Inspection on 04/09/07 for Firth House

This inspection was carried out on 4th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Firth House 25/07/08

Firth House 25/09/06

Firth House 10/02/06

Firth House 18/05/05

Firth House 14/12/04

Firth House 08/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Firth House 18 Firth Mews Millgate Selby North Yorkshire YO8 3FZ Lead Inspector Dawn Navesey Key Unannounced Inspection 4th September 2007 10:00 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 Firth House DS0000007957.V350303.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. Firth House DS0000007957.V350303.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Firth House Address 18 Firth Mews Millgate Selby North Yorkshire YO8 3FZ 01757 213546 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) margaret.millin@anchor.org.uk sharon.blackwell@anchor.org Anchor Trust Margaret Meek Millin Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Firth House DS0000007957.V350303.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th September 2006 Brief Description of the Service: Firth House provides personal care and accommodation for up to 40 older people. The home is a purpose built two-storey property set in its own gardens near to the town centre of Selby. There is parking to the front of the home. The home is divided into four small living units. Two on the ground floor and two on the first floor. Each unit has it’s own dining room, with a small kitchen area attached. One large lounge on the ground floor is provided. All people who use the service have a single en-suite room. The home is situated in a quiet residential area and is in walking distance of shops and community facilities. A copy of the latest Commission for Social Care Inspection (CSCI) report is available on the notice board near the entrance to the home. The weekly fees on the date of the inspection are £510. There are additional fees for the services of a hairdresser and a chiropodist. Firth House DS0000007957.V350303.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was unannounced and was carried out by one inspector who was at the home from 10am until 5pm. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people living there. Before the inspection evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the visit. A pre-inspection self-assessment had been completed by the home before the visit to provide additional information. Survey forms were sent out before the visit to the people who use the service, relatives, advocates, general practitioners (GPs) and other healthcare professionals. Several were returned and information provided in this way will be reflected throughout the report. During the visit a number of documents were looked at and areas of the home were visited. A good proportion of time was spent talking with the people who live at the home as well as with the manager and staff. Feedback at the end of the visit was given to the manager. I would like to thank everyone who contributed to the inspection process and to the home for the hospitality on the day. What the service does well: The home is well managed and the manager and her team show good leadership to the staff. In returned surveys, relatives said, “The home is extremely well run” and “Firth House is well and efficiently run”. People who use the service said, “The manager is wonderful” and “The manager sorts things out well”. Staff spoke highly of the management team. They said, “This is the best home I have ever worked in” and “The management team are very supportive, they help out and don’t just stay in the office”. There is a warm and welcoming atmosphere in the home. Staff and people who use the service have good relationships; there is plenty of interaction and time for just sitting and chatting, which people who use the service said they appreciate. Staff are respectful and polite. Staff have good knowledge of the needs of the people who use the service and people look very well cared for. People who use the service and relatives made very positive comments about the care and support received. They included, “They treat all residents as an individual and with dignity and Firth House DS0000007957.V350303.R01.S.doc Version 5.2 Page 6 respect”, “We get good help, doesn’t matter which staff it is, all do things the same way, the way I like it”, “Staff always come when you need them, always prompt in answering the buzzer”, “We are treated well, want for nothing” and “I can choose who baths me and have one whenever I want”. There is a varied and interesting activity programme which the people who use the service are involved in planning. People spoke highly of the activities and said, “You are never bored, always something to do or someone to talk to”. The environment in the home is attractive, clean and well maintained. In returned surveys, relatives said, “The home is spotlessly clean” and “Surroundings are clean and well kept, bright and cheerful”. People who use the service said, “I am very happy with my room, I have all my own things in here”, “I chose the décor when I moved in”, “I have my own fridge, kettle and toaster in here” and “It is always spotlessly clean”. The layout of the home lends itself to smaller group living. The small kitchens mean that people who use the service can maintain their independence skills. The manager makes sure that the views of the people who use the service are gained by sending out regular satisfaction questionnaires and by having meetings with people who use the service. Many of the people who use the service said they had lots of choice about what they do and how they spend their time. Menus are varied, nutritionally balanced and plenty of choice is offered. People who use the service said, “They are lovely meals, well presented, you can have anything you want”, “There’s a good choice and plenty of it” and “We thoroughly enjoy the meals”. A relative said, “Food is of exceptional quality” What has improved since the last inspection? The manager and her team have introduced a new format for care plans. These are more detailed and person centred. Some staff have been trained in end of life care. The small dining rooms in the home have been re-decorated and re-furbished. The bathrooms have all had new curtains and blinds fitted. The hairdressing salon has been re-fitted and re-decorated. Water coolers have been plumbed in to the kitchen areas, giving people access at all times to fresh cool water. The manager has introduced an audit system for medication to make sure medication does not run out for anyone who uses the service. Firth House DS0000007957.V350303.R01.S.doc Version 5.2 Page 7 The chef has achieved a nationally recognised qualification in catering in care homes. 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. Firth House DS0000007957.V350303.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 Firth House DS0000007957.V350303.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, 3 and 5. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service and their relatives can be sure that the home will meet their needs following assessment before moving into the home. Also from written and verbal information that is comprehensive, interesting and provides enough information for them to decide whether the home will meet their needs. EVIDENCE: The Statement of Purpose and Service User Guide are documents that give information on what the home can provide. These have been produced in an interesting and attractive format using different coloured, contrasting print and photographs, to make them easier to read. The manager said that these can be produced in other formats on request. She said they had produced one in German for a person who used the service in the past. They are kept on display in the entrance of the home, as part of the home’s welcome pack and Firth House DS0000007957.V350303.R01.S.doc Version 5.2 Page 10 each person who uses the service has their own copy. The CSCI inspection reports are available on the notice boards for people who use the service and visitors to see. People who use the service said they did not know about the inspection reports or that they had not noticed them. It would be good practice to raise awareness of the reports and where they can be found. Pre-admission assessments take place for people who are thinking of using the service before they move into the home. The home’s manager or senior staff do these. The level of detail is good and a preliminary care plan is developed from the assessment so that staff have some information on peoples’ needs as soon as they move in. People who use the service and their relatives are involved in the assessment and sign them to show they are in agreement with them. The assessments are person centred and focus on what people want as individuals from the service. People who use the service and their relatives are given opportunity to visit the home prior to moving in. The manager said that introductory visits are part of the assessment process and based on individuals’ needs. She said that she is hoping to improve the service by offering overnight stays as part of the admissions process. In surveys returned from relatives, comments included, “The home fulfils all my parents needs” and “Adequately meets my mother in laws needs”. People who use the service said, “This is a better home than most according to what other people have told me and that’s why I came here” and “I am very happy here, no complaints, we are like one big happy family, I have made myself at home”. Firth House DS0000007957.V350303.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 and 11. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of the people who use the service are met and their dignity and privacy is respected. EVIDENCE: People who use the service have care plans and risk assessments which have been developed from their pre-admission assessment information. The care plans focus on their strengths and abilities while providing information on what they need help with. The plans include life history work, which makes them person centred and individual. The information is detailed and specific, giving good instruction to staff on care and support needs. Staff are currently in the process of reviewing the care plans of all the people who use the service as some new care planning documentation is being introduced. This will enhance what is already in place. The deputy manager is leading this work, coaching staff to further develop their care planning skills. Staff said they enjoyed Firth House DS0000007957.V350303.R01.S.doc Version 5.2 Page 12 being involved in the care planning as it helped them to get to know people who use the service better. People who use the service and relatives made very positive comments about the care and support received. They included, “They treat all residents as an individual and with dignity and respect”, “We get good help, doesn’t matter which staff it is, all do things the same way, the way I like it”, “Staff always come when you need them, always prompt in answering the buzzer”, “We are treated well, want for nothing” and “I can choose who baths me and have one whenever I want”. The plans are reviewed monthly. This involves the person who uses the service their relative, if they wish, and their key workers. People who use the service said they took part in this and were able to get their own care plan out to show the inspector. Care plans are kept in the rooms of the people who use the service and are seen as their property. A relative who returned a survey said, “A regular review system enables any queries to be dealt with quickly and efficiently”. Staff were able to accurately describe the care they give as detailed in the care plans. It is clear that staff have a good knowledge of the needs of the people who use the service. People look well cared for. Staff have a good attitude to helping people who use the service to maintain their independence. They gave good examples of what they do to encourage people and why this is important for the person’s dignity and well-being. People who use the service said they enjoyed being able to do things for themselves knowing there was support if they need it. Staff were seen to be patient, friendly and kind when interacting with people who use the service. They chatted and told people what they were doing when carrying out any task. Support was given in a quiet, discreet and dignified manner. The home has embarked on a programme of end of life care to support and care for people who use the service when they are at the end of their lives. This means that people who use the service will be able to stay at the home to be cared for in the latter stages of life. The home works with medical specialists and palliative care teams to provide this service. Some of the staff team are being trained in end of life care and have been nominated for a national award for their pioneering work in this area. The organisation has developed care plans that are specifically relevant to people who are terminally ill and focus on the wishes of the person as well as their care needs. People who use the service have their own choice of health practitioners such as GP, chiropodist or optician. These are identified as part of the assessment process. The preferred gender of health practitioner is recorded to make sure dignity issues are addressed. The care plans have details of any health Firth House DS0000007957.V350303.R01.S.doc Version 5.2 Page 13 professionals that people who use the service see. These include, GP, dentist, specialist nurse, and optician. Records are kept of any health appointments and their outcome. A number of GPs (General Practitioners), returned surveys, saying, “Firth House is held in very high esteem by the GPs in this practice” and “I think it provides good holistic care”. When asked what they thought the service does well they said, “Appropriate liaison between the home and GP service” and “Caring and maintaining independence”. The home uses a monitored dosage, pre-packed system for medication. All senior staff have been trained to use the system. A record is kept in the home of medication ordered. This is checked against medication delivered and recorded as correct before any medicines are dispensed. Photographs had been taken of all people who use the service, which made sure they are clearly identified on the medication records. The medication administration record (MAR) sheets were checked and showed no errors in administration. In response to a recent medication ordering error, the manager has introduced a new system of auditing the medication to make sure medication does not run out. Each of the units in the home has its own medication trolley. This means that medication is well organised and easily accessible for staff to administer. Good practice in medication administration was seen during the visit. Some people who use the service take responsibility for their own medication and have been provided with lockable storage facilities. Firth House DS0000007957.V350303.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 and 15. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are supported to make choices about their lifestyle. Appropriate and stimulating activities are arranged and a good, healthy, varied diet is offered. EVIDENCE: The manager and staff see activity and social care as important to the well being of people who use the service. A weekly social diary is produced and distributed to people who can then choose what they would like to do. Activities include, card games, quizzes, dominoes, bingo, sing-a-longs, reminiscence, coffee mornings and some occasional outings such as boat trips. One of the staff has been made the “activities ambassador” for the home and she finds out about local events and organises activities such as clothes and makeup parties. The manager said she would like to offer more one to one individual activity to people who use the service and is looking at ways to encourage more of this. Firth House DS0000007957.V350303.R01.S.doc Version 5.2 Page 15 People who use the service are encouraged to use local facilities such as the shops and library. Many people can go out independently and said they regularly do this. Others said that staff take them to the town centre and local market. Some people who use the service have electric scooters to aid their mobility and independence and regularly go out on them. The manager has provided outside sheds for the storage of these. People who use the service said they were satisfied with the level of activity on offer and could choose to get involved or not. Comments included, “You are never bored, always something to do or someone to talk to” and “I prefer my own company and this is respected”. On the day of the visit, people were playing dominoes, enjoying a sunny day in the garden, chatting with staff, going out into the town or spending time in their own room. The home holds regular residents and relatives meetings. Topics discussed recently included, activities, forthcoming events, menus, décor of the home and trips out. The meetings are well attended and people who use the service seem happy to express their views and make suggestions. People who use the service are supported with their spiritual needs. Arrangements are made for one to one communion for people in the faith of their choice. People are also assisted to attend church in the community if they wish. People who use the service are encouraged to keep in touch with family and friends. Some have their own telephone in their rooms. Visitors are offered refreshments and can have a meal at the home for a small charge. People who use the service said visitors who may have travelled some distance particularly welcomed this. There is also a room where visitors can stay overnight at the home. The manager said this is often used for families to stay over if their relative is ill and they want to be with them. Menus are varied and nutritionally balanced. Meals are served in the dining areas and trolleys of food and drink go round every few hours. Tureens and serving dishes are used at the tables to give people more control over their portion size and to increase their independence and self esteem. There is a good choice of food and snacks. It is all home cooked. The chef meets with people who use the service to ask them their opinions on the food and menus. People who use the service spoke highly of the food. Comments included, “They are lovely meals, well presented, you can have anything you want”, “There’s a good choice and plenty of it” and “We thoroughly enjoy the meals”. A relative said, “Food is of exceptional quality”. In a returned survey concern was raised that since food is not pre-ordered, some things such as chips can run out and there not be enough for everyone. The manager was aware of this issue and had met with the chef to make sure there is always enough to go round in the future. This had actually been recorded in the complaints file too. Firth House DS0000007957.V350303.R01.S.doc Version 5.2 Page 16 On the day of the visit, the lunchtime meal was a choice of homemade fish cakes or meat and potato pie with boiled potatoes or potato croquets and fresh vegetables. Followed by lemon sponge and custard or yoghurt. The meal was well presented and looked appetising. The chef is aware of any special dietary requirements and keeps records of these to make sure people get a good choice and variety. The chef has been trained in healthy eating and nutritional screening and was the first person in the country to achieve a nationally recognised qualification in catering in care homes. Two more of the catering staff are now being trained in this qualification. People who use the service spoke highly of the chef and her team. One said, “Nothing is too much trouble for them” another said, “They do us proud”. Firth House DS0000007957.V350303.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 and 18. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service and their relatives have their views listened to, taken seriously and acted upon. There are good systems in place to protect people from abuse. EVIDENCE: The home has a clear complaints procedure that is made available to people who use the service and relatives. It is also referred to in the Service User Guide and a copy is enclosed in the welcome pack to the home. All who returned surveys said they knew how to complain. A number of people who use the service said they were aware of the procedure and who to complain to if needed. Any recent complaints have been recorded, investigated and had the outcome communicated to the person making the complaint. Staff have received training on safeguarding adults. They were able to say what action they would take if they suspected abuse or had an allegation of abuse made to them. They were also able to describe the different types of abuse. They knew where the policy on adult protection was kept and could refer to it. The policy is comprehensive and detailed. A person who visits the home to provide a service has not had a CRB (Criminal Records Bureau) check. This person is not employed by the home but spends Firth House DS0000007957.V350303.R01.S.doc Version 5.2 Page 18 significant time with people who use the service. The manager agreed it would be good practice to carry out a CRB check for this person and began making arrangements to do so. Property lists are maintained for people who use the service in order that their property and belongings are protected. Firth House DS0000007957.V350303.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, 22 and 26. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home offers an attractive, homely, clean and safe environment for people who use the service. EVIDENCE: The home is warm, clean and furnished and decorated to a very high standard. It is seperated into four units. Each unit has its own dining area and kitchen. This means that people who use the service can enjoy some independence by using the smaller domestic style kitchens and the small dining areas which lend themselves to the social occasion of meal times. In returned surveys, relatives said, “The home is spotlessly clean” and “Surroundings are clean and well kept, bright and cheerful”. Many of the people who use the service said Firth House DS0000007957.V350303.R01.S.doc Version 5.2 Page 20 how much they enjoyed having the small kitchens to be able to go and make themselves a drink or snack whenever they liked. People who use the service are encourged to personalise their rooms and to bring familiar pieces of furniture in with them. A person who uses the service said, “I am very happy with my room, I have all my own things in here”. Others said, “I chose the décor when I moved in”, “I have my own fridge, kettle and toaster in here” and “It is always spotlessly clean”. A shared room is available for couples to use. All the bedrooms have an en-suite toilet and sink. There is a large communal lounge for people who use the service to socialise in. It is well set out with chairs arranged in small clusters to encourage conversation and small group activity. There are patio doors which lead out on to a well kept, attractive garden and patio area. There is good access for anyone with mobility problems. And there is plenty of garden furniture and shelter from the sun. There are a number of bathrooms in the home, providing a choice of bath or shower. The baths and equipment in the bathrooms can help people who have mobility problems. The décor, fixtures and fittings in these rooms is very attractive and homely looking. Clinical waste is properly managed and staff wear protective clothing when attending to the personal care needs of people who use the service. Staff have received training in infection control and were able to say what infection control measures are in place. The manager and the organisation are introducing some further training for staff and an audit tool that will measure how they are managing infection control. This is good practice. People who use the service spoke highly of the laundry service at the home. One said, “The laundry always comes back beautiful”. Firth House DS0000007957.V350303.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 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are protected by the home’s recruitment procedures and staff are trained and skilled to meet their needs. EVIDENCE: There are care staff on duty throughout the day and night. There are usually four staff on the morning shift and four on the afternoon shift, with a team leader or senior team leader. The manager or deputy is also available throughout the day during the week and on occasions at the weekend. At night there are three staff on duty or two staff with a senior staff member on call. Staff said they felt there was enough staff to meet the needs of people who use the service properly and they didn’t feel rushed. They also said they had time to take people out and sit and chat or play games with them. People who use the service said they thought there were enough staff and that they never have to wait long for staff to attend to them. In addition to this, there are housekeeping and domestic staff, catering staff, an administrator and a handyman for the home. Firth House DS0000007957.V350303.R01.S.doc Version 5.2 Page 22 People who use the service were very positive in their comments about staff. They said, “Staff treat us very well” and “Staff are wonderful, I can’t fault them”. In a returned survey, a relative said, “Staff are usually helpful”. Recruitment is properly managed by the home; interviews are held, references and CRB (Criminal Record Bureau) checks are obtained before staff start work and checks are made to make sure staff are eligible for work. Staff’s training is mainly up to date. Good records are kept and the manager has good systems in place to make sure training updates are given. Staff have received specialist training such as dementia awareness and end of life care. Staff said this training had made them think differently about people who use the service and to try and see things from their perspective. Senior staff are about to start a five day training course in dementia. This will enable them to be able to teach the staff who work at the home. Over half of the care staff have completed their NVQ (National Vocational Qualification) level 2 in care. Other staff are also working towards this. The manager is also training more staff to be NVQ assessors which will give staff more opportunities for doing the NVQ. Staff spoke highly of their training. They said, “We get loads of training and refreshers” and “It’s the best training I have ever had, they make sure we know what we are doing”. Firth House DS0000007957.V350303.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, 32, 33, 35, 36, 37 and 38. People who use the service experience excellent quality outcomes in this area. This judgment has been made using a range of evidence, including a visit to the service. The home is well managed and the interests and health and safety of people at the home are promoted and protected. EVIDENCE: The home has an experienced and qualified manager who has completed the Registered Managers Award. She offers good leadership to the staff and has good systems in place to make sure the people who use the service are supported and cared for properly. In returned surveys, relatives said, “The home is extremely well run” and “Firth house is well and efficiently run”. People who use the service said, “The manager is wonderful” and “The Firth House DS0000007957.V350303.R01.S.doc Version 5.2 Page 24 manager sorts things out well”. Staff spoke highly of the support they receive from the manager. One said, “This is the best home I have ever worked in”. Another said, “The management team are very supportive, they help out and don’t just stay in the office”. Staff are given one to one supervision on a regular basis. They also have group supervision in the teams that they work in. The manager holds meetings with people who use the service, relatives and staff. Minutes of the meetings were seen and show that people are confident to share their views. The manager said she appreciates any comments or suggestions made if it means the service can be improved. The area manager carries out monthly Regulation 26 monitoring visits. The manager also regularly distributes satisfaction questionnaires to people who use the service, relatives, staff and visiting health professionals. The questionnaires are on a variety of topics such as catering, personal care, staff approach and GP services. The results of the questionnaires are freely available on the notice boards in the home. The manager tries to address any issues or improvements suggested and makes sure this is communicated to everyone. The results of the latest survey showed much satisfaction with the service and comments made were suggestions rather than complaints. Some people hand in money to the home for safekeeping. Records are kept of all transactions when money is handed over on behalf of a people who use the service. The manager carries out regular checks of the money and receipts and the organisation’s auditors also carry out checks. Staff carry out weekly or monthly health and safety checks around the home such as fire alarms, emergency lighting and water temperatures. Maintenance records are well kept. Environmental risk assessments are completed and reviewed to make sure of safe practices. Staff showed a good awareness of health and safety and talked of the training they had done. Accident or incident reports are completed. There is a section for follow up action to be taken after any accident or incident. The manager has a system in place where she can analyse accidents to see if there are patterns, trends or ways of avoiding future accidents. The manager showed a good awareness of the CSCI’s new inspection methodologies. She uses them as tools to measure the effectiveness of the service. The organisation develops a business plan and the manager of the home has an objectives plan that is particular to the home. This means that the service is always working to an action plan to ensure improvement in the service and that they are working to best practice. Firth House DS0000007957.V350303.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 3 X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X 3 X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 3 3 3 3 Firth House DS0000007957.V350303.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP18 Good Practice Recommendations The manager should make sure that CRB (Criminal Record Bureau) checks are carried out for people who provide a service to the home and spend significant time with people who use the service. This will make sure that people are properly protected from anyone who may not be suitable to work with vulnerable people. Firth House DS0000007957.V350303.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Firth House DS0000007957.V350303.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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