Inspection on 07/04/08 for Felmingham Old Rectory

This inspection was carried out on 7th April 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Felmingham Old Rectory 28/08/09

Felmingham Old Rectory 20/07/09

Felmingham Old Rectory 03/04/09

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Felmingham Old Rectory Aylsham Road Felmingham North Walsham Norfolk NR28 0LD Lead Inspector Mr Jerry Crehan Unannounced Inspection 7th April 2008 09:45 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 Felmingham Old Rectory DS0000071073.V362067.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. Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Felmingham Old Rectory Address Aylsham Road Felmingham North Walsham Norfolk NR28 0LD 01692 405889 01692 405528 felmingham@bondcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross BC OpCo Ltd 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) Linda Henden Care Home 41 Category(ies) of Dementia (41), Old age, not falling within any registration, with number other category (41) of places Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 41 2. Dementia - Code DE, maximum number of places 41 The maximum number of service users who can be accommodated is: 41 30th August 2007 (Under new ownership since September 2007). Date of last inspection Brief Description of the Service: Felmingham Old Rectory is situated in the village of Felmingham, approximately 2 miles from North Walsham on the Aylsham Road. The building has two extensions and is registered as a care home to provide accommodation for older people with dementia. There are 31 single and 5 shared bedrooms, many with en-suite facilities. The home is situated within two acres of landscaped gardens, including an enclosed area. There is parking space to the front of the premises. The home provides information about the services it provides and a copy of the most recent inspection report in the entrance foyer. Felmingham Old Rectory is one of several homes in Norfolk owned by the proprietors. The range of weekly fees for the home is £390 - £591. Felmingham Old Rectory DS0000071073.V362067.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 1 star. This means that people who use the service experience adequate quality outcomes. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. This report gives a brief overview of the service and current judgements for each outcome group. Before the inspection the manager of the service completed a lengthy questionnaire about the service. One comment card was received from people who live at the service. Eleven comment cards were received from relatives of people who use the service; four comment cards were received from staff who work at the service. These reflected some positive views about the home and care provided there, such as ‘friendly pleasant staff and warm and comfortable surroundings’, however some contained a negative theme concerning greater care needed with laundry and the sometimes poor appearance of some residents’ clothing. There were positive comments about the service made by people spoken with at the time of the inspection visit. Records held by the Commission and previous inspection reports were checked. This key inspection comprised an unannounced visit to the home that took place over 9.5 hours on 7th April 2008. Opportunity was taken to tour the premises, look at care records and policies, and communicate with residents, care staff, the manager and other senior managers who were visiting the home at the time of the inspection visit. The inspection report reflects regulatory activity since the last inspection and evidence from inspection of Key Standards. Following a number of environmental requirements set out in this report, it has been recommended that a fundamental review of the standard and suitability of the accommodation provided at the home should take place. It should consider the physical and mental health care needs of residents as well as their safety. What the service does well: Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 6 • People who use the service receive good health and personal care that is based on their individual needs and set out in their individual care plan for care staff to follow. Care delivery observed during the inspection visit was good. Carers interaction with residents was professional and courteous, and staff, who although very busy, take their time to assist residents. People who use the services have access to a good diet and meals that are well prepared and served in congenial surroundings. Social and recreational activities are on offer at the home and feedback from residents indicated these are sufficiently varied to meet individual’s needs and expectations. Care staff understand and respond to residents’ need for activity and stimulation. The home benefits from substantial grounds and gardens that are attractively kept. Staff are supported through the availability of good induction and mandatory training. The manager continues to manage in a professional way ensuring that any issues are looked at and dealt with appropriately. She has also managed to provide continuity and stability for residents following the change in ownership of the home. • • • • • • What has improved since the last inspection? • Aspects of the environment at the home have been improved since the last inspection, including the fitting of grab rails around the home’s corridors, a new carpet for the main lounge, some new dining furniture, some new lounge chairs and some replacement windows. New style care records being put in place reflect information gathered at the pre-admission visit and other information relevant to their health and personal care. • Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 7 What they could do better: • A recommendation has been made that carers who have a particular responsibility for coordinating individual resident’s care matters (‘keyworkers’) check the adequacy of residents’ wardrobes and liaise with relatives if new or extra clothing is required. The manager and staff try hard to support residents to manage as much of their own personal care as possible, including dressing. Though striking the right balance to ensure residents’ dignity is not compromised must also be ensured. A significant number of environmental improvements are still necessary to ensure the comfort, safety, privacy and dignity of residents. This includes a continuation of the programme of internal redecoration in individual and communal accommodation. For a home of its size offering care to (up to) 41 people the equipment offered does not adequately meet the assessed needs of residents. The provider should consider how best to make gardens safe for residents as there is a potential risks from trees, which needs to be assessed. Gardens could also be made more accessible and suitable to people with cognitive impairment. There is good dementia care provided at the home, but it needs to be developed to a more professional standard. The provider must ensure that staff that are qualified to a more advanced level in providing dementia care meet the mental health needs of people using the service. All staff at the home must be formally supervised. This will help to ensure that care provided meets the needs of people who use the service and the philosophy of care in the home. • • • • • • 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. Felmingham Old Rectory DS0000071073.V362067.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 Felmingham Old Rectory DS0000071073.V362067.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): Standards 1 & 3 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective people to use the service have their needs assessed, and access to all of the information they need about the service they may choose. EVIDENCE: The provider has an updated ‘Statement of Purpose’ and ‘Service User Guide’ to reflect the services provided at the home since the change of ownership in 2007. These documents contain sufficient information for anyone to make an informed choice about long-term care. The Service User Guide contains a summary of the home’s complaints procedure, which is available in every resident’s room. There is a well-designed assessment pro-forma (pre-admission assessment) used by the manager when collecting information to ascertain the level of Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 10 support required by prospective residents. The manager continues to visit prospective residents and also encourages them and their families to visit the home. There is evidence of assessment for these residents seen in their files, and the manager stated that she always seeks to visit prospective residents in their accommodation prior to admission. A sample of files was looked and at provided evidence of comprehensive individual needs assessment for prospective residents. Assessments seen addressed healthcare, social care, life history, and psychological needs that formed the basis of individual care planning and risk assessment. Felmingham Old Rectory DS0000071073.V362067.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): Standards 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use services have good care records that support personal care based on their individual needs. Staff provide good healthcare support to people who use the service. EVIDENCE: A sample of residents’ care files containing individual care plans was reviewed. All the care plans were well detailed regarding their personal, physical, social and mental health care needs. Care files at the home are currently transferring to the format used by the new proprietor. At the time of the inspection visit this meant that several residents have some information in an old file and some in the new, however all of the information required for care was present in one or other file. The manager stated that the home is working towards all information transferring into the new file as soon as possible. Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 12 Some of the care files examined provided evidence that residents’ names are incorrectly recorded. Each of the plans seen included a range of risk assessments of individual care needs, such as continence, falls & mobility, nutritional needs and other health matters such as tissue viability and risks from pressure areas. Other care documents such as turn charts for residents at risk from developing pressure areas were available in their bedrooms and completed by care staff according to the residents’ care plans. Care delivery observed during the inspection visit was good. Carers’ interaction with residents was professional and courteous, and staff, who although very busy, take their time to assist residents. Residents spoken to during the inspection visit spoke favourably about care staff and the quality of care they provide. It was evident through discussion with staff and the manager, and through direct observation, that the manager and staff try hard to support residents to manage as much of their own personal care as possible, including dressing. Though striking the right balance to ensure residents’ dignity is not compromised must also be ensured. Evidence of community healthcare services such as nursing, chiropody, hearing, dental and psychiatric services were sought for those who required these. The district nurse was visiting the home at the time of the inspection visit. Senior staff and care staff were attentive to a resident who appeared a little unwell, exploring appropriate options to address their possible ill health while offering reassurance to them. There is a monitored dosage system for medication. Only members of the home’s management team or senior staff are responsible for medication handling and administration. Medication seen was stored securely and appropriate records were kept for the receipt of medication into the home, its administration and any medication returned to the pharmacy. Sample audits of medication were undertaken and records tallied with medication held. There are clear guidelines for care staff in the event of administration of ‘PRN’ (when required) medicines. Members of the proprietor’s management team carry out medication audits periodically. Such an audit was carried out on the day of the inspection visit. The results of this audit were shared with the manager with recommendations to act upon. Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 13 Residents spoken with said that their care staff listen to them and treat them with respect. Residents were also clear that staff at the home respect their right to privacy. This was in evidence throughout the inspection visit. Felmingham Old Rectory DS0000071073.V362067.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): Standards 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the services have access to a generally good diet and meals that are well prepared and served in congenial surroundings. Social and recreational activities are on offer at the home and sufficiently varied meet individual’s needs and expectations. EVIDENCE: Residents spoken with during the visit stated that there are activities on offer to choose from, one person stating that they particularly ‘like to dance’. This view was supported by some comments received from relatives who said that the home supports residents to participate in group events, though comment was also made that a shortage of staff sometimes prevents trips outside for walks in the garden. Activities observed during the visit included a colouring activity in a communal room dedicated to activities of various kinds. During the afternoon residents participated in music and dance and were offered afternoon tea and coffee in the main lounge area. Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 15 The manager had recently appointed a dedicated activities coordinator and stated that they will be planning an activities schedule to meet the needs of all residents, including those who cannot or prefer not to participate in joint or group activities. The manager stated that there is a mini bus for trips outside of the home. However, the vast majority of activities are those that take place within the home. Aside from those indicated above, there are entertainments brought in to the home such as sing-a-long entertainers, and ‘Pleasant Pastimes’ who visit weekly for activities such as games, crosswords, reminiscence, bingo and quizzes. Some residents were observed reading their preferred daily newspaper, which were delivered to the home each day. The manager stated that the local vicar visits on a regular basis and that residents can take Holy Communion if they wish. Residents’ visitors are made welcome and there were visitors to the home at the time of the visit. However, environmental limitations restrict residents’ and visitors’ ability to meet privately other than in the resident’s bedroom. Where bedrooms are shared this is a particular problem (see Environment section of this report). Advocates are in place for residents who require someone to represent their interests. There is advocacy information (‘Care Aware’) available in the foyer. There were staffing difficulties in the kitchen at the time of the inspection visit. Consequently the advertised menu options were not available. However, a reasonable, well-cooked and well-presented alternative was made available at relatively short notice. Residents evidently enjoyed their meals and commented that lunches are usually good with choices on offer. At lunchtime care staff were observed catering for residents’ particular preferences. The meal was served in a congenial setting. Dining tables were well presented with clean tablecloths and napkins. Drinks were available at dining tables; however, the availability of water or soft drinks was generally very limited at the home and in residents’ bedrooms. The manager confirmed that a hot tea option would be available to residents late afternoon/early evening, particularly as the lunch option was lighter than usual. Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements for responding to the concerns and complaints of people who use the service are good. People who use the service are protected from abuse. EVIDENCE: The manager keeps a record of all complaints. The manager has dealt with one verbal complaint since the previous inspection, which was managed appropriately. The home has a detailed complaints procedure and information on how to make complaints is detailed in the home’s guide for residents. Residents spoken with during the inspection visit stated that they would be happy to speak with carers if they had a concern or complaint. Each of the staff spoken with during the inspection visit were clear about the action they would take if concerned about the possibility of abuse taking place at the home and were confident that they could deal with this appropriately. They were sufficiently aware of the home’s ‘Whistle-blowing’ procedure and its function. The majority of staff have undertaken ‘Protection of Vulnerable Adults’ (POVA) training with further training on offer over coming months. The current training programme is detailed, including identification of what abuse is, different kinds Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 17 of abuse, the role of the carer in dealing with reported or witnessed abuse, and defining a vulnerable adult. Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 24, 26 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment at the home has been improved since the last inspection. The layout and design of the home does not adequately meet the needs of residents, ensure their privacy and dignity and to ensure that it is suitable, comfortable and enabling for people with dementia. EVIDENCE: The last inspection carried out in August 2007 found improvements being made to the décor of the home and the garden. Since then a number of improvements have been made including the fitting of grab rails around the home’s corridors, a new carpet for the main lounge, some new dining furniture, some new lounge chairs and some replacement windows. There is also improved signage to assist residents in identifying their own accommodation. Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 19 Many, though not all, of the bedrooms seen were personalised and furnished to a satisfactory or good standard. In general those bedrooms in the older part of the home are less satisfactory. There are several old and worn beds, bedding and pillows. Many residents’ bedside cabinets are not fitted with locks, including some of those in the five shared bedrooms at the home. Some residents’ bedroom windows are misted from condensation where double glazed units have failed. There are various stores of old clothing about the home that do not belong to current residents. The home was generally free from unpleasant odours but laundry baskets containing dirty linen had not been taken to the laundry and were left in bathrooms. The baskets also restricted the space available in bathrooms creating a potential hazard. Some external window frames at the front of the main building are rotten in places. There is no recorded environmental assessment of the suitability and safety of the first floor door to the main rear staircase at the home. There is currently no dedicated communal space in which residents can meet their visitors privately. At the time of the inspection visit to the home there were two portable hoists in working order, however, a stand aid preferred by some residents could not be used as a replacement part was awaited. There are four assisted bathrooms at the home, each with a manual hoist in situ. At the time of the inspection visit two of these could not be used due to worn parts awaiting repair/replacement. There is no assisted shower room at the home. Bath hoists are very old and some bathrooms are very limited in size making it difficult for residents and staff alike. Some bathrooms and toilets were not lockable and anybody could walk in at any time. There are well kept and substantial grounds and gardens that residents may benefit from. There are still some potentially harmful plants and trees in the garden including a large yew tree next to the patio area. Gardens are not yet fully accessible and suitable to people with cognitive impairment. The manager stated that she has plans to develop garden areas in this way. Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 20 Felmingham Old Rectory DS0000071073.V362067.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): Standards 27, 28, 29 & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff at the home are deployed in sufficient numbers to support the needs of people who use the service. There is a shortfall of staff with specialist training in dementia care. EVIDENCE: There were 38 residents accommodated at the home at the time of the visit. There is a total care staff complement of 29 staff in addition to ancillary staff and the manager. From observation and from information provided by the manager there are 6 carers throughout the day and 3 carers are on duty at night. Observations showed the numbers of staff on duty during the inspection were sufficient to meet the needs of the 38 residents currently accommodated. All of the eleven comment cards received from relatives of residents indicated that care staff usually or always have the right skills and experience to look after people properly. This was supported by observation of their practice at the time of the inspection, and from comments from residents. Staff were respectful in their approach and clear in their communication with residents. Staff also responded appropriately to residents who were communicating a need for activity and stimulation. Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 22 Information from training records and discussion with staff provided evidence of a good approach to training, with all staff having achieved mandatory training and other training courses. There is a rolling cycle of staff training that addresses mandatory and other training requirements provided by the new proprietor. From information provided by the manager ten care staff currently hold a qualification at NVQ 2 or NVQ 3. A further seven care staff have registered to undertaken NVQ 2. A review of sample staff files provided evidence that residents are protected by good recruitment practices undertaken by the manager and proprietor. Within the last year the majority of care staff have undertaken dementia awareness training. The annual quality assurance assessment for the home indicates that this training will continue to be made available to staff over coming months. There is no evidence to show that staff have had training to a higher level in dementia care. Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36, 38 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and staff at the home promote the health and care of people who use the service within their abilities. Their efforts are compromised, as areas of the building are not suitable for people with dementia. EVIDENCE: The ownership of the home changed in September 2007. Southern Cross Healthcare group of companies now own and operate the home. This has resulted in changes of some policies and procedures within the service. There has been continuity of management at the home and continuity within the staff group, which has provided stability for residents. Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 24 The registered manager is a trained mental health nurse who has over thirteen years experience of working in the residential care setting with older people who may have dementia. She has managed Felmingham Old Rectory for approximately two years and is successfully managing the home through the current periods of change. She has completed the NVQ 3 in Care, the NVQ4 Registered Managers’ Award, Advanced Management in Care and training courses relevant to management and social care. The deputy manager has significant experience at the home and is currently working towards achieving an NVQ 3 qualification. There is an on-call system at weekends when senior staff are in charge of the home. The system provides access to the manager or deputy, and to an area on call support system operated by the proprietor. Observations and discussions show the manager to be a good advocate for the residents’ well-being and she makes efforts to ensure the care they receive is to the best of her and the staff teams’ abilities. The manager has several processes at the home for monitoring the quality of the service it provides. There are regular staff meetings, the manager and the proprietor carry out quality audits covering a range of topics and they send monthly monitoring reports to the Commission. The manager stated that meetings seeking the views of residents are usually carried out on an individual basis with them and their relatives/family. She has a view that this works more effectively as a method of communicating feelings and views than collective meetings. She also stated that she intends to offer a periodic ‘surgery’ for relatives to raise matters of concern or importance with her. The formal quality survey that was to be carried out shortly after the last inspection of the home did not take place due to the change in ownership. However, a survey will be carried out later this year using the new proprietor’s procedure for this. It is understood that residents, relatives and staff will be asked their views on a range of topics. Relatives or appointees manage most residents’ financial affairs. Financial records reviewed were satisfactory and are evidently audited periodically for the protection of residents and staff. There is an established system for providing staff supervision through observation of their practice by senior staff or the manager(s). However, there is not yet a system for formal recorded supervision established at the home. The manager stated that a system was in the process of being set up. Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 25 Maintenance records seen were satisfactory. There is relevant mandatory training for staff, including moving and handling, medication, first aid and health and safety. Felmingham Old Rectory DS0000071073.V362067.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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 2 X 2 X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Felmingham Old Rectory DS0000071073.V362067.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. 1 Standard OP15 Regulation 12 (1)(a) Requirement Water or soft drinks should be provided in bedrooms to help to ensure residents’ health and welfare. The premises must be in a good state of repair to ensure people live in a suitable environment. The external premises and grounds must be in a good state of repair and safe for residents. Communal space must be provided which includes rooms in which residents can meet visitors in private. The premises and any specialist equipment used must be suitable for the assessed needs of the residents. Staff must receive suitable training in dementia care to ensure that the mental health needs of people using the service are met. Staff at the home must be formally supervised. Timescale for action 07/04/08 2 3 4 OP19 OP19 OP20 23 (2) (b, d) & 16(2)(c) 23 (2) (o) & 13 (4) (a & c) 12 (4)(a) & 23 (2)(e) 23 (1) (a) (2) (a, c, e) 18 (1)(c)(i) 31/10/08 30/04/08 31/10/08 5 OP22 31/10/08 6 OP30 31/08/08 7 OP36 18(2) 31/05/08 Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 28 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 OP8 Good Practice Recommendations It is recommended that carers who have a particular responsibility for coordinating individual residents care matters (‘keyworkers’) check the adequacy of residents’ wardrobes and liaise with relatives if new or extra clothing is required. It is recommended that the manager ensure residents’ names recorded in their records are accurate to assist in promoting the dignity of residents and to ensure the veracity of records. It is recommended that the manager dispense with the various stores of old clothing held at the home as it should be unnecessary (and would be inappropriate) for any existing resident to make use of them. It is recommended that a fundamental review of the standard and suitability of the accommodation provided at the home should take place. It should consider the physical and mental health care needs of residents as well as their safety. 2 OP10 3 OP19 4 OP19 Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Felmingham Old Rectory DS0000071073.V362067.R01.S.doc Version 5.2 Page 30 - 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. 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