CARE HOMES FOR OLDER PEOPLE
Hampton Court 34 Scarisbrick New Road Southport Merseyside PR8 6QE Lead Inspector
Mrs Trish Thomas Miss Debbie Corcoran Key Unannounced Inspection 15th May 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hampton Court DS0000065950.V341831.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. Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Hampton Court Address 34 Scarisbrick New Road Southport Merseyside PR8 6QE 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 532173 01704 532172 hamptoncourt@rhcare.co.uk Ramos Healthcare Limited Ms Janet Marshall Care Home 20 Category(ies) of Dementia - over 65 years of age (20) registration, with number of places Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users to include up to a maximum of 20 DE(E). The Service should employ a suitably qualified and experienced manager who is registered with the Commission For Social Care Inspection. 11th July 2006 Date of last inspection Brief Description of the Service: Hampton Court is a large detached building, which has undergone conversion to provide residential care for up to 20 older people who have a degree of mental health need. The building was originally a Victorian dwelling house set in its own grounds, situated on a regular bus route, about half a mile from the town centre of Southport. The accommodation is divided over three floors with the day facilities on the ground floor, with bedrooms on the ground and upper floors. The office is on the lower ground floor, as are the laundry and kitchen. Externally the grounds are secure with seating provided for residents. Ramos Healthcare Ltd own the home and the responsible person is Mr Roland Mangahas Ramos. Janet Marshall is the registered manager. Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an un announced key inspection carried out by two inspectors over a five hour period. The methods used were, discussion with residents, the manager, staff and visitors. Records compiled in Hampton Court relating to care, health & safety and staffing were read and a tour of the premises carried out. At the end of the visit, verbal feedback on the outcomes was given to Mrs. J. Marshall Mr. J.P. Ramos and Mrs. A. Tan. As cctv has been fitted in the office, inspectors requested use of the staff room, where files were read and evidence was recorded. What the service does well:
Residents’ diversity is recognised through recording their beliefs and respecting them by making arrangements for religious services, in accordance with choice. Residents’ appear well cared for and staff on duty during the inspection, were respectful towards them. Hampton Court has a Statement of Purpose and service users’ guide, which provide prospective residents (and their families) with the information they need before a decision is made to move in. Pre-admission assessments are carried out to ensure that the home can offer a service to meet each individual’s needs. The standard assessment document in use in the home includes aspects of support needs relating mental health, risk, nutrition, mobility and history of falls. The outcomes of assessments form the basis of each individual’s care plan. For three of the residents whose care plans were tracked, there were action plans in place to meet their assessed needs and their care plans were satisfactory, having been regularly reviewed. The staff who were on duty during this visit, were seen to be warm and respectful in their treatment of residents. The residents appeared to be well cared for and comfortable. Residents comments during the visit, include, “It’s lovely I have no complaints” “I can’t think of anything I’d change.” “It’s nice and the staff are nice.” Residents’ personal details held on their care plans have details of next of kin/family and contact numbers. Their beliefs, preferences and interests are stated in short social histories. There was evidence in care files that residents have access to advocacy services, social workers and Court of Protection.
Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 Page 6 Hampton Court has a complaints procedure, which is made available to residents as they move in, and is on display in the home. A resident who commented, said she had nothing to complain about, but would speak to a member of staff if she had any problems. The lounges are pleasant, and well presented, though one is used to store the hoist and wheelchairs. Some nice quality furnishings and fittings were observed in these areas, which are generally well maintained. Further training has been carried out since the last visit, including courses for Food Hygiene, Challenging Behaviour, Protection of Vulnerable Adults, and First Aid. Reference was made to the training records for NVQ2 qualifications. Three care assistants have NVQ2 and three have registered and are undergoing training. The manager, Mrs. Marshall, has a management qualification, and residents’ welfare is promoted through health & safety procedures followed in Hampton Court. What has improved since the last inspection?
Improvements were observed in frozen and chilled food storage and labelling of meat, which will protect residents against the risks posed by food contamination. To protect residents’ privacy, all medical examinations/treatments are now carried out in residents’ own bedrooms and their prescribed dressings and nursing notes are held there. To ensure their health is regularly screened, residents who are diabetic have had monitoring visits from the diabetic nursing service. To ensure there is a safe medication system, residents are administered medication from containers with pharmacy labels. The lift has been repaired and noise levels have been greatly reduced. In December 06/January 07, the lift was out of commission for repairs. CSCI gave permission for the ground floor small lounge to be used as a bedroom for two residents who are unable to use the stairs. Staffing levels were increased by one at this time, conditions in the home were monitored by social workers, and all the residents were able to remain in their home for Christmas. Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 Page 7 What they could do better:
Further respect for residents’ diversity could be achieved through recognition of the limitations faced through their mental frailty and the wishes and feelings, which they may be unable to fully express. It is inappropriate for staff to make decisions regarding what residents like to eat and displaying a token menu, which does not truly represent what will be served. To ensure that records compiled in Hampton Court, give an accurate account of the food served to residents and that there is evidence that they receive a balanced and nutritious diet, a requirement is made that the stated menus are followed. To ensure that mealtimes are a pleasant and enjoyable experienced for residents, it is recommended that attention be paid to the presentation of tables and the quality of crockery. To ensure that the resident’s pressure care is managed and risks are assessed, a requirement is made that pressure care, weight loss and use of bedrails are fully addressed in the resident’s care plan. To ensure that an accurate audit of medication is in place, un-used medication must be returned to the pharmacist at the month end. To ensure that under POVA procedures, statements are not obtained inappropriately from staff members, the following action is recommended. That Mrs. Marshall make contact with Sefton’s Protection Of Vulnerable Adults co-ordinator for clarification of any aspects of the POVA procedure, which are unclear to her. This is particularly with regards to the agencies responsible for taking statements when a POVA investigation is in progress. To ensure that residents’ accommodation is maintained to a good standard, it is advised that the lighting, ventilation, water temperatures and window restrictors be checked in all bedrooms. To ensure that good standards of hygiene are maintained, the staff toilet must be thoroughly cleaned and the cause of the odour be identified and remedied. To ensure that residents are not placed at risk of food contamination, the kitchen wall tiles must be thoroughly cleaned and the damaged floor tiles should be replaced. To ensure that residents are not placed at risk of contamination of their food, leftovers should be thrown away or stored (covered), and labelled correctly in the fridge. Three members of care staff have NVQ2 qualifications and three are working towards this, two members of care staff are not taking the qualification. Achievement levels in NVQ qualifications remain below 50 and staff are working towards reaching the target. The importance of care staff being designated solely to the caring role was stated to Mrs. Marshall. A requirement is made that a kitchen assistant be employed to cover meal times when the cook is not present, to ensure residents are not placed at risk when care staff are preparing and clearing away after the evening meals.
Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 Page 8 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. Hampton Court DS0000065950.V341831.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 Hampton Court DS0000065950.V341831.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): Quality in this outcome area is good. Residents have the information they need before choosing to move in to Hampton Court and their needs have been assessed to ensure they may be met by the service provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 1, 3, 4. Hampton Court does not provide intermediate care and is not assessed against standard 6. Hampton Court has a Statement of Purpose and service users’ guide, which provide prospective residents (and their families) with the information they need before a decision is made to move in. To ensure that the information is accurate, both are reviewed from time to time and updated. These documents are readily available to interested parties and the service user guide is displayed in the hallway.
Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 Page 11 The care files of four residents were seen and each of these residents’ needs had been assessed before moving, in by relevant professionals and by staff from Hampton Court. Assessments are carried out to ensure that the home can offer a service to meet each individual’s needs. The standard assessment document in use in the home includes aspects of support needs relating mental health, risk, nutrition, mobility and history of falls. The outcomes of assessments form the basis of each individual’s care plan. Hampton Court is registered to provide a service for people who have dementia. Staff have undertaken short training courses related to dementia/confusion in older people and the home is managed to ensure the wellbeing of residents who may lack awareness of risks and hazards to their safety. Hampton Court DS0000065950.V341831.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): Quality in this outcome area is adequate. Residents had action plans in place to meet their assessed needs, other than for pressure care, weight monitoring and use of bedrails. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 7,8,9,10. Four care plans were read. For three of the residents whose care plans were tracked, there were action plans in place to meet their assessed needs and their care plans were satisfactory, having been regularly reviewed. The care plan of one resident, who is of high dependency, requires updating. The information on record was out of date, as this person’s needs had changed. There was no reference in the care plan to pressure care, although this was recorded as being carried out in daily reports. There was no action plan regarding this resident’s weight loss nor was there a risk assessment regarding use of bedrails. To ensure that the resident’s pressure care is managed and risks are assessed, a requirement is made that pressure care, weight loss and use of bedrails are fully addressed in the resident’s care plan.
Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 Page 13 All residents of Hampton Court are registered with local G.P.s, and there were records in their care plans of referrals for health assessments and paramedical services. It was recommended in a recent strategy meeting that a resident be referred to a G.P. to examine bruising. The manager, Mrs. Marshall said that no medical referral was made when the bruising was discovered and confirmed that this person has now been examined by the G.P. in accordance with the recommendation. Residents’ prescribed medication is administered by staff who have been trained to do so. Medication stocks and records were checked generally, and in more detail for two residents. Medications appear to be generally well managed. Advice was given to the manager, Mrs. Marshall regarding the need to return un-used medication to the pharmacy. Medication administration records were well maintained and each had a photograph of the resident attached. The controlled drug stock was checked. These drugs are stored in a locked cabinet and recorded on controlled drugs register. The medication for two residents, which was tracked in detail, had been satisfactorily maintained. A resident said that staff manage and administer his medication, as he is no longer able to do this for himself. To ensure that an accurate audit of medication is in place, un-used medication must be returned to the pharmacist at the month end. The staff who were on duty during this visit, were seen to be warm and respectful in their treatment of residents. The residents appeared to be well cared for and comfortable. Residents comments during the visit, include, “It’s lovely I have no complaints” “I can’t think of anything I’d change.” “It’s nice and the staff are nice.” The manager confirmed that residents receive medical examinations or treatment in the privacy of their bedrooms. Also that their prescribed dressings and district nurse notes are stored in their bedrooms and are easily available to health visitors. When asked about respect for residents’ privacy and dignity, staff said that some of the residents choose to be on their own when bathing and their choices are respected. They said they always talk with residents and tell them what we’re going to do, when giving personal care. Staff confirmed that there is no set time for getting up and going to bed, this is always down to choice. Hampton Court DS0000065950.V341831.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): Quality in this outcome area is adequate. Residents’ appear to follow a lifestyle, which is to their liking, other than at mealtimes, as menus do not provide a true record of the food, which is served, and eating utensils are basic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 12, 13, 14, 15. Residents’ personal details held on their care plans have details of next of kin/family and contact numbers. Their beliefs, preferences and interests are stated in short social histories. There was evidence in care files that residents have access to advocacy services, social workers and Court of Protection. Mrs. Marshall said that staff arrange leisure and exercise sessions for those who wish to take part. One gentleman was reading a newspaper after his dinner. Another gentleman said he sometimes plays cards or board games with staff in the afternoon. Care staff said that, during the day, they play dominoes and arrange a sing along with the residents. Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 Page 15 There is ramped access to the rear garden, which is secure, with high fences for privacy. The door from the dining area gives access to the gardens and these doors are opened in fine weather to give freedom for residents who wish to go outside. A member of staff who was spoken with said that there is an activities diary. On Thursdays there is an exercise and motivation session. Singers visit once a month for an evening of song, and films are showed monthly. A visit was made to the kitchen, where stew was being cooked for lunch, with home baked cherry pie for dessert. There was no alternative being prepared and the cook said that all of the residents enjoy the stew and don’t want anything else. A four- weekly rotating menu is displayed in the kitchen and dining room. The cook informed an inspector that she had no idea where they were up to on the menu, as they didn’t really follow it. A visitor said that the meals he/she observes regularly being served to residents, are not as is stated on the menu. To ensure that records compiled in Hampton Court, give a true and accurate account of the food served to residents and that they receive a balanced and nutritious diet, a requirement is made that the stated menus are followed. Lunch did appear appetising and residents seemed to be enjoying their meal. They were being served their food on plastic plates and were drinking from plastic beakers. Staff said that the plates were used because of their colour, which can stimulate the appetites of people who have dementia. The tables were not set for lunch, being completely bare with no cloths or flowers. The result provided a basic environment for residents during the meal. To ensure that mealtimes are a pleasant and enjoyable experienced for residents, it is recommended that attention be paid to the presentation of tables and the quality of crockery. Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Although residents’ complaints are listened to and investigated, the manager is unsure of POVA procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 16 & 18. Hampton Court has a complaints procedure, which is made available to residents as they move in, and is on display in the home. A resident who commented, said she had nothing to complain about, but would speak to a member of staff if she had any problems. Hampton Court has procedures for Protection of Vulnerable Adults and “Whistle-Blowing” and a copy of the Merseyside/Sefton POVA procedure is held on the premises. There was one outstanding POVA investigation at the time of this visit. Mrs. Marshall said that there are aspects of the Sefton POVA procedure, which she finds to be misleading. The procedures to be followed, in a situation where accusations may be made against staff, were discussed with Mrs. Marshall. To ensure that statements are not obtained inappropriately from staff, the following action is recommended. That Mrs. Marshall make contact with Sefton’s POVA co-ordinator for clarification of any aspects of the POVA procedure, which are unclear to her. This is particularly with regards to
Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 Page 17 the agencies responsible for taking statements when a POVA investigation is in progress. Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is adequate. Communal areas are comfortable and in good condition but improvements are needed in bedrooms, cleanliness and odour control in the building. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 19 and 26. The lounges are pleasant, and well presented, though one is used to store the hoist and wheelchairs. Some nice quality furnishings and fittings were observed in these areas, which are generally well maintained, though the ceiling in the dining room is in need of attention. There is a front garden, part of which is used as a car park, and a secure rear garden. The grounds are kept tidy but lack the colourful planting and care of flowerbeds, which would provide interest and pleasure to residents.
Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 Page 19 There is a notice board in the hall with the menu and alternatives written on display, (though these not always being followed). There was information on the activities of the day, which read, “sing song”. The results of the latest Quality Assurance audits were published on the notice board. The passenger lift was in working order with less noise than heard during previous inspections following remedial work. Bedrooms are personalised though some of the furniture is in need of replacement, some windows do not open, some of the bedrooms need decoration, one needs a new carpet, another needs a new mattress and two bedrooms were malodorous. No call bell extensions were seen in the bedrooms. To ensure that residents’ accommodation is maintained to a good standard, it is advised that the lighting, ventilation, water temperatures and window restrictors be checked in all bedrooms. The staff toilet was in need of cleaning and there was an odour present, which could have come from the drains. To ensure that good standards of hygiene are maintained, the staff toilet must be thoroughly cleaned and the cause of the odour be identified and remedied. In the kitchen, the tiles around by the wash hand basin were in need of cleaning. Some floor tiles need to be replaced in the kitchen as a number of these are broken or chipped and compromise hygiene. To ensure that residents are not placed at risk by food contamination, the wall tiles must be thoroughly cleaned and the damaged floor tiles replaced. Frozen meat stored in the freezer was labelled and in date. In the fridge an unwrapped lettuce was seen, and a portion of mashed potato, not dated. The cook said that this was from the previous day. To ensure that residents are not placed at risk of contamination of their food, leftovers should be thrown away or stored and labelled correctly in the fridge. The quality audit file was read and refers to a new cleaning schedule and monthly audits of toilets, lighting, wardrobes and food. Housekeeping staff are employed in Hampton Court, and are provided with protective clothing and cleaning materials. Hampton Court has procedures to be followed regarding infection control and the control of substances hazardous to health. Cleaning materials are stored in the laundry room when not in use. A keypad has been fitted to the door to ensure the materials are secured and do not place residents at risk if exposed to them. Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is adequate. Care staff receive training and the staff rosters appear to be in order, however at certain times, care assistants are carrying out catering duties, which could place residents at risk if they are not adequately supervised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 27,28,29,30. Further training has been carried out since the last visit, including courses for Food Hygiene, Challenging Behaviour, Protection of Vulnerable Adults, and First Aid. Reference was made to the training records for NVQ2 qualifications. Three care assistants have NVQ2 and three have registered and are undergoing training. Three members of care staff do not have NVQ2 qualifications. Achievement levels in NVQ, remain below 50 and staff are working towards reaching the target. The staff rosters record three care assistants during the day, and two night staff on duty. There were three care assistants on duty, including the manager. There was also a cook and a housekeeper on duty during the visit. The cook goes off duty during the afternoon and (in addition to their care duties), care assistants serve the evening meal and clear away afterwards, as the evening kitchen assistant is no longer employed. The importance of filling
Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 Page 21 this post was discussed with the manager Mrs. Marshall. One resident requires two care staff for support and the remainder require high levels of supervision from care staff, due to the risks posed by dementia. The importance of care staff being designated solely to the caring role was stated to Mrs. Marshall. Two members of care staff were absent at the time of this visit and their posts were being covered by staff overtime. A requirement is made that a kitchen assistant be employed to cover meal times when the cook is not present. Three staff files were read and have been satisfactorily maintained. An example of training records on file is as follows : 2006 TOPPS induction, Moving and Handling, Alzheimers Awareness, Fire Safety, Protection of Vulnerable Adults, NVQ completed. 2007 First Aid, Challenging Behaviour. Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 Page 22 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 good. The manager is qualified and residents’ welfare is promoted through health & safety procedures followed in Hampton Court. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 31, 33, 35, 38. The registered manager, Janet Marshall is qualified in management and care. Some of her roles, such as medication administration, health & safety, are delegated also to senior care staff. Mrs. Marshall is fully involved in the hands on support of residents, in addition to her managerial duties. The registered providers, Ramos Healthcare Limited, have employed a member of staff for administrative duties since the last visit.
Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 Page 23 The home has a quality assurance system and questionnaires on satisfaction are distributed to residents and their representatives twice yearly. The results are published and displayed in the hallway on the residents’ notice board. Relatives’ comments in recent questionnaires state, “Very friendly atmosphere.” “Never complains about meals and menus are on the board daily. Certainly seem to cover all her needs.” Mrs. Marshall confirmed that there is no involvement in residents’ personal financial affairs by staff of Hampton Court. Residents are billed in arrears for services not included in the fee, and such charges are made known to each resident (and their representatives), before they move in to Hampton Court. A record of the billing system was provided as evidence. The fire safety records were read. Extinguisher awareness training was carried out 14/08/06. The most recent fire risk assessment is dated 20/03/07. Fire systems tests are carried out weekly. Fire extinguishers checked monthly (22/04/07). Emergency lighting checked monthly(22/04/07). A number of fire extinguishers was checked and found to be in date, 2008. The passenger lift has been repaired to a satisfactory standard as stated in Sefton Environmental Health records dated 29/1/07. Electricity certificate 28/04/05 Gas Certificate 23/01/07 Hoist maintenance 7/02/07. The report reads. “Old style seat in service *can result in entrapment.” Mr. Jon Paul Ramos reported this has been dealt with and the seat will be replaced when next service is carried out. The Environmental Health officer’s report was satisfactory. Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 Page 25 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 OP15 Regulation 13 (3) Requirement To avoid the risk of contamination, leftover food must be stored and labelled appropriately at all times. To ensure that an audit trail of medication is maintained, unused drugs must be returned to the pharmacy at the month end. To ensure that residents receive a balanced diet, the menu must be followed and give a true representation of the meals which have been served. To ensure that staff have the qualifications and skills suitable to the work that they are to perform, at least 50 of staff must obtain NVQ qualifications. Outstanding from the last inspection, extended time limit given. To prevent infection, toxic conditions and the spread of infection in the care home, the kitchen tiles and staff toilet must
DS0000065950.V341831.R01.S.doc Timescale for action 15/06/07 2. OP9 13 (3) 30/06/07 3. OP15 16 (2) (i) 15/06/07 4. OP28 19 (5) (b) 15/09/07 5. OP26 13 (3) 15/06/07 Hampton Court Version 5.2 Page 26 be thoroughly cleaned. 6. OP26 13 (3) To ensure that the home is maintained in a fresh, clean and odour free condition, bedroom carpets (as stated) must be thoroughly cleaned and the odour in the staff toilet be eliminated. To ensure that residents are not left unsupervised, kitchen staff must be employed to prepare the evening meal and clear away, when the cook is off duty. 15/06/07 7. OP27 18 (a) 15/07/07 8. OP7 15 To ensure a resident’s needs in 15/06/07 respect of health and welfare are fully addressed, a care plan must be updated regarding pressure care, weight loss and use of bedrails. 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 OP15 Good Practice Recommendations To ensure that mealtimes are a pleasant and enjoyable experienced for residents, it is recommended that attention is paid to the presentation of tables and the quality of crockery. The manager should consult with Sefton’s POVA coordinator, aspects of the procedure which are not clear to her. It is recommended that an audit of bedrooms is carried out (as discussed) regarding ventilation, lighting and window restrictors, decoration and refurbishment. It is recommended that consideration be given to replacing chipped and broken floor tiles in the kitchen.
DS0000065950.V341831.R01.S.doc Version 5.2 Page 27 2. 3. 4. OP18 OP19 OP19 Hampton Court Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Hampton Court DS0000065950.V341831.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
