Inspection on 19/09/06 for Hafod Residential Home

This inspection was carried out on 19th September 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hafod Residential Home 08/10/09

Hafod Residential Home 20/04/09

Hafod Residential Home 30/04/08

Hafod Residential Home 03/05/07

Hafod Residential Home 23/01/06

Hafod Residential Home 27/09/05

Hafod Residential Home 01/03/05

Hafod Residential Home 28/09/04

Hafod Residential Home 24/02/04

Hafod Residential Home 16/10/03

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

CARE HOMES FOR OLDER PEOPLE Hafod Residential Home 14 Anchorage Road Sutton Coldfield West Midlands B74 2PR Lead Inspector Amanda Lyndon Key Unannounced Inspection 19th September 2006 11:00 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 Hafod Residential Home DS0000016917.V309774.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. Hafod Residential Home DS0000016917.V309774.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hafod Residential Home Address 14 Anchorage Road Sutton Coldfield West Midlands B74 2PR Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) 0121 354 5607 0121 354 2616 Mr Alan Pearce Eleri Perry Acting Manager Janet Taylor (not registered with CSCI at time of field work visit) Type of registration Care Home Hafod Residential Home DS0000016917.V309774.R01.S.doc Version 5.2 Page 4 No. of places registered (if applicable) 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Hafod Residential Home DS0000016917.V309774.R01.S.doc Version 5.2 Page 5 SERVICE INFORMATION Conditions of registration: none Date of last inspection 23rd January 2006 Brief Description of the Service: Hafod Residential Home provides accommodation in a large and sympathetically adapted Victorian building situated at the junction of Anchorage Road and Lichfield Road approximately one mile from the centre of Sutton Coldfield. There are good bus links from Birmingham and Lichfield. Personal care can be provided for up to sixteen persons who are aged 65 years or above. The Home does not provide nursing care and does not have a category to care for people with dementia. The Home does not accommodate people who require the use of wheelchairs and hoisting equipment is not available for general use. There are 14 bedrooms, two of which are shared rooms, the Home utilises these as single rooms, and the majority have en-suite facilities. There is a call bell facility in each bedroom for residents to use in order to summon assistance or urgent help in the event of an emergency. Bedrooms are located on the ground and first floors and a passenger lift gives access to these areas. Communal areas are available on both floors, these are spacious, attractive, well appointed and in keeping with the age of the property. A conservatory leading off the ground floor lounge serves as a dining room. Assisted bathing facilities are strategically located on each floor offering a choice of bath or shower facilities, including a Jacuzzi facility and staff are available to provide assistance in these areas as required. The Home has a large enclosed and attractive rear garden. There is limited off road parking at the front of the premises. There are notice boards located throughout the Home displaying forthcoming events and other information of interest to residents and their visitors in a large print format. The most recent CSCI inspection report was accessible to residents and their visitors. The weekly fee to live at Hafod Residential Home is between £575 and £650 and weekly physiotherapy is included within the weekly fee. Items not covered by the fee include hairdressing, private chiropody, newspapers, outings and holidays. Hafod Residential Home DS0000016917.V309774.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This report reflects the findings of a one day unannounced field work visit undertaken by one Inspector when there were fourteen residents living at the Home. Four of these residents were on holiday and one resident was in hospital. Information was gathered by speaking with residents and staff, case tracking, examining care, medication and health and safety records and observing the staff perform their duties. A tour of the Home was undertaken. Prior to the field work visit positive comments were received from residents about the service provided including: “ I always like the meals” and “I always receive medical support” A negative comment was received from a resident about poor communication amongst staff members on occasions. During the field work visit the Manager had completed a pre inspection questionnaire, giving some information about the Home, residents and staff which was taken into consideration. What the service does well: Residents’ individual care needs are reviewed regularly and any changing care needs are monitored to ensure that they could continue to be met at the Home. Care staff provide support for residents to receive the appropriate medical care that they require and monitor any treatments prescribed to them, ensuring that any health problems are improving. Staff take time to explain any treatments to the residents and this ensures that they have an understanding of the care that they are receiving. Residents are cared for in a respectful manner and this ensures that their dignity and self esteem are maintained. Residents are able to exercise control over their daily lives and the activities that they choose to participate in which promotes their individuality and independence. There is a wide variety of activities on offer at the Home for the residents to participate in should they choose. Visitors are made to feel welcome. Hafod Residential Home DS0000016917.V309774.R01.S.doc Version 5.2 Page 7 Residents’ individual religious beliefs and cultural preferences are respected. There are opportunities for religious worship and support is provided by staff in this area. Residents are served a choice of wholesome and nutritious meals that meet any special dietary requirements for reasons of health, taste or religious/cultural preferences. There is a comprehensive complaints procedure accessible to residents and visitors should they need to make a complaint. Residents are provided with an attractive, well maintained, comfortable and clean living environment in which they feel safe and secure. Residents can personalise their rooms to reflect their individual tastes, cultural choices and interests and this ensures that they feel comfortable in their surroundings. Aids and adaptations are provided to assist residents in maintaining their independence. Staff recruitment procedures are robust and safeguard residents. Staff receive appropriate training to ensure that they have the knowledge to work competently within their job roles. Residents are invited to regular meetings to discuss the service provided at the Home and there was evidence that any suggestions made are acted upon and this ensures that residents are involved in the running of the Home and the facilities on offer. The Home was regularly monitored for quality. There is a robust system for the management of residents’ personal allowances should they choose for the Home to hold this on their behalf. What has improved since the last inspection? What they could do better: Hafod Residential Home DS0000016917.V309774.R01.S.doc Version 5.2 Page 8 A pre admission assessment had not been completed in respect of a resident who had come to live at the Home and this may prevent their individual care needs and preferences regarding their daily lives from being met. Residents were not always involved in the agreeing and reviewing of their care plans and this may prevent their preferred routines in respect of their daily lives from being maintained. There were some poor practices in respect of the management of medication and these may result in medication administration errors. Some staff members had a poor knowledge of adult protection procedures and this may not safeguard residents. The adult protection procedure did not include local contact details and this may prevent all relevant people from being informed promptly in any instances of alleged or actual abuse. Staff meetings are not held regularly and this may prevent important information about residents’ care from being conveyed amongst the staff team. 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. Hafod Residential Home DS0000016917.V309774.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 Hafod Residential Home DS0000016917.V309774.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admission and assessment processes are comprehensive and this enables residents and their families to make an informed choice about whether they would like to live at the Home. A lapse in this procedure may prevent individual care needs from being met at the Home. EVIDENCE: Prospective residents are encouraged to visit the Home in order to sample what life would be like to live there and during this time a pre admission assessment is undertaken by senior staff to ensure that the person’s individual care needs could be met whilst living at the Home. If prospective residents are unable to visit the Home, pre admission assessments are undertaken within their own home or hospital setting in order to prevent inappropriate admissions and the possibility of residents having the upheaval of moving home again. Hafod Residential Home DS0000016917.V309774.R01.S.doc Version 5.2 Page 11 An exception to this was that the Home’s staff had failed to undertake a pre admission assessment regarding a resident who have recently come to live at the Home and although this person had been a regular visitor to the Home, this lack of information may prevent their individual care needs and preferences in respect of their daily life from being met. New residents are issued with information about the terms and conditions of their stay Care reviews are undertaken should a resident’s care needs change in order to determine whether their care needs could continue to be met at the Home. The Home does not accommodate people who require the use of a wheelchair and hoisting equipment is not provided. An exception to this had been made with the agreement of an existing resident at the time that their physical health had deteriorated in order for their care needs to continue to be met at the Home. An extra member of staff was funded by the resident for a period of time and an appropriate transfer hoist was purchased by the resident. Intermediate care is not provided at Hafod Residential Home. Hafod Residential Home DS0000016917.V309774.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and personal care delivery is good and medicine is administered in a safe manner. Residents are cared for in a respectful manner and this ensures that their dignity and self esteem are maintained. EVIDENCE: On admission to the Home, comprehensive assessments are undertaken of the individual resident’s care needs including their life history, interests, religious/cultural beliefs, abilities and health care needs. It was pleasing that these included resident’s individual preferences in respect of their daily lives in order to ensure that these would be maintained whilst living at the Home. Generic care plans were used and did not always state the specific support required by the staff in order to meet the residents’ care needs based on their individual preferences. It was however apparent that all staff had a good knowledge of the support required in respect of each resident living at the Home. Hafod Residential Home DS0000016917.V309774.R01.S.doc Version 5.2 Page 13 Care plans had been derived from this information, however these had not been signed by residents and/or their representatives to confirm that they agreed with the content of these. Care plans were reviewed in good detail each month however there was no evidence that the residents were involved in this process. Daily reports were informative and included good detail of the activities that the residents had engaged in. Residents had access to a range of Health and Social Care Professionals including District Nurses, Dentists and Chiropodists. Residents can retain their own General Practitioner on admission to the Home (if the GP is in agreement) Professional advice is sought by the care staff in order to ensure that the changing health and care needs of residents are being met, for example a resident had recently been referred to the “falls clinic” in order to promote her mobility whilst maintaining her safety. Weekly physiotherapy is provided, funded by the Home and this promotes the health and independence of residents. Staff support residents to visit the local Optician to ensure that their safety is maintained whilst maintaining their independence. One resident commented that they always received the medical support that they required. There was evidence that the staff take time to explain to residents the reasons for any treatments prescribed or changes to the care provided and it was apparent that any health problems were monitored. Residents are weighed at least every month in order to promote their health. The management of medication was generally good and the systems in place were regularly audited to safeguard residents. However, the actual dosages administered in respect of variable doses were not always recorded, hand written entries on to medication administration charts were not always signed or countersigned and completed medication administration charts were not always filed away which may lead to the duplication of a medicine being administered. Residents appeared to be well supported by staff to maintain their personal hygiene and to choose clothing and jewellery appropriate to their individual tastes, age, gender, cultural preferences and the time of year. The preferred name of individual residents was recorded within care plans and staff were observed to be greeting residents by these. All residents are offered a key for their bedroom door in order to respect their privacy and promote their independence. Hafod Residential Home DS0000016917.V309774.R01.S.doc Version 5.2 Page 14 The second floor of the Home provided self contained living accommodation for a member of staff and family and whilst this area is separate from residents’ living areas, measures must be in place to ensure that the privacy and safety of residents are maintained whilst the family and their visitors gain access to their accommodation. Hafod Residential Home DS0000016917.V309774.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities on offer meet the needs and expectations of residents living at the Home. Residents exercise control over their daily lives so that their independence and individuality are maintained. The choice of wholesome and well presented meals meet any special dietary needs of residents for reasons of health or cultural/religious beliefs. EVIDENCE: The Home does not employ an activities organiser however all staff had a responsibility for this and a variety of activities were on offer including handicrafts, movement to music, card games, video evenings, manicures and trips to the local park and pub for lunch. A green house had recently been purchased in response to a request from residents. At the time of the field work visit, four residents had chosen to go on a holiday accompanied by staff from the Home. One visitor said “ The staff always encourage my mother to take part in activities”. The hair dresser visits the Home every fortnight. There were opportunities for religious worship both within and outside of the Home. Hafod Residential Home DS0000016917.V309774.R01.S.doc Version 5.2 Page 16 A church service is held at the Home every week and staff were aware of how to access opportunities for worship for people of non Christian faiths although this was not required at the current time. There was an open visiting policy for visitors at all reasonable times and there was an “open door” policy for visitors to discuss the care and service provided at the Home with the management team. There were no rigid rules or routines at the Home and residents could go outside of the Home on their own or with their families and friends as they chose. One resident said “My daughter takes me shopping once a week” It was pleasing that residents’ preferences and choices were respected with attention to detail, for example, one resident had a special “mug” to drink out of and all staff were aware of this and made sure that her drinks were served in this way. Residents confirmed that they could choose the times that they go to bed at night and get out of bed in the morning. During week days, the main meals were prepared at the nearby nursing home run and managed by the Registered Providers of Hafod Residential Home and were transported to the Home under controlled conditions to ensure that the meals were served at the correct temperature. This was originally a temporary arrangement due to the extended leave of the Cook, however residents appeared to be happy with this service, therefore it may continue. A weekend Cook is employed and a variety of fresh baking is undertaken during this time. A cooked breakfast is available and a snack meal is available at suppertime and during the night, using fresh ingredients that are available at the Home at all times. Weekly menu options are distributed to residents in order for residents to choose the meals that they would like to be served. These included a variety of wholesome hot and cold meal options. Special diets can be provided for reasons of health or religion and alternatives to the main meal options were always available. The main meal option for lunch on the day of the field work visit was gammon and pineapple with vegetables and all of the residents had chosen this option. Residents were encouraged to serve their own vegetables using terrines that were on the dining tables, promoting their independence. A glass of sherry was served with lunch and there were good social interactions between residents and between residents and staff at this time. Music of the residents’ choice was being played so that lunch was an enjoyable social event. One resident said “ The food is very nice. You have what you want, not what they want to give you”. Hafod Residential Home DS0000016917.V309774.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure is comprehensive and accessible to residents and their visitors should they need to make a complaint so that complaints are dealt with in an appropriate and timely manner. Staff knowledge in respect of adult protection was poor at times and this may not safeguard residents. EVIDENCE: Since the last visit CSCI had not received any concerns, complaints or allegations about the service provided at Hafod Residential Home and no complaints had been recorded in the complaints register held at the Home. A comprehensive complaints procedure was on display in a prominent position of the Home and a suggestions box was provided in the reception area of the Home in order for residents and visitors to put their views forward. Residents commented that they would feel confident to complain if the need arose. One resident said “ I would speak to the person in charge if I had to complain” Another resident said “ I have no grumbles, the staff are very good”. Some staff members had limited knowledge about adult protection procedures however training in this area was scheduled to be provided during the week after the field work visit. Hafod Residential Home DS0000016917.V309774.R01.S.doc Version 5.2 Page 18 The adult protection policy was comprehensive, however did not include the local contact details of persons to be informed in the event of an alleged or actual abuse and it is recommended that this be reviewed to incorporate this detail. Hafod Residential Home DS0000016917.V309774.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in an attractive, safe, clean and homely environment and the Home is designed to respect the privacy of residents living there. The physical environment of the Home and equipment available meets the needs of the residents. EVIDENCE: The internal environment of the Home is homely in style, comfortable and is full of interesting features. For example, a fish tank had been purchased in response to a request made by residents. There is a rolling programme of refurbishment and redecoration in place. Residents had the choice of two lounges, one of which was currently being redecorated to a high standard. There was also an attractive and comfortable dining area within a well lit conservatory, looking over the garden. Hafod Residential Home DS0000016917.V309774.R01.S.doc Version 5.2 Page 20 The back garden was accessed through the conservatory and residents had to negotiate a small step into this area. The garden was well maintained and split over two levels with a ramped access to the lawn area. A new garden swing chair had recently been purchased in response to a request made by residents. There was one assisted “walk in” shower facilities and one assisted bath, which included a recently purchased Jacuzzi facility and these met the needs of the residents living at the Home. One bedroom included an en suite shower facility and plans were in place for further refurbishment of these areas. The main bathroom was decorated in a homely style to ensure that residents felt relaxed whilst using this facility. Aids and adaptations provided to assist residents living at the Home included hand rails near to toilets and in corridors, raised toilet seats and pressure relieving mattresses and cushions for residents assessed as being at risk of developing sore skin. One resident was using a reading light to enable her to read independently. Hafod Residential Home is registered to accommodate sixteen residents however fourteen residents are currently living there as the two shared bedrooms are being utilised as single occupancy bedrooms to promote the comfort of residents. Bedrooms were personalised to reflect residents’ individual tastes, cultural choices and interests and this ensures that they feel comfortable in their surroundings. One resident said “ I have a room of my own, it is so nicely decorated” A lockable facility and call bell facility is provided in each bedroom. One resident said “ If I need help I use my call bell and the staff come and help me”. The Home was found to be clean and fresh on the day of the filed work visit and hygienic hand washing facilities were located throughout. Two residents had chosen to use commodes in their bedrooms and these were cleaned by the staff manually. It is recommended that a risk assessment and infection control procedure be written regarding this in order to prevent the spread of infection and safe guard the health of staff. An effective and hygienic system for the laundry of residents’ personal clothing and bed linen was in place. Hafod Residential Home DS0000016917.V309774.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels and appropriately trained and vetted staff ensure that a good consistent standard of care is provided to meet the care needs of the residents. The systems in place for communications amongst staff are lacking at times and this may prevent important information regarding residents’ care from being conveyed. EVIDENCE: Staffing rotas identified that one senior carer, one carer and a housekeeper are provided during the morning hours and one senior carer and one carer are provided during the afternoon/evening. The Acting Manager works in addition to these staffing levels and kitchen staff provide support with serving meals. There is a staff member awake at the Home during the night and another staff member provides “sleep in” support. Agency staff is not used at the Home and the Acting Manager and staff team provide shift cover during periods of staff sickness and annual leave, ensuring that continuity of care is maintained. The Registered Provider and Acting Manager provide “on call” support to the person in charge of the shift. Positive comments were received from the staff team about the good support provided to each other within their team. One resident said “ The staff are very nice and kind here” Hafod Residential Home DS0000016917.V309774.R01.S.doc Version 5.2 Page 22 A negative comment was received from a resident about poor communication amongst staff members on occasion, this being despite staff training in this area and a staff meeting had not been held recently. This may prevent important information regarding residents’ care from being conveyed and does not provide staff with the opportunity of putting forward their views about the running of the Home. Staff files contained all information required by regulations and all staff working at the Home were deemed to be safe to work with vulnerable people. A new member of staff confirmed that she had received information about fire and health and safety on her first day working at the Home and this safeguards all people within the Home. Comprehensive induction training was provided in line with “Skills For Care”. Staff had received training appropriate for their job roles including accredited medication training and infection control. 70 of care staff have achieved NVQ level 2 in care and this ensures that they have the appropriate knowledge to work in a competent manner. Hafod Residential Home DS0000016917.V309774.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This is a well managed Home and is run in the best interests of the residents living there. The systems for resident consultation are good, residents’ views sought are acted upon and systems are in place to monitor the quality of service provided. Residents’ health and safety are maintained. EVIDENCE: The Registered Manager/Provider had recently been replaced by an Acting Manager however she would still continue to provide input in to the running of the Home. The Acting Manager has had much experience of working with older people and was previously the Deputy Manager at the Home. She is due to complete her registration with CSCI in the near future, has a management qualification and is currently working towards the Registered Managers’ Award. One resident said “The owners are very nice people, they are very good”. Hafod Residential Home DS0000016917.V309774.R01.S.doc Version 5.2 Page 24 Residents’ meetings are held regularly and the minutes of these were printed in a large print format and distributed to all residents living at the Home. All other memos and information of interest to residents were produced in a large print format to ensure that they were easy to read by people with poor eye sight. There was evidence that requests made by residents in respect of food choices, equipment for residents’ use and activities arranged by the Home were acted upon without delay. In house service satisfaction questionnaires were distributed to all relevant people regarding the service provided at the Home and in addition to this an external formal quality assurance programme is undertaken in order to monitor the standard of services provided. The Home do not manage the personal finances of any residents living at the Home however there was a facility for the safekeeping of small amounts of residents’ money and the system for this was robust. Staff had received training in health and safety issues including first aid, basic food hygiene, fire safety and a fire drill had been undertaken recently. Refresher training in respect of moving and handling had been scheduled for the near future. Maintenance checks and servicing of equipment used at the Home were undertaken regularly in order to safeguard residents, visitors and staff. Comprehensive risk assessments had recently been undertaken in respect of fire safety. An independent external health and safety audit had been undertaken at the Home recently and no requirements had been made. Remedial action had been undertaken following a recent Fire Officer’s visit in order to safeguard residents. Accident records were well maintained and audited regularly, however did not always detail any action taken by staff or the outcome of the accident and this may prevent future accident preventative measures from being implemented. There was evidence that appropriate medical advice is sought promptly following an accident involving a resident as required. Hafod Residential Home DS0000016917.V309774.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 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 2 3 3 3 3 x 3 3 3 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 2 3 3 x 3 x x 3 Hafod Residential Home DS0000016917.V309774.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? yes 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 OP3 Regulation 14(1) Requirement Timescale for action 16/10/06 2. OP7 15 Pre admission assessments must be undertaken for all residents prior to coming to live at the Home. Care plans must be agreed and 16/11/06 reviewed with the involvement of residents and/or their representatives Care plans must identify the specific support required by staff to meet residents’ individual care needs based on their individual preferences The actual dose administered in respect of variable drug dosages must be recorded on the medication administration charts (MAR) Staff must sign and countersign all hand written entries on to MAR charts Completed MAR charts must be filed away A risk assessment must be 16/10/06 undertaken in respect of the current use of the second floor of DS0000016917.V309774.R01.S.doc Version 5.2 3. OP9 13(2) 16/10/06 4. OP10 12(4)(a) 13(4) Hafod Residential Home Page 27 5. OP18 13(6) the Home with the residents’ privacy and safety in mind. The registered person must complete the already commenced process of staff training in adult protection. (previous four timescales not met) The Acting Manager must complete the Registered Managers’ Award 01/12/06 6. OP31 9(2)(i) 01/04/07 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. Refer to Standard OP18 OP26 OP27 OP38 Good Practice Recommendations The local contact details of persons to be informed in the event of an alleged or actual abuse should be included in the adult protection policy It is recommended that a risk assessment and infection control procedure be written regarding the manual cleaning of commode pots. Staff meetings should be held regularly Accident records should include detail of any action taken and outcomes following accidents involving residents living at the Home. Hafod Residential Home DS0000016917.V309774.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 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 Hafod Residential Home DS0000016917.V309774.R01.S.doc Version 5.2 Page 29 - 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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