Inspection on 16/05/06 for Halcyon House

This inspection was carried out on 16th May 2006.

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

Halcyon House 28/02/06

Halcyon House 17/02/05

Halcyon House 13/07/04

Halcyon House 09/03/04

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

CARE HOMES FOR OLDER PEOPLE Halcyon House 55 Cable Street Formby Merseyside L37 3LU Lead Inspector Mrs Claire Lee Unannounced Inspection 16th May 2006 9:00 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 Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 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. Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Halcyon House Address 55 Cable Street Formby Merseyside L37 3LU 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 833350 halcyonhouse@btopenworld.com Abbeyfield North Mersey Society Limited Mrs Anne Garmona Terry Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 31 OP. Maximum no. registered 31, of which up to a maximum of 31 PC (personal care) and up to a maximum of 15 N (nursing) - this to be increased to 16 places to accommodate a named service user and only until such times as the named service user continues to reside at the home The service should have a suitably qualified and experienced manager who has been approved by the CSCI 28th February 2006 3. Date of last inspection Brief Description of the Service: Halcyon House is registered to provide residential (personal) care and nursing care for up to 31 older people. The home was first opened in 1992. The home is owned and managed by Abbeyfield North Mersey Society Ltd. This is a charitable organisation. Halcyon House is located in a residential area in Formby and is close to local shops and transport links. The home is a single storey building that has a large garden and patio area in the centre. All bedrooms are single rooms and have en-suites. There are adjoining rooms available for married couples or for those who wish to share. There is a large lounge and dining room and the garden area is overlooked by a sun lounge. Other facilities include a small chapel and library. There is a large car park at the front of the home. The range of fees for accommodation is £1,672.61 a month for residential provision and £2,183.92 per month for nursing provision. Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day for 9 hours and 31 residents were accommodated at this time. It was an unannounced inspection (site visit). A partial tour of the premises took place and a number of the home’s care, staff and health and safety records were viewed. Discussions took place with 7 residents, 5 staff, the home’s administrator, manager and Chairman. During the inspection 4 residents were case tracked (their care files were examined and their views of the home were obtained). This process was not carried out to the detriment of other residents who also took part in the inspection process. Discussion also took place with 2 relatives. All the key standards were inspected and also previous requirements and recommendations from the last inspection in February 2006 were discussed. Satisfaction survey forms “Have Your Say About …” were distributed to a number of residents prior to the inspection and some were also left for relatives to compete at the time of the visit. Comments included in the report are taken from the survey forms and also during the site visit. What the service does well: The home presents with a very warm, welcoming and friendly atmosphere. The team of staff are well established and residents and relatives were complimentary regarding the standard of care and support they receive. A resident said, “The staff are very good, you could not wish for nicer people”. Visitors were observed popping in at various times of the day and chatting with staff. A relative said, “You can come in to the home at any time and the staff are always helping and spending time with the residents”. Prior to admission residents’ health, social and psychological care needs are assessed by the manager and/or a qualified member of staff. The assessment information is then used to form the basis for a plan of care. Care files seen were organised, easy to read and provided good detail with regard to individual care needs. Through discussion and observation it was evident that residents were treated respectfully and the home ensures good standards of privacy and dignity. A resident said, “All the staff are polite and they are my friends”. The homes’ routine is relaxed and based around the wishes of the residents. Those residents seen were appropriately dressed and staff were observed to assist residents with their lunch in a sensitive manner. A number of residents go out most days however the home does offer a very good activities programme and social events have been organised for the summer months. The home has a garden and enclosed patio area that lends itself to garden parties. Activities are advertised and residents interviewed Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 6 were pleased with the social aspect of the home. Residents’ meetings take place regularly and residents are also given further opportunities to comment on the home through questionnaires. Residents and relatives were complimentary regarding social arrangements in the home. The home’s menu is varied and well balanced. Changes have been made to the menu however this has been carried out with the agreement of the residents. The catering arrangements are well organised and residents interviewed were pleased with the quality of the food served. The chef meets with residents to ask what they would like from the menu each day and has information on their individual dietary needs and preferences. Residents interviewed commented on the good choice of hot foods served. The home is very pleasantly decorated and areas viewed were clean and well furnished. Residents interviewed were pleased with the general maintenance and cleanliness of the building. Bedrooms had personal items and a number of resident commented on the comfortable beds. A resident stated, “If you cannot live at home, this is the next best thing”. Staff have access to a good standard of training in safe working practice areas and they also attend courses relevant to the care of the older client group. A high percentage of staff are qualified to a National Vocational Qualification (N.V.Q) Level 2 in care. Courses are also arranged for staff with regard to caring for the older person. What has improved since the last inspection? What they could do better: With regards to recruitment, a number of staff files were viewed. It was noted that one staff file only contained one reference and two are required prior to am employee commencing work. A photograph is required for each member of staff for verification purposes. Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 7 The home should provide residents with a more formal contract, a signed copy of which should be kept on file. A full breakdown of the fee structure should be included. Staff interviewed discussed their induction when commencing work at the home and induction booklets are provided. A record of staff induction should be maintained in the staff files. The home should contact the fire safety department regarding the frequency of ‘in house’ checks of emergency lighting and fire prevention training for staff. Fire prevention equipment is subject to an annual maintenance contract however the safety certificate was not available as the home are in the process of changing contractors. A copy of the new contract should be forwarded to the Commission. 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. Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 (Intermediate care is not provided – Standard 6) The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Pre admission assessments help ensure that the home can meet the needs of the residents and residents are provided with a contract. EVIDENCE: Although Standard 1 was not assessed, residents and relatives interviewed state that the home provided sufficient information regarding the service. Residents and/or their representative are provided with terms and conditions of the home. The contract is in ‘letter form’ and residents sign their agreement to the fees charged. It is recommended that a more formal contract be used and a copy of the signed contract be kept on file. Residents with private means are informed of the nursing banding (high, medium and low) following a determination of their care needs by the primary care trust. A full breakdown of the fee rate should however also be included in the contract. Residents have an assessment of need which is carried out by the manager and/or qualified member of staff. The assessments had been completed in detail with regards to health, personal and social care and this information had Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 10 been used to form the basis for the plan of care. In addition to the assessment a ‘pen picture’ (which is a brief outline of the person and their background) is provided by members of the resident’s family along with information on the resident’s social, cultural, ethnic and spiritual needs. Standard 6 is a key standard to be assessed however the home provides long term care only and does not provide intermediate care. Some of the residents have lived at the home for a number of years. Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8, 9 and 10. The quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. Residents’ health, personal and social care needs are addressed in detailed care plans. Residents are treated with respect and dignity. This ensures an excellent standard of care in the home. EVIDENCE: Residents have an individual care file and four files were viewed as part of the case tracking process (two files of residents on the residential unit and two files of residents on the nursing unit). The care files are accessible for staff, they are organised and the information is easily read. Care documentation seen had also been reviewed regularly to ensure it was accurate and reflected any change in care or treatment. Staff pay a great deal of attention to recording all aspects of care, for example, maintaining a safe environment, communication, personal care, food and nutrition, mobilising, social needs and sleeping. The resident’s right to privacy and dignity had also been incorporated in the care plans and there were good instructions for staff on how to deliver the care. Survey forms make reference to residents receiving the care and support they need. Care plans are written for specific care needs that may arise and emphasis is placed on recording any problem with communication for Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 12 example, visual impairment or hearing loss and what staff need to do to communicate effectively. The care plans examined had been signed by the resident and/or their representative and relatives interviewed were familiar with the care reviews. General risk assessments including manual handling instruction are in place for residents who are at risk of falling or who require assistance with their mobility. Risk assessments for, nutrition, care of resident’s skin and self medication had also been completed. There was evidence that a plan of care was in place where a risk had been identified. Residents who may have difficulties with their diet or weight loss are referred for specialist support. A record is kept of GP visits or external health appointments and a resident said, “I can see my doctor at any time and the chiropodist comes regularly”. Residential residents receive input from the District Nurses. The District Nurses maintain their own notes and advise staff of the treatments they are giving. There was evidence of their visits in a care file examined. Comments from residents regarding the care include: “Staff are excellent” “The care is really good” “Could not wish for better” “If I wish to see my doctor or my dentist or need a change of prescription this is dealt with very promptly” Standard 9 is a key standard however it was not assessed in full on this occasion as a Commission for Social Care Inspection pharmacy inspector conducted a site visit 9th May 2006 to inspect this standard. A separate pharmacy inspection report will be sent to the home. Only the MAR (medicine administration sheets) of residents who were case tracked were examined and medicines had been administered as prescribed The home is also in the process of introducing a new disclaimer form for residents who wish to self medicate and a homely remedy protocol as advised by the pharmacy inspector. A number of residents do self medicate and this is good evidence of the home promoting independence and individual choice. Staff were observed as being competent and caring in their attitude when providing personal care for residents and also having sufficient time to spend with them; they did not appear rushed in any way. Residents interviewed stated that staff were very respectful and also had a good understanding of how to care for older people. Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 The quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. Residents are able to exercise choice and control over their lives and are offered a choice of well balanced and nutritional meals. EVIDENCE: The home has a very pleasant friendly atmosphere and staff give a great deal of thought to arranging social activities to suit individual needs and preferences. Social needs are assessed in detail when a resident is admitted and residents spoken with were pleased with the home’s varied programme of social events. Staff work hard to ensure social interests are stimulating and it was evident through discussion with a number of residents that they enjoy a full lifestyle. Regular outings are arranged and the staff accompanied nine residents to dinner at a local restaurant last week.Social evenings, race nights, bingo, scrabble, dominoes, musical entertainment, chairoebics are organised and summer and winter fairs held. A garden party is also going to take place as part of the home’s Golden Jubilee celebrations. A number of residents were observed using talking books and the home has contact with external societies, for example, Royal National Institute of the Blind. The hairdressing was visiting Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 14 and residents commented on this good service. The home has a manicurist and also members of an organisation with pets visit the home. Residents are encouraged to attend local clubs and community based events. This was discussed in relation to an art club and stroke club. The home also offers a mobile shop, library and newsletter. A resident confirmed that a church service is held in the dining room and Holy Communion offered. This enables residents to continue to practice their own faith. Activities are advertised and residents interviewed were familiar with aware of forthcoming events. A number of the residents are independent and go out with their family and friends and also arrange their own holidays. Some residents prefer to stay at the home and staff respect this wish. Staff were observed spending time on a one to one basis with residents in the dining room and/or in their bedrooms. Visitors were seen popping in at various times of the day and a relative stated that she always received a warm welcome whatever time she arrived at the home. Residents were receiving visitors in their own rooms or in the communal areas. Residents are encouraged to manage their own finances and staff also assist with financial arrangements when required. A financial record for one resident was viewed and this contained receipts of expenditures a a balance total. Staff signature following completion of any writtern entry should be added. A relative said the manager would help with any financial concerns. The Board members are alo on hand to offer support and advice. Lunch was served in the dining room by the care and catering staff. The dining room tables were attractively laid and the home offers three well balanced meals day with light refreshements at other times. A choice is available at each meal time and the menu is displayed. The residents gave very good feedback on the quality and quantity of meals and the contact they have with the chef each day. The chef asks residents each day what they would like from the menu and they are also given the opportunity to give written feedback on their meals as a comments book is kept at the entrance of the dinning room. Changes have been made to the menu with regard to comments and requests by the residents. The home caters for special diets and this was discussed in relation to diabetic meals. The chef had detailed information regarding this condition. The home receives nutritional support and advice from a dietician and all meals served are assessed via the home’s catering firm to ensure they are well balanced. Food preferences are recorded in the resident’s plan of care and on individual diet cards, which are kept in the kitchen. The chef and catering staff are qualified in food hygiene. An environmental health inspection was conducted in February and there were no requirements. The storage areas evidenced a good supply of fresh fruit and vegetables. Survey forms makes reference to the food being always or usually good and comments from residents and relatives include: “The food is very good” “The food is served on time” Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 15 “The food is fresh” “The menu is changed frequently” Residents attend meetings in the home with the manager and also separate meetings are held with the Chairman. They are also asked to complete survey forms to give their views of the care and service provided. Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17, and 18 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents and relatives have confidence that their concerns will be dealt with. Abuse policies and procedures are in place to protect the residents. Residents are able to vote. EVIDENCE: The home’s complaint procedure is on display and residents and relatives interviewed were satisfied with all arrangements in the home but were aware of how to make a complaint if needed. A staff member said, “If a resident wanted to make a complaint, I would go to the nurse in charge”. The complaint log was seen and no complaints have been received. Residents are asked to sign a form if they wish to continue to vote when they arrive at the home. This form was seen in the care files examined. The home has acquired the latest Sefton Guide for the Protection of Vulnerable Adults and staff will be advised of the document. The home also has an abuse policy and procedure. The staff training record evidenced abuse awareness training for a number of staff and staff interviewed had an understanding of how to report an alleged incident. Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26. The quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. Residents live in very pleasant, safe, comfortable and well-maintained surroundings. EVIDENCE: The home is purpose built and all accommodation is provided at ground level. It is fully accessible to people who are physically disabled and is fitted with aids and adaptations to promote independence. The main entrance hall is spacious and there is ample information available regarding Halcyon House and the service it provides. The home is well maintained, decorated to a good standard and was clean and tidy during the site visit. There is a garden and car parking space to the front and the home has a central patio area with easy access on all sides of the home. The patio is equipped with patio furniture and sun umbrellas; residents were enjoying the sun during the site visit. A partial tour of the building was conducted, two bathrooms, a shower room and six Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 18 bedrooms were viewed. The bathrooms were clean and tidy and hot water temperatures are recorded each month to ensure the hot water is delivered to a safe temperature. The home has a special adapted bath and walk in shower facilities. Bedrooms viewed had individual items and were homely’. A resident said, “I have everything I need, including some of my own furniture”. Bedrooms have door locks and storage space for valuable items. Bedrooms have a call system with a hand held buzzer to call for assistance. Two bedrooms are fitted with overhead tracking for a hoist and staff commented on the good overall provision of equipment to assist them with their work. Residents have full use of a large dinning room, a sun lounge and four smaller lounges located around the building. A resident who was sitting in one of the small lounges stated that she preferred this area as it was quieter. The home is equipped with comfortable furniture, fittings and electrical equipment, including a computer. The home has a well equipped laundry and there was evidence of gloves and aprons for staff use. Infection control training is given to staff and infection control policies are available. Residents commented on the good laundry service. Fire risk assesmsents of the building are in place and emergency lighting is provided throughout. The emergency lighting is subject to a full maintenance contract however this was not available as the home are in the process of changing contractors for their fire prevention equipment. It was agreed that a copy of the new contract would be forwarded to the Commission. The fire safety department should also be contacted with regard to the ‘in house’ monthly safety checks that are recommended in the home’s fire log book as these are not being undertaken. Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29, and 30 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. There are appropriately trained and experienced nurses and care staff employed so that residents feel supported and that their needs are understood and met. The home’s recruitment policy is generally robust to protect the residents. EVIDENCE: The staffing rota for the month of May 2006 was viewed. Sufficient numbers of staff were on duty at the time of the site visit to care for the resident and the staff team comprised of five care staff, the manager, two registered nurses, a maintenance man, domestic and catering staff. The home has a good stable workforce and a number of staff have worked at the home for many years. No new permanent staff have been appointed since the last inspection and outstanding shifts are filled by existing or bank staff. Staff were complimentary regarding the support they receive from the manager. Residents interviewed described the staff as “Caring”, “Helpful” “Good company”, “Polite” and “All the members of staff support us and each other in a wholly admirable way”. The home has a rolling programme for staff training and a training book viewed evidenced courses attained in safe working practices including, fire prevention, manual handling, infection control, first aid and health and safety. Food hygiene has been booked for later this year and a further first aid course Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 20 planned. Staff attend abuse awareness training and other courses relevant to the older person. The assistant manager is commencing a course in Palliative (terminal) care as a link nurse for the home. A staff member said, “The home offers good training”. A high percentage of staff have attained a National Vocational Qualification (N.V.Q) Level 2 in care and NVQ Level 3 is also being accessed. New staff receive an induction however completed staff induction books were not available as they are kept by the staff. A record of the induction should be kept in the home and include dates and details of information provided. Staff interviewed stated that they had received an induction and the assistant manager confirmed that supernumerary hours were arranged for her when she took on her new position. The manager is also looking to introduce a new format for induction, which will include more relevant information to the employee’s position in the home. A blank induction book training and induction for care staff was seen. Four staff files were viewed with regard to recruitment practices and these evidenced the necessary checks to protect the residents Staff had completed a job application form and references had been obtained. One staff file evidenced only one reference; two must be obtained prior to employment. CRB enhanced disclosures are obtained for staff. A record is made of the date the CRB is sent off and received. A disclosure for one member of staff was not available although it had been received and checked by the manager. A photograph of staff is also required for verification purposes. Staff receive contracts of employment. Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 and 38 The quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. The home employs a manager who has been approved by the Commission. The manager has the experience to manage the home. Policies, practices and procedures are in place to safeguard the health, welfare and safety of residents and staff. EVIDENCE: The manager has qualifications in management and keeps herself updated by undertaking mandatory training in safe working practice areas with her staff. Staff interviewed stated that Mrs Terry (manager) was, “Supportive”, “A good listener” and “ Very organised”. Mrs Terry works closely with staff and undertakes supervision either on a one to one basis or within a group. Staff supervision was not assessed however supervision records were available in some files seen. Staff meetings are held and the time spent together also Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 22 becomes a social event. Discussions with residents detailed that the manager makes herself available at any time and is, “Very helpful and so kind”. There are some good quality initiatives that ensure residents’ views are instrumental in the running of the home. Residents and relatives regularly attend meetings and are provided with survey forms to establish what they think of the home. Residents and relatives interviewed were satisfied with the overall management of the home and were pleased with the support offered by the manager and staff. The Chairman visits the home on a monthly basis to meet with residents and staff and view the environment. A written report is then submitted to the Commission in accordance with Regulation 26 of the Care Homes Regulations. Board members are also available at any time to meet with residents. A number of resdients and relatives are also members of the Committee. A resident said, “I can express my point of view and say what I think we need”. It was evident that residents’ views are listened to. Residents manage their own money when appropriate. Where a resident needs support with managing their money then a record of all money they give in and take out is kept and receipts are kept for purchases whenever possible. The manager undertakes a regular review of the home’s policies and procedures for health and safety. Following a review it is recommended that the policy document be signed and dated. Maintenance contacts were seen for gas, electric, portable appliane testing and hoist equipment. These were all in date. Fire prevention equipment is checked annually however as previously stated the home is in the process of changing contractors and the current certificate was not available. It was agreed that a copy of the new contract would be forwarded to the Commission. Training files evidenced fire prevention training for staff. The fire safety officer should be contacted for the latest advice regarding the frequency of fire prevention training for staff. There was written evidence of fire alarms being checked weekly and an external contractor was undertaking a safety check of fire extinguishers at the site visit. Any accident to a resident is recorded in the home’s accident book. An entry for a resident was seen and this evidenced the treatment given. Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 23 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 X 3 X 3 3 Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 24 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. 2. Standard OP29 OP29 Regulation 19 Schedule 2 Reg 19 Requirement Timescale for action 01/06/06 The manager must obtain two references for employees prior to commencing work The manager must obtain a 01/06/06 photograph of staff for verification purposes 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 OP2 Good Practice Recommendations A more formal contract should be provided for residents and/or their representative, a signed copy of which should be kept on file. A full breakdown of the fee structure should be included Residents’ financial files should include a staff signature following a written entry The fire safety department should be contacted regarding ‘in house’ monthly checks of emergency lighting A record should be kept in the home of induction The fire safety department should be contacted regarding the frequency of fire prevention training for staff DS0000017280.V288849.R01.S.doc Version 5.1 Page 25 2 3. 4. 5. OP14 OP25 OP30 OP38 Halcyon House 6. 7. OP38 OP38 A copy of the home’s contract for the safety check of fire prevention equipment should be forwarded to the Commission Policies and procedures should be dated and signed following review Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Halcyon House DS0000017280.V288849.R01.S.doc Version 5.1 Page 27 - 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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