that we (the Commission) were going to visit. During the site visit we spoke with the majority of the clients, 4 in more depth, staff on duty, the Registered Manager and the Provider. Observations were made of clients enjoying coffee and lunch in the dining room, taking part in afternoon activities, and the way in which the staff interacted with the clients. We had a tour of the building and observed its cleanliness, maintenance, and infection control procedures. We looked at medication including administration, policies, storage, and records. A variety of other records were in inspected including care plans, complaints information, records of monies handled for a client, staff recruitment files, staffing rotas, staff training matrix, quality assurance records, and some health and safety records. The people who use this service are referred to as clients and this term has been used to describe them throughout the report. Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Environmental improvements during the past 12 months include the purchase of new chairs for the dining room and lounges. New curtains have been fitted in the dining room and 4 bedrooms. New carpet has been laid in the dining room and 1 bedroom. 2 bedrooms have been redecorated. New net curtains have been hung. 3 new televisions have been purchased. Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 7 2 additional members of staff have completed their NVQ (National Vocational Training) since the last inspection, and all staff are currently doing a course on dementia 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. Favorita House DS0000023411.V367454.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 Favorita House DS0000023411.V367454.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): 3, & 4. Standard 6 is not applicable in this home Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective clients and their representatives have the information needed to choose a home that will meet their needs. EVIDENCE: Prospective clients and their representatives can access the homes web site, and their statement of purpose and service user guide to give them detailed information about the home. All comment cards received confirmed that clients were provided with sufficient information prior to admission. Comment cards also confirmed that clients have received a contract. Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 10 Before arrangements are made for any client to be admitted to the home the manager and/or one of the proprietors visits them to carry out an assessment of their needs. This assessment looks at the client’s immediate health care needs in order to ensure that the home can meet these needs. Once the client is happy with the home and the home is satisfied that it can meet the client’s needs, a second assessment is undertaken. The second assessment is to establish information about life history, values and beliefs, routines, and likes and dislikes etc. Where a client has been allocated a care manager prior to admission a copy of the County Council assessment is also received. The homes has a policy to only admit clients whose needs they are confident of meeting. Care Manager comment cards included, ‘The home appear to be meeting all the needs of the clients. If a client is ill the home put in intensive care until client is better’, ‘The home copes very well with clients unsocial and sometimes aggressive behaviour’, and ‘The home appear to meet the needs of all my clients who reside at the home’. The home’s AQAA confirms that ‘When specialist services are required they are accessed from the community’. A comment card received from a client/clients representative included, ‘It was the best move we have made it is an excellent home’. This service does not offer the facility of intermediate care, which is a specialised service with dedicated accommodation, facilities, equipment and staff, designed to deliver short-term intensive rehabilitation and to enable clients to return to their own homes. Favorita House DS0000023411.V367454.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that clients receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: A holistic, person centred care plan is in place for each client. The care plan is based on information gained during the pre-admission assessments and is updated and reviewed monthly. All care plans examined were person centred and included a variety of individualised risk assessments. The homes AQAA says, ‘The care plans include various risk assessments, information on things the clients are able to do and things they would like help with, and details of Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 12 their activities, hobbies and past times. A nutritional assessment is completed and weights are recorded monthly. Visits to doctors and other health care professionals are recorded, and a daily report is completed at least twice daily’. All care plans seen had been reviewed on a monthly basis. Care manager comment cards confirmed that accurate information is gathered and that the correct service is always planned. Comments included, ‘Risk assessments and care plans reflect clients individual risks and needs accurately, they are not generalised’, and ‘Care plans reflect the client’s individual needs’. Each clients health is promoted by the home supported by a multidisciplinary health care team. Any suspected pressure areas that are identified are reported to the district nurses who give assistance and support as required. Evidence was seen in the care plans of contact with Doctors, District nurses, chiropodist, speech therapist and optician. Clients said, “I get a new hearing aid on Friday”, “They look after me”, “Since I have been here she has gone downhill”, and “They arrange for a doctor when I need one”. A client confirmed that her spectacles had been returned to the optician for repair as she had broken them. Comment cards received from clients and their relatives confirmed that they always receive both the care and support, and the medical support that they need. Comments included, ‘He has the best of support he needs’, ‘They are very good at sorting out his medical needs’, and ‘My relative requires round the clock care and as far as I am concerned she is looked after extremely well in very friendly surroundings’. A health professional comment card said that the home, ‘Responds to clients needs appropriately gauging need for face to face consultation’. Care managers confirmed that individuals health care needs are properly monitored and attended to by the home. Their comments included, ‘The home always liaise with/seek advice from members of multidisciplinary team’, and ‘Since my client has been living there their health has improved and they appear far more settled and happier’. The homes AQAA states, ‘Our medication records show the recording of receipt, administration and disposal of medication in the home and we feel that the storage of medication meets current good practice. A lockable drugs fridge is provided when required and there are photographs of clients in the medication administration record book. 2 members of staff carry out all administration of medication to ensure safety and administration of medication is undertaken discreetly and appropriately. All members of staff who administer medication have received relevant training’. This was confirmed through observation and inspection of records on the day of the site visit. A care manager comment card stated, ‘Medication is requested to be reviewed by the home on a regular basis’. Currently the home does not hold any controlled drugs. We advised the manager of the recent change of regulations regarding the storage of controlled drugs and suggested the purchase and Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 13 fitting a Controlled Drugs cabinet that meets the regulations, be considered, ready for use if and when needed. Clients are generally treated with dignity and their privacy is respected. Clients and their clothes are kept clean and tidy. Clients comments included, “They make sure I’m clean and tidy”, “They do their best for you”, and “The girls are very kind”. Staff address clients by name or appropriate endearments instead. Staff said, “We always try to shut the doors when clients are in the toilet”, “We promote privacy and dignity as best we can”, and “We try”. Favorita House DS0000023411.V367454.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 good. This judgement has been made using available evidence including a visit to this service. Clients are able to make choices about their life style. Social, cultural and recreational activities need to be expanded to meet individuals expectations EVIDENCE: The home does not have a formal activities programme or an activities coordinator. Activities that take place are organised by the care staff. The homes AQAA says, ‘We remain vexed on how we can engage clients in activities with more success although when asked, our clients state that they are happy with what they are doing. We would however still like to establish more interactive activity’. Client comment cards were varied in their response about activities and included the comments, ‘I don’t want to, I go out’, ‘I don’t join is as it is not something I do, I like my own company’, to ‘I would like to see a bit Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 15 more entertainment and activities, as there seems to be a lot of sitting around and sleeping in the day’. A health care professional commented, ‘Possibly more ‘stimulating’ interaction with clients to encourage more intellectual challenges’. A care manager comment card also said, ‘More activities would be good’. A staff comment card answered the question what could the home do better, ‘Maybe do a few more activities with the clients’. Clients’ religious and cultural needs are taken into consideration. A Roman Catholic priest visits the home every 2/3 weeks. The manager confirmed that services from another denomination were offered but that none of the clients were interested. One client told us, “I’m a Roman Catholic, I want to see the Priest”. This was discussed with the manager who confirmed that, although her information is that the person is not a Catholic, she would arrange for the priest to see this client on his next visit. On the day of the site visit Staff said, “The activities are fine but the clients are apathetic, we do bingo, dominoes, skittles, balls and balloons”, “We did have musical activity”, and “The clients prefer things like reminiscence”. Discussions were held with clients and staff about activities and trips out. Clients said, “We get bored”, “You can’t go anywhere here”, “I go out the front and watch people going past”, “I enjoy doing my word searches”, and “It would be nice to get out to the sea front for an ice cream”. Staff commented, “There is a party at Kimberley sometimes and our clients are invited, they had a singer there”, “I took some of them to the pub”, “Quite a few like to sit in the garden”, and “There is not enough time to take clients out, but when they do get the opportunity they won’t go”. Activities and outings were discussed with the Manager who confirmed that she would try to arrange for clients, particularly those whose family do not take them out, to be taken out more often. She also confirmed that she would look into increasing the activities on offer in the home. The home has recently changed their hairdresser and the new person visits weekly as opposed to the previous person who only visited once a fortnight. The weekly service gives clients a better opportunity of look after their appearance and to enhance their self-esteem. A client said, “We have got a new hairdresser, she is good”. Clients are encouraged to keep in touch with their friends and family and there are no restrictions on visiting times. Clients commented, “My family are taking me to the hospital for my new hearing aid”, “My wife visits me twice a week”, “I see people taking their mums out”, and “They all come and visit”. Clients are supported to exercise choice and control over their lives as far as they are physically and mentally able. A client said, “I can’t get used to being here, I have always been on my own and would prefer to live on my own but know I cant, but the staff are very kind and will do anything they can for you”. Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 16 Choices are given in all aspects of daily life from time of getting up and going to bed, choices of food, what to wear, where to sit and who to sit with, and whether to watch TV or join in activities. Staff commented, “They have choices for their needs and capabilities”, and “Choices include food, clothes, where to eat, whether to lay in, what time to go to bed, video’s etc”. The home provides clients with a balanced, wholesome and varied menu. Vegetables are steamed for freshness and flavour. Comment cards from clients and their representatives confirmed that clients always or usually like the food. One added, ‘They are nice meals and are always prepared so I can eat them alright’. There is a choice of food for each meal and the cook asks clients during the morning which choice they would prefer for lunch. If the client does not like either choice a further alternative is found. Care staff were observed asking clients what they wanted for tea and giving choices. Pureed food is served in separate portions to look as normal as possible. The meal observed on the day of the site visit looked appetising, was attractively served, and was served at an appropriate temperature. The home has achieved 4*, very good, Scores on the Doors from the Environmental Health department for their kitchen cleanliness. Client comments on the day of the site visit included, “The food is nice”, “The meals are alright”, and “I like the food”. A member of staff said, “The food is fine”. Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 17 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, & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients and their representatives are able to express their concerns, and have access to a robust, effective complaints procedure. Clients are protected from abuse. EVIDENCE: The home has a robust complaints policy and a copy is on display in the entrance hallway. There are also forms readily available for the use of anyone wishing to make a formal complaint. There have been no complaints made to, or about, the home since the last inspection. Comment cards received from clients and their representatives confirmed that they knew how to make a complaint, and knew who to speak to if they were not happy. Comments included, ‘I have no need to complain as they look after me very well’, ‘When I visit my relative she is very content in the circumstances. The communication between me and the owners of the home is excellent’, ‘Everything is done for me, but if I have a problem they look into it’, and ‘I have no complaints at all I am well looked after by everyone’. Care manager comment cards included the Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 18 statements, ‘No concerns raised’ and ‘No complaints from relatives of client’. Comment cards received from staff confirmed that they know what to do if a client or visitor has concerns about the home. Clients in the home are protected from abuse. Since the last inspection no adult protection alerts have been raised regarding the home. No new member of staff is employed in the home until a satisfactory check of the protection of vulnerable adults register has been received. The majority of staff have been trained in the Protection of Vulnerable Adults and courses are being arranged for those not yet trained. The staff spoken to on the day of the site visit confirmed that they had received training about abuse, and that they were aware of the whistle blowing policy and the action to take if they suspected abuse. Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 19 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, 20, 24, & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables clients to live in a safe, well-maintained and comfortable environment. EVIDENCE: The home is suitably located with easy access to the facilities of Herne Bay and the seafront. There is some on street parking at the front, but this is limited to a restricted time. The home is well maintained, comfortable and homely. Bedrooms are situated on the ground floor, and a first floor which is Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 20 set out on two levels. There are 2 stair lifts in the home to provide access to the upper rooms. Since the last inspection environmental improvements have included the purchase of new chairs for the dining room and lounges; new curtains have been fitted in the dining room and 4 bedrooms; new carpet has been laid in the dining room and 1 bedroom; 2 bedrooms have been redecorated; new net curtains have been hung; and 3 new televisions have been purchased. A care manager comment card included the comment, ‘The home always appears homely and well run’. Clients were observed sitting in the front garden and enjoying ‘watching the world go by’. One commented, “I come out here a lot, I like to sit here, I enjoy the fresh air”. Shared facilities include a main lounge, a dining room, a smaller lounge with dining area, and a small conservatory. Furnishings and fittings are all domestic in character and suitable for the needs of the clients. Client’s bedrooms are personalised to meet their own needs and wishes. A comment card from a care manager included, ‘Clients are encouraged to have their own possessions, not only in their bedroom but around the home’ and this was observed on the day of the site visit. All bedrooms are fitted with wash hand basins, nurse call system, lockable doors, and lockable facilities for valuables. Although the home has 2 rooms that are registered for occupation by two people, at present all are occupied as single rooms. Privacy screens are available should the rooms be occupied by two people at any time. The home is clean and odour free. All comment cards received from clients and their families confirmed the home is always clean and fresh. They stated, ‘Everywhere is spotless; it is a credit to the staff’, and ‘Certainly when I have visited the home is fresh and clean’. The home has an effective infection control policy, and appropriate infection control procedures are in place. A discussion was held with the manager on the day of the inspection regarding measures which would further benefit the home and clients, and she agreed to look into these. The homes AQAA states, ‘Whilst we do not yet have a washing machine with the specified programming ability to meet up to date disinfection standards, we are aware that special care needs to be taken in this area. In 41 years of operation we are unaware of a noticeable problem generated by this system but we are not complacent and intend to upgrade when the machine requires replacement’. Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 21 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 adequate. This judgement has been made using available evidence including a visit to this service. Some adjustments to the staff compliment and implementation of the planned updates of staff training would enable staff in the home to support the clients more effectively. EVIDENCE: Staffing levels at the home are adequate to meet the needs of the clients. A client comment card included, ‘There’s always staff about if needed’. The homes AQAA states, ‘There are ancillary staff to ensure the home is kept clean and hygienic and that the clients’ dietary needs are met’. A cook is employed but staff confirmed that at present there are no separate staff for cleaning duties. Staff comment cards stated, ‘Staffing is covered (when sick or annual leave) with either other members of staff or agency, who sent the same lady to maintain continuity’, ‘Standard answer (to are there enough staff) is never enough people. Always enough people according to rules and regulations but never enough time for staff to feel they have done tasks well. Even in small homes carers should be there to care for most of needs of clients but not to Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 22 carry out cleaning/domestic chores. Clients and home are well cared for but staff get disillusioned at having to wear so many hats’, and ‘if the powers that be would desist from finding more and more paperwork (reports, surveys, questionnaires) for us to fill in we might have a chance to finish some of our work. I know paperwork is necessary but a small home does not have enough manpower hours to get on top of it all’. A health care professional comment card said, ‘Staffing numbers and time with clients we would imagine is a constant issue’. Comments made under the outcome area Daily life and Social Activities support the fact that the home should keep staffing levels under review to ensure that all of the assessed needs of the clients, including social care, are met, and a recommendation is about this. The majority of staff working at the home are trained to NVQ level 2 or above, and it is planned for newer staff to start this training. Staff said, “I have NVQ 2”, “I have not done my NVQ yet”, and “Yes, I have NVQ Level 2 and 3”. The home has robust recruitment policies and procedures. No new member of staff is employed until 2 satisfactory references have been received, an enhanced disclosure has been submitted to the Criminal Records Bureau, and a satisfactory check of the Protection of Vulnerable Adults register has been received. The homes application form currently asks for a 10-year employment history, whereas the current requirement is for a full employment history. This was discussed with the manager and she indicated that she would obtain a full employment history for all staff. All staff are issued with a statement of terms and conditions, and all are made aware of the General Social Care Council Code of Conduct. Some staff training in mandatory subjects is now out of date, although the manager is currently organising courses to address this. A requirement has been made about this. All staff are currently undertaking a course on dementia. The manager has recently attended training on the Mental Capacity Act. All staff that administer medication have been trained in the safe handling of medication. Staff comments included, “We all did fire training last week”, “I am due for an update in First Aid”, “I have done medication training”, “We are due updates in moving and handling”, and “Yes, we have all done infection Control”. A health care professional comment card stated, ‘Staff, especially the manager, seem to have a good understanding of the needs of elderly people who need ‘care’’. General comments about the staff from clients included, “They are all nice girls”, “The staff are beautiful”, and “The girls are very kind”. Staff said, “I like working here”, and “We are a happy band the majority of the time”. Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A qualified and competent manager is in charge of the home and ensures that management and administration is based on openness and respect. Effective quality assurance systems are in place to ensure that the home is run in the best interests of the clients. The health, safety and welfare of clients and staff is promoted and protected. EVIDENCE: The registered manager is qualified, competent and experienced to run the home and to meet its stated purpose, aims and objectives. Recent health Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 24 issues have prevented the manager from ensuring that all staff training is fully up to date but she now has this in hand. Staff confirmed that the manager is supportive to them, one said, “Yes we get support from the management if not we would not stay”. The provider is also very supportive to the home and visits most days. Clients comments about the manager included, “Pauline is all right, she is a nice little lady”, “Pauline is wonderful”, and “Pauline would do anything for you”. One health care professional comment card included, ‘The clients are lucky to have an extremely diligent, conscientious, hard working and most importantly of all kind manager looking after them’. The home completed its AQAA and returned it to us by the due date. It gave us all of the information we required, although we would like to see the home being more proactive in identifying areas of possible improvement. The home has developed its own quality assurance system to ensure that it is run in the best interests of the clients. When questionnaires are returned they are analysed and any comments needing attention are actioned. When the next questionnaires are returned the manager has agreed that she will produce a written analysis. A copy of this should be readily available for clients and their representatives to view. Extracts taken from Quality Assurance Questionnaires viewed on the day of the site visit include, ‘Favorita is a friendly, welcoming home where nothing is ‘hidden’ from visitors - who are always made welcome by staff. I can only praise the quality of care provided for my mother in the few months she has resided there’. ‘The quality of care to her health and needs has been excellent and our thanks go to all the staff’. And ‘I am very pleased with the home. Thank you for looking after dad’. The home only helps one client with finances. The manager collects this client’s allowance and the client then signs for it. Individual clients or their representative deal with all other clients’ monies. The home protects and promotes the health, safety and welfare of clients and staff. All safety records seen were up to date. Some health and safety related training is currently in need of update but the manager is addressing this issue. This is discussed under the section on staffing. The AQAA tells us, ‘On 18 September 2007 the Home was assessed by Canterbury City Council under its Scores on the Doors scheme. This is a scheme which lets the public see the latest hygiene rating following a programmed food hygiene inspection carried out by food officers in the Councils Commercial Health Team. The score is shown by a star rating. The Home achieved a 4 star rating (a maximum of 5 being achievable) being classed as Very Good with Good food safety management, and a High standard of compliance with food safety legislation’. A copy of this certificate is proudly displayed in the home. Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Favorita House DS0000023411.V367454.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 Standard OP30 Regulation 18 (c) (i) Requirement Staff training in the mandatory subjects and POVA should be kept up to date and valid. Timescale for action 31/10/08 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 Refer to Standard OP27 Good Practice Recommendations Staffing levels should be kept under constant review to ensure that the holistic needs of the clients are being fully met. Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Favorita House DS0000023411.V367454.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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