Inspection on 01/10/08 for Good Companions

This inspection was carried out on 1st October 2008.

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

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

Other inspections for this house

Good Companions 30/10/06

Good Companions 01/03/06

Good Companions 04/10/05

Good Companions 09/12/04

Good Companions 23/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/02/2009.

CARE HOMES FOR OLDER PEOPLE Good Companions 113 Roe Lane Southport Merseyside PR9 7PG Lead Inspector Michael Perry Unannounced Inspection 1st October 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Good Companions DS0000005324.V372693.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. Good Companions DS0000005324.V372693.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Good Companions Address 113 Roe Lane Southport Merseyside PR9 7PG 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) 01704 220450 F/P 01704 220450 Mrs Jennifer Moffatt Mr David Michael Moffatt Mrs Jennifer Moffatt Mr David Michael Moffatt Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Good Companions DS0000005324.V372693.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies 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 The maximum number of service users who can be accommodated is: 23 Date of last inspection Brief Description of the Service: Good Companions is a Registered Care Home providing personal care and accommodation for up to 23 older people. The home is owned and managed by Mr and Mrs Moffatt. Mrs Moffatt is the Registered manager. The two deputy managers Ruth Watson and Mhairi Cairns are also actively involved with the day-to-day running of the home. The home is a large, converted Victorian property with an added extension to the rear and side of the building. The home is serviced by a passenger lift and access is available to all floors. All but one of the bedrooms has en-suite facilities. Communal facilities include two lounges, a large pleasant dining area and a hairdressing room. There are two bathrooms that provide assisted baths and one shower unit. There is a large well-maintained rear garden, which the home uses for garden parties and activities. The garden also provides a pleasant area for the service users to sit in the summer months. The front entrance provides an attractive approach to the home and parking for visitors. The home has a minibus, which is used frequently for day trips. The cost for the service is £379.90 per week Good Companions DS0000005324.V372693.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 the people who use this service experience adequate quality outcomes. This was an unannounced inspection that lasted one day. During this time residents in the home were spoken to and members of staff on duty as well as the registered manager, provider, and assistant managers. Prior to the visit the manager completed a pre inspection information document annual quality assurance assessment [AQAA], which provided evidence of the daily running of the home. A sample of service users care plans and risk assessments were inspected as well as staffing and other health and safety records. Also a tour of the building was made and all day areas and some [not all] resident’s bedrooms were seen. The inspector was accompanied by an ‘expert by experience’. This is a person who has had previous experience with care services and who can make observations and talk to both staff and residents and provide valuable feedback to the inspector. Observations are used in the report. What the service does well: We saw plans of care for residents and these demonstrated the care needs of individual residents are being met. Access is available to health care professionals and all visits by GP, district nurse and chiropodists are recorded. For example the District Nurse is visiting one person regularly. Staff interviewed demonstrated a clear understanding of the care needs of the residents and felt that there is sufficient information in place to ensure they provide the correct care. Residents and visitors told us that the home is meeting their needs and the staff employed always treat them with dignity and respect when providing the care. “All staff are very friendly and helpful” “Everyone is ready to help us be happy and feel at home” “I am quite happy here. They are very eager to please” “The staff are well trained and polite – sensible people” Good Companions DS0000005324.V372693.R01.S.doc Version 5.2 Page 6 “They will do anything for you” “The staff are great” “ If I knew any where better I would go there’ ‘It’s like being a family” Residents spoke highly of the quality of meals and standard of cooking. The cook was considered to be very good and flexible. ‘There is a good variety of vegetables - sometimes we have three as well as potatoes’ ‘The cook is very good. We have cereal, toast and marmalade tea/coffee, an egg boiled or poached will be served if requested’. Residents appear to get a well balanced diet, with plenty of fluids. Meal times are sociable occasions and staff were observed to be assisting and supporting residents. The home provides a pleasant, comfortable and homely setting for residents and is well maintained. All areas of the home were found to be clean and odour free. The home employs sufficient domestic staff to maintain the home to a high standard. Repairs and maintenance are addressed when required and the home has an ongoing improvement plan. Residents were observed to be comfortable in their surroundings and visitors commented on their satisfaction with the standard of the homes environment. What has improved since the last inspection? What they could do better: The information supplied by the home such as the ‘Statement of Purpose’ is out of date. For example the complaints procedure and examples of care documentation do not reflect current practise. The information is not user friendly and may be difficult to read easily. This may make it difficult for residents to readily access. We would recommend that the information is reviewed and updated and presented in a way that is more accessible for residents. Good Companions DS0000005324.V372693.R01.S.doc Version 5.2 Page 7 We received some comments about the menu displayed. The cook has a 4 week regime in the kitchen saying what meat/ fish will be provided each day, but not how it will be cooked and served. Some residents said they would like to know beforehand what is on the menu. There are no records to show that staff are receiving continued support through regular supervision sessions by the managers. Staff spoken with confirmed this. This is recommended, as it is important that staff feel supported and can raise issues with managers on an ongoing basis as part of their development. Some residents self medicate which means that they are being encouraged to be more independent. It is important that any risks are assessed however so that this can be monitored safely. This also applies to people who may be taking medication on a ‘when necessary’ basis. There should be continual monitoring through the care plan and there are recommendations in the report to improve current practice. We looked at the policies and procedures around making complaints and reporting of any allegations of abuse in the home. We found them to need updating so that staff and residents are fully aware of rights in this area. A selection of staff files were viewed to check whether the managers had made the necessary recruitment checks before employment. These are required to ensure that staff are recruited following the correct procedures and are therefore fit to carry out care work with vulnerable people. The records seen failed to meet requirements in that staff have been taken on to work in the home before the required checks have been made. This could put residents at risk. This has been a failing on the last key inspection and a requirement was made at that time. We view this renewed failure as very serious. Also one of the staff had contradictions in the application form around dates worked prior to applying for a job in the home. There were no interview notes or notes by managers to explain these discrepancies. It is of particular concern that the managers were still unsure as to the requirements for employment checks and we spent some time explaining these. The managers conduct internal audits and checks of some of the care systems in the home. There was some discussion on the depth of these audits as they were not in any detail. This lack of detail may contribute to some key areas not being monitored to a high standard. Good Companions DS0000005324.V372693.R01.S.doc Version 5.2 Page 8 The accident records were seen. These give good detail for each accident but it was unclear whether relatives had been informed of accidents, as there were no notes around this so that the home can be seen to be transparent in this area of care and keep relatives and supporters up to date. The current storage of the accident records does not meet data protection guidelines and this was discussed and should be rectified. 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. Good Companions DS0000005324.V372693.R01.S.doc Version 5.2 Page 9 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 Good Companions DS0000005324.V372693.R01.S.doc Version 5.2 Page 10 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 1,2,3,6. (Standard 6 Intermediate care is not provided at the home). Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Pre admission assessments carried out by the manager and there is information about the home for prospective residents, which helps ensure that the home can meet the needs of people admitted. EVIDENCE: Surveys received from residents indicated that they had received sufficient information on the home prior to their admission and had a contract outlining their terms and conditions of occupancy. We asked to see the current information available for residents. we were shown a brochure and a ‘statement of purpose’. The managers explained that a guide for residents in simpler format is not available and that they use the standard contract as the main way of giving information about the home. Good Companions DS0000005324.V372693.R01.S.doc Version 5.2 Page 11 Some of the information is out of date however. For example the complaints procedure has out of date contacts for social services and the Commission for Social Care inspection [CSCI]. Also there are example copies of documents used in the home, which are different to those currently in use. It is recommended that these document [s] are reviewed and updated to reflect the current service. It was also agreed that the information could be more user friendly for the resident group in the home [and perhaps could include their input]. Assessments viewed for three residents confirmed details of their personal history, health care needs, medication, likes and dislikes and risk assessments are in place to ensure the home can meet their needs. Some of the assessments were not dated which can be confusing. The managers explained that prospective residents are invited to the home to spend some time and this provides an opportunity to complete some of the assessment process. Good Companions DS0000005324.V372693.R01.S.doc Version 5.2 Page 12 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are treated with dignity and respect and their health care need are met although their needs to be some attention paid to issues around people who are self medicating so any risk is consistently monitored. EVIDENCE: We saw plans of care for residents and these demonstrated the care needs of individual residents are being met. Care plans and records are kept up to date and reviewed regularly to reflect changing need. A ‘residents individual requirements’ record is maintained and regularly updated when the need arises. Access is available to health care professionals and all visits by GP, district nurse and chiropodists are recorded. For example the District Nurse is visiting one person regularly, and the G.P. is going in to offer the `flu vaccine’ to residents. Care files viewed showed that personal care needs are reviewed regularly to monitor weight, pressure care, risks and moving and handling needs. Good Companions DS0000005324.V372693.R01.S.doc Version 5.2 Page 13 There are daily notes made by care staff and currently these are maintained in a diary and entrants are made here for all residents. There may be some issues here around maintaining confidentiality of information, as these notes are not stored in individual files. It is also more difficult for staff to make reference to care plans while writing these notes as the care plans are maintained separately [in another folder]. Staff interviewed demonstrated a clear understanding of the care needs of the residents and felt that there is sufficient information in place to ensure they provide the correct care. Surveys and comments received from residents confirmed that the home is meeting their needs and the staff employed always treat them with dignity and respect when providing the care. “All staff are very friendly and helpful” “Everyone is ready to help us be happy and feel at home” “I am quite happy here. They are very eager to please” “The staff are well trained and polite – sensible people” Residents spoken with told us: “They will do anything for you” “The staff are great” “ If I knew any where better I would go there ‘It’s like being a family” Medication policies and procedures are in place and records kept of all administrations made. The senior care staff are responsible for the administration of medication and have received training in this. All medication is securely stored. We discussed three of the residents who are self medicating to varying degrees. There is no detailed information on the care plan as to the arrangements for these people. There is also no measure of any risks involved. This was discussed as the importance of ongoing monitoring of risk is important as a persons ability to self medicate may change from time to time. One resident was reviewed who is on medication that is only given when necessary [PRN]. Again this was not mentioned in the care plan and so the reasons for administration may not be clear to all staff and there is a risk of staff not being consistent. This can potentially put the resident at risk. Good Companions DS0000005324.V372693.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are helped to exercise choice and control over their lives, receive a wholesome and appealing diet and maintain contact with friends and family. EVIDENCE: Residents spoke highly of the quality of meals and standard of cooking. The cook was considered to be very good and flexible. ‘There is a good variety of vegetables - sometimes we have three as well as potatoes’ ‘The cook is very good. We have cereal, toast and marmalade tea/coffee, an egg boiled or poached will be served if requested’. We received some comments about the menu. The cook has a 4 week regime in the kitchen saying what meat/ fish will be provided each day, but not how it will be cooked and served. Some residents said they would like to know beforehand what is on the menu. We discussed this with the cook. Good Companions DS0000005324.V372693.R01.S.doc Version 5.2 Page 15 Residents appear to get a well balanced diet, with plenty of fluids. Perhaps not a lot of fruit but plenty of vegetables and sometimes salad at teatime. Although there is no choice on the lunch menu, staff do keep a “dislikes“ list in the kitchen, so with a small number, of residents individual preferences are known so an alternative is served. The dining room is very pleasant and overlooks the garden. Meal times are sociable occasions and staff were observed to be assisting and supporting residents. There are no regular organised activities at the home. Residents are taken out from time to time, (two trips a year on the canal), and occasional outings in the mini bus - much depending on the weather. These trips are thoroughly enjoyed by residents, but only 9 out of the 16 residents went on the recent canal trip. An outsider sometimes comes in to entertain. The majority of residents spend most of the time in their rooms. Some have regular visitors and are taken out, whilst others do not have relatives living near, and few friends able to visit. One resident has a taxi to go to church most Sundays, and another has communion brought by the Catholic Priest. Some residents are keen readers, and two ladies meet in each others room most evenings to play Scrabble or Dominoes. This shows that the home is willing to support chosen lifestyles as much as possible. The main lounge is comfortable but not really used by the majority of residents. One commented: ‘I don’t like the lounge. I don’t want television on all day’. We were told that a few years ago some one attended twice a week and organised group games and activities. It was said to be very popular. There are no organised resident/ staff meetings, where residents ideas could be put forward and discussed with staff. This could be of benefit to the staff as well as residents. This was discussed with the deputy managers during the inspection. The deputy managers agreed to review the activity programme with the residents. Good Companions DS0000005324.V372693.R01.S.doc Version 5.2 Page 16 Relatives and friends are encouraged to call at any time and have a choice of rooms to meet with the residents i.e. two lounges, dining room or bedroom. Visitors were observed to call in at all times of the day and made very welcome by the staff. We spoke to one visitor who commented that the home was always very welcome and friendly. Good Companions DS0000005324.V372693.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): Standards 16,18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents are confident that their complaints will be listened to and acted upon but the information in the home around complaints and safeguarding need to be updated so that residents are sure their rights are fully protected. EVIDENCE: There have been two complaints received by the Commission for Social Care Inspection [CSCI] concerning the home since the last inspection. The first was a complaint regarding care practices carried out by staff that work at the home. They included lifting and handling procedures, the treatment of residents and reporting of concerns. A random inspection was carried out in May 2007 and a requirement was given with regard to treating residents with respect. A recommendation was made with regard to the manager completing a record to show residents’ concerns are listened to, taken seriously and acted upon, staff should use the necessary moving and handling equipment when transferring residents to ensure their safety and residents care plans should be updated to reflect any change in their needs to ensure that they are met at the home. Good Companions DS0000005324.V372693.R01.S.doc Version 5.2 Page 18 The second concern was over staffing numbers at night. Occasionally the home was staffed with only one waking night staff although the owners are always on site to assist if needed. We discussed staffing with the owners in general terms and asked them to look at assessed needs of residents at this time. The owners were satisfied that assistance was always on hand. During the inspection we asked residents about raising concerns and they felt that they could approach staff with any concerns. We were informed that the complaints procedure is within the contract given to residents which also acts as a guide to the home [service user guide]. This was found to be out of date however with incorrect references for contacting official complaints bodies such as social services [for example]. The information needs updating and residents in the home should have fresh copies so that they are fully aware of their rights. We talked to staff about the training they have around abuse awareness and those spoken with were clear that they would report any concerns. The assistant managers were aware of how an investigation of any alleged abuse would be carried out in general terms and understood the importance of alerting authorities but where not clear about specific contacts so that appropriate action could be taken and residents would get the right support. Given the findings of inspectors in May 2007 we expected the information about reporting procedures to have been reviewed and updated but this was not the case. We asked for the homes copy of the locally agreed procedures and were given old policies from 2000 and 2004 [this first was a copy of an annual report from Sefton and not a policy document], which have since been superseded. It is important that staff and managers have the correct information and contacts for reporting such incidents and that training in the home links in with locally agreed protocols so that residents are fully protected. Good Companions DS0000005324.V372693.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): Standards 19,26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home offers very comfortable, ‘homely’ accommodation and all areas are well maintained which contributes to a good quality of life for the residents. EVIDENCE: All communal areas and a number of private rooms were viewed. Private rooms contained resident’s own personal possessions. The home provides a pleasant, comfortable and homely setting for residents and is well maintained. The home is a large, three storey converted building. A passenger lift provides access to all three floors and the home is accessible via steps and a ramp. Assisted bathing facilities are in place. There are car-parking facilities at the front of the building and a large garden at the rear, which is used in the summer months. The garden has disabled access and can also be accessed directly from the dining room. Two communal lounges provide areas for the residents to sit, meet their visitors, read, watch TV or take part in activities. Good Companions DS0000005324.V372693.R01.S.doc Version 5.2 Page 20 There are appropriately placed bathing and toilet facilities [communal] as well as all bedrooms but one having ensuite facilities. This ensures that people with disability have easy access to these facilities. It was also observed that there were disability aids such as raised toilet seats and a diverse range of bathing facilities. All areas of the home were found to be clean and odour free. A well-organised laundry service is in place. The home employs sufficient domestic staff to maintain the home to a good standard. Repairs and maintenance are addressed when required and the home has an ongoing improvement plan. For example the AQAA tells us about the upkeep of the home- rooms decorated, new carpets, redecoration of hall, stairs and corridors and new carpet to these areas, new chairs in TV lounge, new chair in quiet lounge and decoration of dining room. Residents were observed to be comfortable in their surroundings as some residents sat in the lounge reading the papers, or watching TV, while others relaxed in their own rooms. Residents, visitors and relatives commented on their satisfaction with the standard of the homes environment. Good Companions DS0000005324.V372693.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment and selection procedures must be more robust to protect the residents. EVIDENCE: Sufficient staff were on duty at the time of the unannounced visit to meet the needs of the residents. For 16 residents at the time we found three care staff on duty including a senior staff. The owner was also available and the assistant managers later arrived to assist with the inspection. There is a cook on duty all day and there is domestic staff. We asked for two staff files of recruitments since the last inspection. It is a concern that both staff were commenced in employment without the necessary checks being made prior to this. Both staff did not have the required checks made to ensure that they were not on the Protection of Vulnerable Adults register [POVA] and they also did not have the required written references. These checks must be made by law so that staff employed in the home are checked as ‘fit’ to work with vulnerable people. Failure to compete these prior to employment can put residents at risk. Good Companions DS0000005324.V372693.R01.S.doc Version 5.2 Page 22 In addition, one application form was not clear around dates worked prior to applying for a job in the home. There were no interview notes or notes to say whether managers had considered this. One staff declared a previous criminal conviction. Again there were no notes available in the record from managers to evidence whether this had been considered along with any necessary risk. It is of particular concern that the managers were still unsure as to the requirements for employment checks and we spent some time explaining the basic requirements. The failure of the home to make adequate pre employment checks is a concern particularly as this was previously raised on the last key insopection. A training plan is in place and covers all statutory training required, i.e. manual handling and first aid. Additional training is also provided in areas relating to the care of the elderly such as dementia. Staff interviewed confirmed that the training is good and kept up to date. All training is conducted with Mulberry House who are a training organisation, with the exception of first aid. The home has a training room to conduct ‘in house’ training. There are staff who are qualified to instruct in house moving and handling. In terms of quality, staff may benefit from more diversity to the training with more external courses being arranged. This is particularly so with abuse awareness for example where in-house provision alone has not ensured managers and staff are completely up to date. Staff are encouraged to undertake National Vocational Qualifications (NVQ). This has improved since the last inspection with at least 50 of staff now having this qualification at least at level 2. This shows that there is a solid core of staff who are competent to carry out care work in the home. Good Companions DS0000005324.V372693.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes management systems need to be thorough enough to monitor key areas to a good standard so that the home can be consistently run in the best interests of the residents. EVIDENCE: The Registered manager and provider for the home is Mrs Moffet and she shares the day to day running of the home with two deputy managers who supervise all of the care and general running of the home. The Providers live on the premises and are therefore in day to day contact. Good Companions DS0000005324.V372693.R01.S.doc Version 5.2 Page 24 The managers have organised some external quality assurance audits so that they can continue to develop the home with reference to the needs of the people in the home. For example they have a yearly audit by ‘assured care’ which looks at the care of the residents and seeks their comments and opinions which are then fed back to management. The home also conducts their own surveys. The feedback for these is very positive and generally the people living in the home feel cared for and positive about their daily life. The managers also conduct internal audits and checks of some of the care systems in the home and these were seen. For example there are regular health and safety checks on the environment. There was some discussion on the depth of these assessments as those seen list only dates of checks made but do not detail what was checked and how these were checked so it is not possible to see how the managers are evidencing good standards. This lack of detail may contribute to some key areas not being monitored to a high standard. For example the staff files [see staffing] do not meet the required standards for recruitment checks and process. It is a serious concern that this particular area of management has not been addressed following requirements made on a previous key inspection. Managers must address requirements so that the home can meet its legal requirements. The AQQA tells us that basic health and safety certificates such as gas and electrical safety are up to date. The fire safety in the home is well monitored with input from external agents who have conducted a risk assessment of the home so we can be sure that the environment is safe. The accident records were seen. These give good detail for each accident but it was unclear whether relatives had been informed of accidents, as there were no notes around this. The current storage of the accident records does not meet data protection guidelines and this was discussed and should be rectified. Good Companions DS0000005324.V372693.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 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 2 X 2 Good Companions DS0000005324.V372693.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? 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 OP9 Regulation 13(4) Requirement Residents who are self medicating should have risk assessments carried out to ensure they are safe. There must be full and appropriate checks made for all applicants prior to commencing work in the home as listed in schedule 2 of the care homes regulations. These must include full written references and checks with the protection of Vulnerable Adults register. This ensures that staff who work in the home are fit to do so and that residents are fully protected. 3 OP33 10(1) 30/12/08 Managers must ensure that all requirements identified in previous CSCI inspection reports are progressed in the agreed timescales so that the home can meet its regulatory requirements and residents can be assured that the home is run in their best interests. DS0000005324.V372693.R01.S.doc Version 5.2 Page 27 Timescale for action 30/12/08 2 OP29 19 30/12/08 Good Companions 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 OP1 Good Practice Recommendations It is recommended that the current information for residents such as the statement of purpose is reviewed and updated to be more easy to read and reflects current practice in the home. All assessments should be dated. The managers should review how daily notes are recorded for individual residents and consider the use of individualised personal record sheets instead of the current use of a generic diary. Residents who have PRN medication should have this monitored through the care plan to ensure medications are given in the same way. The home should continue review the activity programme in view of the comments made in the report. Some resident reported that would like a menu produced so that they are more aware of what food is to be provided. The complaints procedure for the home should be reviewed and updated and new copies given to residents. Managers should acquire an up to date copy of the local safeguarding protocol and ensure that training given to staff references current information. Any discrepancies in staff application forms such as gaps in employment should be checked out by manages and appropriate interview notes made. Any previous criminal record should be fully explored and a record made of managers assessments around risk. Managers should ensure that the internal audits conducted are robust enough to monitor key areas to a good standard. It is recommended that all staff receive ongoing 1:1 supervision as specified under this standard. Accident records should record details of whether relatives have be informed and if not why not? The current accident records do not meet requirements for Good Companions DS0000005324.V372693.R01.S.doc Version 5.2 Page 28 2 3 OP3 OP7 4 5 6 7 8 9 OP9 OP12 OP15 OP16 OP17 OP29 10 11 12 OP33 OP36 OP38 data protection as this should be addressed. Good Companions DS0000005324.V372693.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North West Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 Good Companions DS0000005324.V372693.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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