Inspection on 11/01/07 for Fitzwarren House

This inspection was carried out on 11th January 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

Fitzwarren House 16/12/08

Fitzwarren House 13/03/06

Fitzwarren House 10/08/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Fitzwarren House Kingsdown Road Stratton St Margaret Swindon Wiltshire SN3 4TD Lead Inspector Steve Cousins Unannounced Inspection 09:30 11th – 12 January 2007 th 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 Fitzwarren House DS0000064069.V325009.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. Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fitzwarren House Address Kingsdown Road Stratton St Margaret Swindon Wiltshire SN3 4TD 01793 836920 01793 836921 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) home.fxg@mha.org.uk Methodist Homes for the Aged Mrs Wendy Champion Care Home 60 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30) of places Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users aged 65 years and over with dementia that may be accommodated at any one time and in receipt of personal care is 30. These persons may only be accommodated on the ground floor. The maximum number of service users in receipt of nursing care who may be accommodated in the category OP at any one time is 30. These persons may only be accommodated on the first floor. The staffing levels set out in the Notice of Decision dated 14 June 2005 must be met at all times. 5th July 2006 2. 3. Date of last inspection Brief Description of the Service: Fitzwarren House is purpose built care home that was first registered with the Commission on the 14th June 2005. It is situated in a semi rural area on the outskirts of north Swindon and is well designed and equipped. The home is owned and managed by the Methodist Homes for the Aged group. The home is divided into two distinct areas. Personal care for elderly people with dementia is provided in a specially designed unit on the ground floor. Elderly people who require nursing care are accommodated on the first floor. Mrs Wendy Champion is the registered manager and there are individual managers for both of the homes units. The nursing unit has a registered nurse on duty at all times, supported by care assistants. The dementia unit has a senior carer in charge of each shift, supported by other care assistants. Domestic, laundry, catering, administration and maintenance services and staff are also provided. The fees at the time of this report range between £509 to £638 per week. Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 11th and the 12th January 2007 in order to inspect all of the key minimum standards relating to care homes for elderly people. The inspector visited the home between 9.30 a.m. and 5.00 p.m. on the first day and 9.30 a.m. and 4.45 p.m. on the second day, making a total of 14.75 inspection hours. The inspector then met with Mrs Champion, the registered manager, in order to discuss the outcome of the visit. The findings from this inspection are based on a tour of the premises, speaking to residents, relatives, the manager and staff, and visiting frail residents. A number of records were inspected, including care plans, medication records and staff records. Comment cards were received from eight residents’ relatives and two of the home’s General Practitioner’s (GP) following the inspection and their views are incorporated in this report. The judgements contained in this report have been made from evidence gathered during the inspection and take into account the views and experiences of people using the service. What the service does well: What has improved since the last inspection? A social organiser has been employed and efforts have been made to enhance the level of social activity available to residents. Improvements have been made in ensuring residents who are at risk from not eating enough are regularly weighed and more information is available in care Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 6 plans regarding how residents wish to be cared for towards the end of their lives. 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. Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 7 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 Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 8 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 and 3. Standard 6 does not apply to this home. Information is available to allow people to make a choice about moving into the home and their needs are assessed before doing so. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A comprehensive statement of purpose has been produced and there is a service users guide, which is well produced and easy to read. The homes last CSCI report was available in the entrance lobby. Residents records reviewed by the inspector contained pre admission assessment forms that had been completed either by the manager or one of the unit managers. In two cases, a visit to the person had not been possible, however comprehensive assessment information had been obtained in order to assess whether the home could meet the persons needs. The information Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 9 contained in assessments, some of which had been supplied by relatives, was used to aid completion of individual care plans. Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Individual care plans are in place but some improvement is required to ensure they fully reflect residents’ needs. Residents’ health needs are addressed and they are treated with dignity and respect. The medication procedures protect the residents. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector reviewed the care of six residents, two males and four females between the ages of 67 and 88. They had varying physical, social and mental health needs and were accommodated in either the nursing or dementia units. Some were new to the home and others had been at Fitzwarren House for some time. One was unable to verbally communicate and was fully dependent on staff support and two were unable to comment on their care due to the level of their dementia. Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 11 The residents care plans were reviewed. These were generally based on an assessment of the residents needs however there were areas where care planning and assessment procedures required improvement to reflect best practice. Where a resident had been assessed as at risk from developing pressure damage, plans were not always in place to record and direct care and one resident did not have a specific plan for the management of their diabetes. In one case, wound assessment forms had not been used to record subsequent reviews and treatment of wounds. Not all moving and handling assessments were signed and dated by the person completing them and assessments were not always reviewed. The manager stated that a new care plan system was being introduced that should help improve the current level of planning. The inspector visited the residents and found that interventions were generally in place to meet their assessed needs, such as pressure relief equipment, continence aids, manual handling equipment. One frail resident had been assessed as nutritionally at risk and at risk from tissue damage, however positional changes and fluid and nutritional intake were not being recorded, therefore practice could not be fully evidenced. The residents’ appeared to be having their personal hygiene needs met and those who were able to communicate indicated satisfaction with the care given. Where possible, those who were assessed as being nutritionally at risk were regularly weighed. Records indicated that residents had access to their GP and that staff took prompt action when there was a health care need. Records also indicated that staff sought the advice of other health care professionals, such as the community mental health team, when required. Residents spoken with felt that staff generally tried to come quickly in response to the call bell, but one felt that they sometimes said, “I’ll be back soon” but do not return. The inspector brought this to the manager’s attention. One resident commented, “They know their stuff” and another “The staff are very good”. One stated, ”They take me to the toilet when I want”. Of the eight comment cards received from relatives, six answered yes to the question ‘Are you satisfied with the overall care provided?’. Comments added included, “An excellent nursing home, our relative is very well cared for”, “ I am happy that my mother is receiving first class care and attention” and “This home provides --- love and security in a protected environment”. One relative responded that they were fairly satisfied and another did not respond directly but added generally favourable remarks about the home along with some concerns regarding care plans not being individualised and a comment about there being an ‘Emphasis on behaviour of residents, not causes of that behaviour’. Comment cards were received from two General Practitioners (GP’s) who attend the home. Their opinions were divided on the service provided. One felt that the home communicated clearly and worked in partnership with them and Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 12 agreed that staff demonstrated a clear understanding of the residents care needs and was satisfied with the overall care provided, the other indicated that they felt this was not the case. It is recommended that the home approaches GP’s who visit the home to ascertain their opinion and take action where necessary. The arrangements regarding administration of medication were reviewed and found to be satisfactory. Registered nurses are responsible for the administration of medicines on the nursing unit and senior care assistants on the residential dementia unit, provided they have undertaken a medication administration course. Medications were safely and securely stored and records of receipts, administration and disposals are maintained. Indirect observation confirmed that medication was being safely administered. Due to their needs, no residents currently self-administer their medication. Nurses’ competency to administer medications is not routinely checked on induction and the inspector recommended that this be introduced to reflect best practice. Further good practice could be demonstrated by routinely checking the competency of all staff members who administer medications. There was evidence to suggest that residents’ privacy and dignity was respected. Personal care was given behind closed doors and staff knocked on doors before entering a room. For those with dementia, their appearance indicated that efforts were made to ensure that they were appropriately dressed and their personal hygiene needs met. Relatives spoken with felt that staff did respect residents’ dignity and felt that the level of care was good. Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 13 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 Social activity is provided and efforts have been made to further enhance this. Residents are able to maintain contact with family and friends and as far as possible, have choice and control over their lives. Nutritious, balanced meals are available, which the residents appear to enjoy. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents differed in their opinion regarding activities, one said,“ yes, there is enough to do”, another said they “enjoy what they put on for us” but one stated “It’s a bit quiet” and another “ I don’t like what they do”. One relative recorded on a comment card: ‘Some lack of activities, seems to be being addressed’ and another spoken to during the inspection felt that the home had not been meeting it’s Statement of Purpose with regard to social activity. The manager was aware of these concerns, which had also been highlighted in a recent audit, and the home now employs two activity staff. The social organiser, Mrs Bird, had just commenced employment in the home. She has had previous experience in the role and stated that she was presently Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 14 reviewing the residents’ social needs with an aim to enhance the current level of social activity, including more opportunities for residents to go out of the home and appropriate activities for the male residents. Where possible, residents are able to maintain contact with family and friends. The eight comment cards received from relatives all indicated that they were able to visit in private and were welcomed at any time. The majority also indicated that they were kept informed of important matters concerning the resident and consulted about their care, however two felt that this was not the case. Visitors were in evidence throughout the two days of the inspection and several residents confirmed that they had visitors and were able to keep in contact with friends and relatives. Residents are able to receive visitors in their own rooms or in one of the communal areas. As far as possible, residents appeared to be supported to exercise choice and control in their lives. The inspector observed that some were left to sleep undisturbed in the mornings and others were having a late breakfast. One said “I get up, and go to bed when I want”. Some residents had brought in personal items and furniture for their rooms and residents indicated that they had a choice as to whether they joined in any activities that are organised. Those who wish to can attend the religious services that are held in the home. Two staff spoken to confirmed that they endeavoured to respect residents choice regarding what time they got up, or went to bed, although it was acknowledged that there could sometimes be delays depending on the needs of individual residents at the time. Comments from residents regarding the meals at Fitzwarren House were generally positive. One described the food as “Very nice” and another “Very good”. The inspector observed part of the lunchtime meal over two days. The food appeared well cooked and nutritious. Residents who required assistance with their meals were provided with support from staff in a discreet and sensitive manner. Residents are able to eat in one of the four dining areas incorporated with in the lounge areas or in their own rooms if they want to. The main meal of the day is at lunchtime with a lighter menu available in the evening. Tea and cakes are served during the afternoon. There are additional kitchen facilities attached to each dining area, to allow the preparation of drinks and snacks at any time. Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 15 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 17 Residents and relatives’ complaints are taken seriously and promptly investigated. As far as possible, residents are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Complaints leaflets are available on the homes notice boards and the procedure is also in the Service Users Guide. The complaint record indicated that complaints were promptly addressed and the manager stated that a monthly report is sent to Methodist Homes. One resident told the inspector that they had been to see the manager twice regarding problems and both times they were dealt with to their satisfaction. Relatives spoken to also felt that they could approach the manager should they need to complain. All of the eight comment cards received from relatives indicated that they were aware of the complaint procedure. Two stated that they have had to make a complaint and both indicated that the complaint had been dealt with to their satisfaction. The manager was aware of adult protection procedures and staff spoken to during the inspection also demonstrated awareness. Copies of the local procedures for reporting allegations of abuse were available and Methodist Homes produce two leaflets, one for residents and one for staff, entitled ’No Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 16 Secrets Here’ that include details of confidential free-phone services to report any concerns. Details of advocacy services were displayed on notice boards and the home encourages the involvement of families and volunteers, which provides an extra level of support and protection for residents. Review of training records indicated that staff received training about abuse awareness and a review of staff employment documentation indicated that procedures for the protection of residents had been carried out, including Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks. Residents spoken to who could offer an opinion confirmed that they felt safe in the home. One resident told the inspector “They (the staff) are very kind to me” and another “They’re always nice to me”. Comments received from relatives included ‘Helpful and kind staff, almost without exception’ and ‘I am very impressed with the attitude of the care staff to residents – caring and sensitive’. A record of compliments received contained positive comments from a number of residents and relatives. Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24 and 26 The home meets, and in some areas, exceeds the standards, providing a clean, comfortable, well-equipped and safe environment for residents, which meets their needs. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Fitzwarren House is a recently constructed, purpose built home, which is furnished and equipped to a high standard. There are ample, well-furnished communal areas and good access to the surrounding grounds where there is an enclosed garden, with walkways. All rooms have full en suite facilities and there are also assisted bathrooms and other toilets close to communal areas. Entry to the building is controlled and access between the units is by keypad. Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 18 Residents spoken to were happy with their accommodation; bedrooms are well decorated and fittings were of a good standard. Some rooms were personalised and some on the dementia unit had photographs outside in order to help the resident’s orientation. Beds are height adjustable, profiling and have pressure relief mattresses and there are comfortable chairs for residents. One relative commented “Excellent physical environment and surroundings”. The cleanliness of the home would indicate that sufficient cleaning staff are employed, as the home was clean and free from unpleasant odour. Comments included, “The cleaning is very good indeed”. The laundry was clean, tidy and the equipment working. Infection control precautions were in place with regard to dealing with soiled linen. The kitchen was clean and food safety checks were carried out. A maintenance person is employed and records indicated that essential equipment and services are regularly maintained. Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Although there appear to be enough care staff on duty to meet residents needs, evidence suggests there are some periods of the day where their ability to do this punctually is compromised by the number of staff available. Residents are protected by recruitment procedures. Staff induction training is good, as is the level of care assistants with an NVQ, however not all staff had received full mandatory training. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The number of care staff on both days of this unannounced inspection appeared to be enough to meet residents’ needs and call bells were answered without any undue delays. Duty rotas indicated compliance with the homes minimum staffing notice. One staff member felt that care staff levels were generally “O.k.” and another said “It’s busy at times if someone is off sick, but we manage”. Staff indicated that the morning and evening times, when residents wanted to get up, or go to bed were the busiest, particularly on the nursing units and this was a view shared by two residents. The manager was aware of this and said she had made provision to provide an extra care assistant for the early shift. Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 20 The inspector recommended a review of the staffing level on the nursing unit at night as some comments received indicated that with three staff, it was sometimes difficult to meet residents’ needs promptly, particularly when the nurse is undertaking the medicine rounds and the other two staff members are attending to a resident. Of the eight relatives who had filled in comment cards four had indicated that they felt there were not always sufficient numbers of staff on duty and one added the comment ‘ I feel there are vulnerable times when staffing is tight, i.e. after supper when some residents are going to bed and others are in the lounge’. Another wrote the comment ‘Slow response sometimes to call bell’. The recruitment records of four recently recruited staff members were reviewed. Criminal Record Bureau (CRB) checks had been obtained or applied for, and references and Protection of Vulnerable Adults (POVA) checks had been obtained prior to the person starting employment. Other documentation required was in place apart from one case where a current photograph was required and the manager was made aware of this during the inspection. In another case, where an employee had previously undertaken work with vulnerable people on a voluntary basis, it was recommended to the manager that a reference be obtained. The arrangements for staff training were reviewed. Records indicated that comprehensive induction training was provided for new staff and the manager reported that the programme was currently being reviewed to ensure that it meets the Skills for Care induction standards. Induction training was linked to Methodist Homes policies and procedures and included a performance review. Two new staff members described their colleagues and the manager as very supportive and confirmed that they had commenced induction training. Training records indicated that staff were undertaking mandatory training in moving and handling, health and safety, infection control, abuse awareness, fire safety and food hygiene. It was noted that not all staff had received updates in food hygiene, infection control and health and safety. Other training provided included dementia care, care planning, continence care and end of life care. National Vocational Qualification (NVQ) training is available for care staff and the manager reported that there were currently 26 out of 48 care assistants with NVQ (Care) and a further 10 currently undertaking NVQ. Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 The registered manager is fit to run the home and does so effectively and in the best interests of its residents. Very good quality assurance systems are in place. The health, safety and welfare arrangements generally protect the residents and staff, but fire safety checks need to be more robust. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager, Mrs Wendy Champion, has nine years experience as a registered manager having previously worked in two nursing homes for elderly people in Oxfordshire. She is a registered nurse who obtained the Registered Managers Award in 2004 and has previous experience caring for people with dementia. The home is owned and managed by Methodist Homes for the Aged, Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 22 who currently have 55 homes throughout the UK. Mrs Champion is line managed by the regional manager, and is supported in her role by two unit managers. Quality assurance systems include an annual questionnaire for residents and relatives, which had been carried out in October 2006. A summary of the outcome is sent to the manager but this had not yet been shared with the residents or relatives. The manager stated that she would include the results in the monthly newsletter. Methodist Homes also undertakes an annual ‘Standards and Values’ audit designed to measure the homes performance in meeting the organisation’s standards. A report is produced along with an action plan. Internal quality audits are also undertaken every six months by staff members and focus on aspects of care delivery, the October audit looked at choice, independence and dignity. Relatives meetings are held every three months on the dementia unit. There had not been a meeting on the nursing unit for some time but the manager said that these would recommence. This may be a reflection of a comment from a relative who felt that a “More formal voice needed for residents and relatives” was required. The arrangements for handling service users money were checked and found to be satisfactory and secure. Audits are recorded and signed. The manager reported that no staff member is an appointee or advocate for any resident’s finances. The arrangements for the management of health and safety were reviewed. The manager stated that following the annual audit in October, a health and safety officer had been appointed and that he would be attending risk assessment training. Mrs Champion stated that all seniors attend training days on health and safety, risk assessment and control of substances hazardous to health (COSHH). Meetings were to be introduced and representatives from each department would attend. Health and safety audits had been carried out in June and October 2006. Hot water temperatures are controlled and radiators are covered. Water has been tested for Legionella and electrical appliances are tested annually. Environmental risk assessments have been undertaken, however these should also include residents’ bedrooms. Moving and handling equipment is available. Accidents are recorded and the manager reviews these monthly. Records showed that there were occasions when fire safety checks had not been completed and this was brought to the attention of the manager. Fire alarm checks need to be undertaken in the maintenance person’s absence. Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 23 A food hygiene inspection had taken place in November 2006. The environmental health officer wrote that they had ‘high confidence in management and staff’. Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 24 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 3 3 3 3 X 4 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 3 X 4 X 3 X X 3 Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 (1) Timescale for action The registered person shall, after 01/03/07 consultation with the service user, or a representative, prepare a written plan as to how the service users needs in respect of their health and welfare are to be met. In relation to: • Pressure area care • Diabetes • Wound care 01/03/07 The registered person shall ensure that at all times, suitably qualified, competent and experienced persons are working in such numbers as are appropriate for the health and welfare of the service users. In relation to: • The number of care assistants on the nursing units during the morning and at night. • The number of care assistants in the home during the evening. The registered person shall 01/03/07 ensure that persons employed to work at the care home receive training appropriate to the work DS0000064069.V325009.R01.S.doc Version 5.2 Page 26 Requirement 2 OP27 18 (1,a) 3 OP30 18(1,c,i) Fitzwarren House 4 OP38 23 (4,c,v) they are to perform. In relation to: • Infection control • Food hygiene • Health and safety The registered person shall after 01/03/07 consultation with the fire authority, make adequate arrangements for reviewing fire precautions, and testing fire equipment, at suitable intervals. In relation to: • Fire alarm testing. • Emergency lighting checks. • Fire escape routes. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 4 5 6 Refer to Standard OP7 OP8 OP8 OP9 OP33 OP38 Good Practice Recommendations In order to evidence good practice it is recommended that all assessments and entries in care plans are signed and dated by the person completing them. It is recommended that, for those assessed as nutritionally at risk and/or at risk of pressure damage, records are kept of nutritional/fluid intake and positional changes. It is recommended that the manager ascertain the views of the GP’s regarding the service provided by the home. It is recommended that nurses’ competence relating to drug administration be assessed during induction and at regular periods thereafter. It is recommended that residents and relatives meetings be held for those on the nursing unit. It is recommended that residents’ bedrooms are included in the review of environmental risk assessments. Fitzwarren House DS0000064069.V325009.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Fitzwarren House DS0000064069.V325009.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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