Inspection on 10/06/06 for Hampton Court Care Home

This inspection was carried out on 10th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hampton Court Care Home 12/12/07

Hampton Court Care Home 05/04/07

Hampton Court Care Home 12/01/06

Hampton Court Care Home 11/05/05

Hampton Court Care Home 20/12/04

Hampton Court Care Home 22/06/04

Hampton Court Care Home 09/03/04

Hampton Court Care Home 06/10/03

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

CARE HOMES FOR OLDER PEOPLE Hampton Court Care Home Wrottesley Park Road Perton Nr Wolverhampton West Midlands WV8 2HE Lead Inspector Mrs Sue Mullin and additional inspector Mrs J Capron Key Unannounced Inspection 10 July 2006 09:45 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 Care Home DS0000022329.V303519.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 Care Home DS0000022329.V303519.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hampton Court Care Home Address Wrottesley Park Road Perton Nr Wolverhampton West Midlands WV8 2HE 01902 840317 01902 844200 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) Mrs Gurdip Kaur Sahota Mr Resham Singh Sahota, Mrs Kamaldip Gill Mrs Joanne Christine Moore Care Home 52 Category(ies) of Physical disability (22), Physical disability over registration, with number 65 years of age (32) of places Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. PD 30 Nursing Minimum Age 60 on admission OP - 22 (PC only) minimum age 60yrs on admission Date of last inspection 12th January 2006 Brief Description of the Service: Hampton Court is a care home located in Perton near to Wolverhampton. The home was purpose built, with residents all accommodated on the ground floor level. The home is registered to accommodate up to 52 residents over the age of 60 years with physical disabilities, requiring nursing care or personal care only. The home can also take up to 5 day care residents who require personal care only. There are 42 single rooms and 5 double rooms all with en suite facilities, some with their own shower area. The corridor areas are wide and allow easy access for mobility and moving/handling aids. There are two large communal day rooms, each with a comfortable dining area. There is also a large reception area and a peaceful garden lounge where visitors can be received in private. The home is directly accessed from the main road and there is ample car parking facilities at the front. The home was built in open countryside backing onto farmland and there are rural areas all around the home, which are accessible to residents including wheelchair users. Amenities can be reached easily by transport, but are not within walking distance. Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This statutory unannounced visit was made on the 10th July 2006 from 9.45am to 4.45pm. The inspection was carried out by two inspectors who used the National Minimum Standards for Older People as the basis for the inspection. The inspection took a total of 14 hrs of inspector input during the visit plus pre inspection and fieldwork. The inspection included a tour of the building, inspection of records, observation, discussions with several residents and relatives, discussions with the staff members on duty, and dining with the residents at lunchtime. Residents generally spoke highly of the quality of care provided by the staff from the initial visit to the home, to the day-to-day living within the home. They were involved in the whole process of deciding if the home was right for them, being sure that it could meet their needs and once in the home, having those needs met very well. All aspects of health, personal and social care needs were addressed to a high standard but the recording aspects in the care planning documentation need to be strengthened. Residents felt that they were treated with dignity and respect and staff recognised and supported their need for privacy when required. The home itself was bright, warm and clean. It provided a happy environment for the residents and staff. The home was quite large but still managed to retain a homely atmosphere. Most of the bedrooms were decorated to a high standard and he communal areas were clean, warm and tidy. The laundry service was well organised and adequate. The food was well presented and nutritious, with choices available to meet a variety of needs. A large proportion of the inspection time was spent talking to residents, staff and visitors. At present the care manager is working 20 hours a week since having a baby and the home are putting forward the deputy manager to also be registered as a part time care manager. This is currently being processed. Both posts will make up a full time care managers duties. Following consent for the home to take up to 5 residential people in for day care, the Statement of Purpose will need to be amended to reflect this change. Discussions were also held with the responsible individual Ms Dee Sahota and the deputy manager and verbal and written feedback was given at the end of the inspection. What the service does well: Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 Page 6 One of the main strengths of this home was the quality of service provided by the staff. From qualified nurses, care staff and ancillary staff; everyone worked hard to provide a positive, high standard of service to the residents. Residents who spoke to the inspectors said that they were happy in the home and there was good communication between the staff and residents. The standard of meals served at the home was well received by the residents. The home is well managed and the numbers, experience and skills of the staff are adequate to meet the needs of the residents. Staff are polite, attentive and have a good rapport with the residents. Residents are cared for in an environment where individuals are involved in discussions along with their families about ongoing health care, dietary, and medical needs. Residents feel safe at the home and feel that their privacy is promoted and dignity respected. The assessed needs and continuing healthcare needs of residents are met by the home. Residents have access to specialist services as required. The home offers a comfortable environment for the residents who live there. Bedrooms and communal rooms are well presented with residents able to adapt rooms to their individual requirements and preferences. What has improved since the last inspection? What they could do better: A small portion of the residents/visitors engaged in conversation had some complaints about the service and the staffing levels. These included waiting for long periods of time after pressing the nurse call system. One stated that she had wet herself whilst waiting and another representative stated that his partner had soiled herself whilst waiting for a member of care staff to attend to her. One resident stated that she likes to go out into the garden every day for some fresh air but had been left outside the day prior to the inspection, for over two hours and was cold. There was no way of summoning staff from outside and she was only attended to when the afternoon drinks were served. This lady informed the inspector that she would ask staff to take her outside prior to lunch, so that they would remember to come and fetch her back into the building. All residents must have a pre admission assessment carried out prior to admission. This must meet the criteria laid down in standard 3.3 Care planning needs to be developed further. Daily entries of events were kept in a separate file and were found to be difficult to read at times. Entries were squashed in where new forms should have been commenced. Care plans seen also contained some illegible entries. Care plans must be Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 Page 7 completed legibly, signed and dated in line with NMC requirements. All care plans must also accurately record the current physical and mental needs of each individual. The staff in the home should consult with residents about their social interests and to further develop the opportunities for activities both in and out of the home. It was also recommended that the home should circulate up to date information about activities, so that all interested parties are kept fully informed. Any complaints made to the home must be acted upon in line with the homes procedures. A complaints book was in place but recordings had ceased since August of last year. All complaints, grumbles and concerns must be recorded, acted upon and available for inspection when required. All staff must be provided with the necessary information and training in adult protection issues. Care staff must receive two monthly supervision. The home must operate a robust recruitment and selection procedure that ensures that all pre employment checks are made and that the information identified in Schedule 2 is maintained on file. The management of the home must ensure that all disciplines of staff receive the training appropriate to the work they are to perform including induction training and the necessary health and safety training. A quality assurance development plan must be made available to the CSCI. The registered person must ensure• • • • Fire alarms are tested weekly and that all staff are familiar with this procedure. That all staff have received adequate yearly fire safety training. That all staff have received adequate fire drills. Two a year for day staff and 4 times a year for night staff. Fire doors are not wedged open. 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. Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 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 Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 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): 1,3,4,5. Information contained in the homes Statement of Purpose and Residents Guide about services/facilities provided was readily available to those who needed it. The homes quality of staffing and the involvement of a range of external health care professionals enabled the residents and their carers, to have confidence that the home was able to meet identified needs. EVIDENCE: The home provides up to date detailed information to prospective residents and their carers to enable them to make an informed decision about moving into the home. Anyone accessing the service received clear, detailed and easy to understand information, to enable them to make an informed choice about the home. Following disscussions the inspectors were informed that all residents have a pre admission assessment prior to admission to the home. However, for the residents care plans that were examined on the day of the inspection, it Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 Page 10 appeared that all the assessements had taken place on the day of admission. The deputy manager stated that this was a problem with the newly implemented admission plans provided by the company and went on to confirm, that an initial assessment is always carried out for prospective residents prior to the day of admission, ( with the exception of emergency admissions) and confirmation that their needs would be met is given to them in writing. One file that was examined did not evidence allocation to a named key worker following immediate admission to the home. All residents must have a pre admission assessment carried out prior to admission. This must meet the criteria laid down in standard 3.3. The community care plans provided by the social worker, as part of the individual needs assessment process, were seen within one of the resident plans examined on the day of inspection. Another file, which should have a community care plan provided by the social worker contained in it, was found to be missing. Staff could not account for its whereabouts. Residents have the opportunity to visit the home prior to choosing to stay. A visitor of a resident stated that his partner ‘ seems happy’ and he was relieved that she is now ‘safe and secure’. A visitor stated that their friend’s bedroom (seen by the inspector) was a very pleasant environment, well personalised and homely. This was obviously very important to the visitor that their friend had ‘nice’ things around her, to feel at home in her own room with her own belongings. Prior to admission families are provided with the Home’s brochure and residents are registered with a GP as soon as possible following admission. Visitors spoken to on the day the inspection, stated that they were made very welcome and that they were impressed by the approachability and friendliness of the staff. Following consent for the home to take up to 5 residential people in for day care, the Statement of Purpose will need to be amended to reflect this change. Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 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): 7,8,10 Each resident has an individual plan of care in place, which is regularly evaluated. However, not all entries were completed, signed legibly or dated. The assessed health and personal care needs of residents were being met, with good standards of care being delivered. EVIDENCE: During this inspection, four residents files were examined from the residential wing and the nursing wing. All files had a pre admission assessment in place but some of these were found incomplete. Care plans and risk assessments were developed very quickly following all admissions and include (where necessary) pressure area care, manual handling assessments, nutritional assessments, monthly weight monitoring, risk of falls, 24 hour personal hygiene requirements and bedrail assessments, along with written consent from the family. Individual moving and handling assessments are in place. Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 Page 12 A spiritual/social history is kept in the resident’s rooms. Staff stated that social assessments are completed with the families assistance and they are encouraged to be involved in the care process and are asked to sign the care plans, to record their involvement. Residents are also encouraged to be fully involved and in agreement with the implementation of their own personal care plans. Care plans seen were evaluated on a monthly basis monthly and the majority of residents were assigned to a key-worker. Information regarding any health needs/check ups and the subsequent appointments made are recorded. There were records of GP visits/specimens taken and evidence of District nursing involvement for residential residents. Daily entries of events were kept in a separate file and were found to be difficult to read at times. Entries were squashed in where new forms should have been commenced. Care plans seen also contained some illegible entries. Care plans must be completed legibly, signed and dated in line with NMC requirements. All care plans must also accurately record the current physical and mental needs of each individual. Not all residents had their base line observations recorded following admission. Chiropody services are available and the home has a visiting hairdresser. There is a designated hairdressing/therapy room. Residents and relatives spoken to spoke highly of the staff at the home. Staff respected residents privacy, knocking on doors prior to entering bedrooms and were respectful of residents’ dignity when undertaking personal care tasks. Residents were wearing their own clothes and residents were supported to choose the clothes they wanted to wear. During the inspection there were a number of visitors present and they said they were welcomed and could always see their relative in private. Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Whilst the home provided activities there was scope for further development and to include opportunities to access the community, in order to provide residents with a more varied and fulfilling lifestyle. The residents were provided with meals that offered a choice and variety. EVIDENCE: The home had not developed care plans relating to residents social and leisure needs although life story books were reported to have been developed for each resident. The home had a part time activity staff member employed at the home. Organised activities took place in the afternoon and included bingo, skittles, ludo and bowls. The records showed that around ten to twelve residents took part in this and those that did, enjoyed it. The activity staff member reported that she also undertook some individual activities with some residents in their bedroom. The home also provided entertainment such as musicians coming into the home and garden parties in the grounds. The home offered residents massage/aromatherapy sessions, which were undertaken on a private paying basis. The residents had not been out on any trips although the activity staff member said that she was in the process of planning one. A hairdresser visited the home every week. The home provided an Anglican service on a monthly basis. A schedule of activities was not evident in the home. Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 Page 14 Throughout the inspection a number of visitors came to the home. Several spoken to stated that they were made to feel welcome and could always see their relative in private, either in their bedroom or in the quiet lounge or the conservatory. The home supported residents to maintain their independence. One resident confirmed that she undertook most of her own personal care but staff supported her with bathing. She chose her own clothes. Another resident spoken to had a large bedroom that had been made into a bed sitting room where she could entertain visitors and make drinks, having her own fridge. Residents were able to bring in items of furniture to the home. Two bedrooms seen showed that they had part furnished their bedrooms, with items from home. Residents said they liked the food. Examination of the menus showed that varied meals were being provided. Residents confirmed that they always had a choice at mealtimes. At breakfast there was the choice of a hot meal. The main meal was at lunchtime and there was always a choice of both main course and sweet. At teatime it was a lighter meal for example sandwiches, soup and cakes. A supper was provided. The chef said and this was confirmed by a relative that if they did not want any of the choices that an alternative meal would be provided. The home had a resident from another culture at the home and their dietary needs had been discussed prior to admission and it had been agreed that the family would on occasions bring a meal into the home for the resident, although she was happy to eat British food. The home was able to provide for special diets including soft, pureed and diabetic. Discussions with residents and relatives confirmed that meals could be taken in the dining room or in their bedroom. The staff supported residents to eat where needed and one resident was being supported to choose her meal by having the opportunity to see the meals before making a choice rather than the usual practice of making a choice earlier in the day or the night before. Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Residents and their representatives were confident that their complaints and concerns would be taken seriously and acted upon by the manager of the home. However, the home needs to provide evidence of this. Residents are protected from abuse as far as possible in the daily routines of the home but not all staff have received training in the protection of vulnerable adults. EVIDENCE: There was a clear and accessible complaints procedure located in the reception area of the home. A copy of the complaints procedure is also included in the homes Statement of Purpose. A relative spoken to confirmed that they had not seen the complaints procedure but stated that they would feel confident about approaching staff or management should there be any reason to make a complaint. Those residents spoken to stated that they knew who to do to if they had any concerns or worries. Any complaints made to the home must be acted upon in line with the homes procedures. A complaints book was in place but recordings had ceased since August of last year. All complaints, grumbles and concerns must be recorded, acted upon and available for inspection when required. Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 Page 16 Discussions with staff over adult protection identified that some were aware of the issues and had received training in this area whilst others had not. The training records seen did not show that staff had received such training. Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,26 The internal environment was spacious and bright and generally satisfied the needs of the residents, although some improvement is needed to ensure residents live in a safe, comfortable environment. The external environment was kept in good order. The environment was clean and hygienic throughout. EVIDENCE: A tour of the home included individual resident bedrooms and communal areas such as the lounges and the dining rooms. There was evidence of an ongoing commitment to continue to improve all areas of the home, especially those used by the residents. The home was bright, clean and warm, and even though it was a large building, it had retained a ‘homely’ atmosphere. A relative engaged in conversation on the day of the inspection stated that her family were impressed by the cleanliness of the home, lack of odour and general brightness of the décor. Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 Page 18 As on ongoing project a number of bedrooms had been redecorated to a good standard, including the use of colour co-ordinated bed linen and curtains. Residents had many of their own possessions in their rooms and comments from residents were very positive about their home. ‘I feel really at home here’, ‘I have no complaints at all, the staff are lovely’. The home offered a safe environment for the residents in that all radiators had low surface temperatures and up-to-date recording of hot water temperature tests. Specialist equipment was provided for the residents to promote their independence and risk assessments were completed for residents to determine whether they could access all areas of the home independently Adequate hand washing facilities were available throughout the home. The dining areas were laid out well. The laundry facility was well maintained. Gardens generally provide a pleasant area for residents to wander around in warmer weather. Bathrooms and toilets are satisfactory in number and appropriately sited around the home and several floors were currently being replaced. This will be checked on the next inspection. Foot operated clinical waste bins were provided in all areas where there is clinical waste including used incontinence wear. Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The staffing numbers and skill mix are appropriate to the assessed needs of the residents but staff were not suitable trained commensurate with their duties. The home does not have robust procedures for the recruitment and induction of staff. EVIDENCE: As the home has been registered under South Staffs Health Authority prior to 31st March 2002, the levels and skill mix implemented and agreed at that time, must be maintained. At the time of inspection, staff on duty were satisfactory in number to meet the needs of individuals in their care. There were 15 residents requiring nursing care and 27 residents requiring personal care only. The home had 7 vacancies, as they tend to use their double rooms for single use. The home is split into two wings one for residential residents and one for nursing residents. There is always a qualified nurse on duty during the twenty-four hour period. Additionally there are 6 care staff on the early shift and 5 on the late shift and 3 care staff over the night shift. Day care residents will receive a ratio of 1 member of care staff to 8 people. The residential unit is usually under the management of a senior member of the care staff team. All staff attend regular handovers where information is shared to the oncoming shift. Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 Page 20 The care manager is part time and works 20 hours on a supernumerary basis. The deputy manager is currently applying for registration for a job sharing the care manager’s post, who will also have 20 hours supernumerary time. There are sufficient laundry and domestic staff over a seven-day period. There is a cook and an assistant in the kitchen daily. The general manager works full time in the home. There is an administrator for the home who works full time. There are also two handymen/gardeners available. The staffing compliment on the day of the inspection was found to be satisfactory. A sample of personnel files and computer data was examined as part of the inspection. The home was aware that there were gaps in the records and the examination confirmed this. Three files did not have two references present, one did not have an application form and one had gaps in the employment history. Not all files contained confirmation of identity and recent photographs of the staff members. The home could not evidence that all staff had a satisfactory CRB and POVA check. The home could not supply records to show that all staff had received induction training. The home reported that 7 staff had obtained at least NVQ level 2 but this was not always recorded on file. A further 6 staff were reported to be enrolled on NVQ training. The home maintained a computer record of staff training and this showed there to be a number of staff who were not up to date with the necessary training including Fire safety and moving and handling. This must be addressed as son as practicably possible. Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36,38 The home have recently proposed a new (job share) care manager to ease the workload of the other part time care manager. The home appeared to be appropriately organised but there was a lack of records pertaining to the requirements outlined in the National Minimum Standards. Not all Health and safety issues had been addressed. EVIDENCE: The home reported that it undertook actions to assess and monitor the service provided to residents. The Responsible Individual stated that she undertook monthly visits including random night checks. The home unfortunately could not provide the documentation to evidence that these review and improvement systems were in place. Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 Page 22 Several members of care staff were spoken to in the home and it was determined that formal supervision is not undertaken regularly. Two monthly formal supervision sessions must be undertaken for all care staff. This is a requirement of the report and a recommendation was made that copies of supervisory records are provided to individual staff members. A tour of the premises was conducted without revealing any areas of concern, for the health and safety of residents or of staff or visitors to the home. Maintenance is of a good standard. However, records required by regulation were not all in place. There was no documentation available to evidence all staff have received regular fire drills or that external annual fire safety training had been undertaken. Records showed irregular testing of fire alarms, some months showed only two tests. The system must be tested every week in line with the fire authorities regulations. Fire extinguishers have all had annual servicing. Hot water temperature checks are undertaken but need a little tweaking to ensure that the records show what the temperature of the water was found at and what temperature it was left at (following any remedial action). The home had a recent visit from EHO to inspect the kitchen and no requirements were made. All mobile and bath aids were serviced 6 monthly. Wheelchairs and cot sides were checked regularly for any faults. The home has robust procedures in place for completing accident and incident records. Observations throughout the day confirmed that generally safe working practices were in operation with the exception of some bedroom doors that had been wedged open by residents or visitors. Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 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 3 X 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 2 X 1 Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14(1)(a,b,c,d) Requirement All residents must have a pre admission assessment carried out prior to admission. This must meet the criteria laid down in standard 3.3 All the residents care plans must meet the National Minimum Standards. They must • Accurately record the current physical and mental needs of each individual. • Be legible, signed and dated. The management of the home must consult with residents about their social interests and to further develop the opportunities for activities both in and out of the home. Any complaints made to the home must be acted upon in line with the homes procedures. These must be recorded and available for inspection when required. DS0000022329.V303519.R01.S.doc Timescale for action 10/07/06 2 OP7 14(2)(a)(b) 15(1) 10/07/06 3 OP12 16(2)(m,n) 10/08/06 4 OP16 22(3)(4)(8) 10/07/06 Hampton Court Care Home Version 5.2 Page 25 5 OP18 13(6) 6 OP29 19 (5) Sch2 18(1)(a)(c)(i) 7 OP30 8 OP33 24(1)(a,b) 9 OP36 18(2) 10 OP38 23 (4)(c)(v) 11 OP38 23(4)(e) 12 OP38 23(4)(d) 13 OP38 13(4)(a) The registered person must ensure that all staff have the necessary information and training in adult protection issues. The registered person must demonstrate robust recruitment procedures within the home. The registered person must ensure that all staff receive the training appropriate to the work they are to perform, including induction training and the necessary health and safety training. The registered person must provide the Commission for Social Care Inspection with evidence of its systems for the review and improvement of the quality of care provided to the residents. The registered person must ensure all care staff are appropriately supervised every two months. This must be recorded and available for inspection when required. The registered person must ensure fire alarms are tested weekly and that all staff are familiar with this procedure. The registered person must ensure that all staff have received adequate fire drills. Two a year for day staff and 4 times a year for night staff. The registered person must ensure that all staff have received adequate yearly fire safety training. Fire doors must not be wedged open. DS0000022329.V303519.R01.S.doc 10/08/06 10/07/06 10/08/06 10/08/06 10/08/06 10/07/06 10/08/06 10/08/06 10/07/06 Page 26 Hampton Court Care Home Version 5.2 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 OP36 OP30 OP38 OP12 Good Practice Recommendations It was recommended that following formal supervision of care staff that they are provided with a copy of the documentation. A training matrix was recommended to easily identify individual team member training needs. Accident sheets should be filed following inspection and a log created for auditing purposes. To circulate up to date information about activities throughout the home. Hampton Court Care Home DS0000022329.V303519.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. 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