Inspection on 05/04/07 for Hampton Court Care Home

This inspection was carried out on 5th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 10/06/06

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 Mr Keith Jones Key Unannounced Inspection 5 April 2007 09:00 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 Care Home DS0000022329.V334603.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.V334603.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 vacant 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.V334603.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 10th June 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.V334603.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over one day, by one inspector; the registered Provider, Care Manager (designate), senior Nursing and care staff, in a professional, frank and open manner. The last inspection report was discussed with vigour, and it was noted that requirements and recommendations had been dealt with satisfactorily, or are being actively pursued. On the day of inspection there were 47 service users in residence, of which 20 were assessed as needing nursing care. A tour of the Home allowed free and open access to all areas for inspection. The opportunity was taken to speak with a number of service users and members of staff. Service users and staff took an active role in the inspection process and contributed to the subsequent report. Throughout the entire inspection a sense of relaxed and familiar confidence pervaded into aspects of daily activity expressed by those people met. A sample review of the administrative arrangements confirmed solid practice and a significantly improved management. A full verbal report was offered at the end of the inspection, and the inspector thanked all concerned for their contribution to a pleasing and constructive inspection. What the service does well: Hampton Court offers a genuine and much improved commitment to care with an open and personable approach, which reflects a confident relationship between carer and resident. The establishment of a professionally accountability towards effective assessment, care planning and review of resident’s needs are meaningful in formulating a good standard of care. This personable attitude from the Nursing and care staff, managers and support staff to care was appreciated and welcome by residents and visitors alike. It is pleasing to observe the managerial style released from external influences operating at a successful level, observed in the interactions throughout the day. Hampton Court Care Home DS0000022329.V334603.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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 Care Home DS0000022329.V334603.R01.S.doc Version 5.2 Page 7 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.V334603.R01.S.doc Version 5.2 Page 8 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): 1,2,3,4 and 5 The quality in this outcome area is good. The resources and services set aside by the home are of a much improved standard in considering the needs of residents, families and the ability of the home to meet those needs. It is acknowledged that the Statement of Purpose represents the foundation on which the home operates upon, offering service users and their relatives the opportunity to make an informed choice about where to live. Residents are admitted to Hampton Court following a pre-admission needs assessment, always carried out by a senior member of staff. This assessment initiates the process of care, each individual having a plan of care. The registered person also makes a judgement as to the suitability of each prospective service user using the same criteria. Prospective residents and their relatives are able to visit and assess the quality, facilities and suitability of the Home at any reasonable time, to meet with staff and management Hampton Court Care Home DS0000022329.V334603.R01.S.doc Version 5.2 Page 9 EVIDENCE: The Statement of Purpose and service user’s guide represent a good description of the home’s aims and objectives, philosophy of care and terms and conditions, offering service users and their relatives the opportunity to make an informed choice about where to live. All the requirements prescribed in Schedule 1 are addressed. The document is presently under review by the Care Manager (designate) to reflect changing circumstances. It is clearly stated in the Statement of Purpose that independence, privacy and dignity are encouraged, with the full involvement of family in all matters concerning the well being of service users. The Statement of Purpose also clearly indicates the terms and conditions, which are discussed with service users and relatives prior to admission. Examination of four care files presented a solid foundation in securing a working care plan. It was acknowledged that the Care Manager (designate) has invested a substantial effort in establishing improvements in risk-based assessment. A pre-admission assessment, was seen to be carried out by a senior member of staff, in appreciated any special needs of the individual including cultural, social or personal needs, which are fully discussed and documented. This assessment initiates the process of care, each individual having a plan of care based on a daily living process. The Provider demonstrated through case tracking, that the assessor explained this information in respect of each individual to ensure a clear understanding is established. The Registered Provider also makes a judgement as to the suitability of each prospective service user using the same criteria. At all times the family is kept fully informed of the situation, offering service users and their relatives the opportunity to make an informed choice about where to live. Relatives spoken to were positive and appreciative of the communication with care staff and management. Hampton Court Care Home DS0000022329.V334603.R01.S.doc Version 5.2 Page 10 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): 7,8,9,10 and 11 The quality in this outcome area is good. The Service Users’ assessment provides the base, from which care planning is formulated. It is recognised that this reflects an individual profile of needs, discussed fully with family. The home has access to a number of GPs that visits the Home frequently, and the majority of service users are registered within 48 hours. The Statement of Purpose, admission assessment and care plans are geared to engender a sense of individuality and privacy. The inspector observed the free, courteous interaction between service users and staff based on a level of confidence of essential mutual trust and respect. The provision of a secure and safe medicines administration is managed effectively. EVIDENCE: There was evidence to show that a review of the care process has produced a satisfactory standard of meeting care needs. The pre-admission assessment Hampton Court Care Home DS0000022329.V334603.R01.S.doc Version 5.2 Page 11 represents the foundation for an informative care planning process. Four residents’ care files were tracked and demonstrated a system of a satisfactory level of detailed information on the individual, their life style and needs, events and contacts, procedures and actions measured on a daily basis and reviewed monthly. The policy of the home is to maintain service users own GP support wherever practical; otherwise residents are registered with the local surgery. Specialist nursing services are also received, with which the home has an established and positive professional rapport. Paramedical support is openly obtained when necessary. Discussions with service users confirmed their acceptance and confidence in the overall standard of care and service given. “ I am happy and comfortable here”, ”I saw the doctor last week, it was very welcome”, were some of the comments offered by residents. Carers were seen to interact with residents with purpose and compassion. The facilities and bedrooms were presented to facilitate privacy for the individual, which included medical examinations and personal care procedures, being performed in private. There was evidence that suitable equipment was deployed effectively. The administration of medicines adhered to procedures to maximise protection to service users. Recordings, stocks and storage were secure, with satisfactory added security for controlled drugs. A controlled drug register was examined and found to be in order. The Care Manager (designate) was advised to bring the Homely Remedy procedure and signature list up to date. There were no residents self-medicating at the time of inspection. Each service user has the opportunity of their own lockable facility in their bedrooms on request. The procedure for handling accidents and incidents was inspected and found to hold a policy of referral for medical/paramedical opinion if in doubt. Reports were informative, detailed and meaningful. Recording and archiving of reports are satisfactory in ensuring protection of information. The Care Manager (designate) was advised to analyse accidents on a 3 monthly basis. Family and friends have relative freedom of visiting, those spoken to remarking on the importance of maintaining social contact. There was also an observed knowledgeable, and positive attitude by staff towards residents, and feedback from the residents. The Statement of Purpose clearly and openly states that the wishes concerning arrangements after death would be discussed and respectfully carried out. The spiritual needs of service users were recorded and observed by the staff, with due respect. Hampton Court Care Home DS0000022329.V334603.R01.S.doc Version 5.2 Page 12 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): 12,13,14 and 15 The quality in this outcome area is good This judgement is based on discussions with service users, staff and examination of records in relation to social activities undertaken and general observations during to course of the inspection. The home had a relaxed and welcoming atmosphere where people were encouraged to continue with their individualised lifestyle. Those who wish to bring in personal possessions are encouraged to do so. During the course of the inspection staff were observed to interact with the service users in a positive and polite manner. The home operated a four-week menu providing a varied, nutritional and well balanced diet; service users had a choice of meals and were also offered alternative choice. Special diets were accommodated with the cook making every effort to engage with service users to discuss personal preferences. Staff were seen to offer discreet assistance to those who required it at lunchtime when a very attractive and delicious luncheon was presented. Hampton Court Care Home DS0000022329.V334603.R01.S.doc Version 5.2 Page 13 EVIDENCE: Discussions with service users and staff identified a relaxed atmosphere in which the service user’s needs were respected. A routine exists to establish a framework for managing the home, not as a regime for service users to comply with, but for a point of familiarity. Several residents expressed their appreciation for the freedom they enjoyed, with the security that there are routine events to the day they could relate to. 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 home offered residents massage/aromatherapy sessions, which were undertaken on a private paying basis. A hairdresser visited the home every week. The home provided an Anglican service on a monthly basis. Those service users’ rooms inspected showed a significant influence of personalisation in the inclusion of belongings, some furniture and general décor. During the course of the inspection staff were observed to interact with the service users in a positive and polite manner. The good standards of catering offered a satisfactory service, to which service users spoken to were complimentary of all aspects of quality. A menu on a four weekly cycle offered a wholesome, varied and suitable choice. A very pleasant lunch of braising steak was served during inspection, with choices available, served in dining rooms adjacent to the lounge areas. Three meals were provided daily, with hot and cold beverages and snacks available throughout the day. Service users that were interviewed confirmed that that the quantity and quality food provided was good. Individual preferences were recorded in assessment and conveyed to cook, who met with, and discussed their requirements. One resident said that to wait from 5pm to breakfast was too long, although staff kept her sandwiches back until later in the evening. This was confirmed as standard practice. It was confirmed that the cook knew each service user, and some of the relatives. Diversity was discussed with the cook, who indicated his awareness in meeting individual needs. Staff were seen to offer discreet assistance to those who required it. The choice of dining room, lounge or bedroom was at the discretion of service users. The kitchen was inspected with the cook, and found to present a well equipped and organised area. All fridges and freezers were well maintained and checked daily by the kitchen staff. A cleaning schedule was in place and seen to be up to date and accurate. Hampton Court Care Home DS0000022329.V334603.R01.S.doc Version 5.2 Page 14 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): 16, 17 and 18 The quality in this outcome area is good The home had a meaningful complaints policy in place to ensure the protection of resident’s legal rights, identifying the CSCI as a resource to approach with a complaint or grievance. On discussions it was evident that matters of concern were handled in a timely fashion, discretely and to the satisfaction of all concerned. The home has systems and procedures and to protect residents from abuse. EVIDENCE: Residents’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care planning and policies in place i.e. the complaints procedure. The complaints policy was seen and records examined. There had been a number of complaints recently, with intervention by CSCI, although the complaints had not been supported as regulation had been met in each case. There were several concerns raised recently, and dealt with by the Provider and Care Manager (designate) in a satisfactory manner. On examination of records and discussions it was evident that matters were handled immediately, discretely and to the satisfaction of all concerned. The Hampton Court Care Home DS0000022329.V334603.R01.S.doc Version 5.2 Page 15 overall policy of openness and transparency was acknowledged and actively pursued. The policies, procedures and training in place at the Home helped to ensure that service users were safeguarded from abuse in its various forms. Hampton Court Care Home DS0000022329.V334603.R01.S.doc Version 5.2 Page 16 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): 19,20,21,23,24,25,26 The quality in this outcome area is good. This judgement was based on discussions with service users, staff and a tour of the premises. The home is well appointed to meet the needs of an elderly population of service users in providing a safe and comfortable environment. There are two sections to the Home, the East wing predominately residential care, the west wing to nursing care. On inspection, bedrooms were highly personalised with most displaying service user’s own furniture, and with personal belongings. All communal areas are of a good standard, offering social as well as private reflection, as the mood takes. The overall environment was found to be safe for service user’s comfort within risk assessed limits. The domestic services in the home were seen to be of a good standard, with no evidence of unpleasant smells or unsightly debris anywhere throughout the inspection. Hampton Court Care Home DS0000022329.V334603.R01.S.doc Version 5.2 Page 17 EVIDENCE: A tour of the Home verified that the premises were fit for purpose, clean warm and tidy, and being well maintained. The surrounding garden areas were tidy although basic, the surrounding countryside providing a pleasant vista for relaxation within warmer months. Internal access was facilitated with suitable fittings of hand and grab rails, in adequate, well-lit and airy corridors. Wheelchair access was satisfactory throughout all areas of the home. On admission the provider or care manager assesses each individual service users’ needs for equipment and necessary adaptations. Efforts had been made to provide a homely atmosphere and the décor in most areas of home was found to be of a high standard. The home provided two lounge areas that were pleasantly decorated providing essential furnishings and items to provide a comfortable area where service users were able to interact with fellow service users, or to entertain their guests. The ’nursing area’ lounge is large and has had furniture moved to facilitate small group areas. This move was appreciated and could be enhanced further with floral display dividers. It was noted that few residents took advantage of the lounge areas during the morning. The central conservatory provided a tranquil area where service users could experience the views of the surrounding grounds. There were spacious dining areas at each wing where service users were able to dine in comfort. Toilets and bathrooms were located on both floors and were in close proximity to bedrooms and communal areas. Bedrooms were well maintained to meet service user’s personal preferences. On inspection, most bedrooms were highly personalised, with some displaying service user’s own furniture, and most with personal belongings. It is the policy that on bedrooms becoming vacant that each room is reappraised for redecoration, as confirmed during the Inspection. There is throughout a satisfactory standard of furnishing. Service users spoken to expressed a sense of belonging and satisfaction in the quality and presentation of their living areas. An effective call system is installed; care staff reacted readily to tests. The care manager expressed a willingness to meet any reasonable demand for special needs. A locked facility and lockable bedroom doors are made available on request, following suitable risk assessment. The evidence seen on inspection of service user’s rooms, and on discussion with the individual service users and family, assured that this standard was well met. Kitchen presentation showed good standards of cleanliness and evidence of sound food hygiene practices. The laundry was very well organised and Hampton Court Care Home DS0000022329.V334603.R01.S.doc Version 5.2 Page 18 equipped to a good standard. Red Alginate linen bags are available and widely used. Notices regarding chemical handling in the areas that store chemicals are displayed. It was advised that items should not be stored on toilet cistern lids. The external and internal environment was well maintained and secure. The Registered Provider and Care Manager (designate) are to provide the Inspector with a development plan for 2007/08. Heating and ventilation were found to be satisfactory and lighting was domestic in style. Aids, adaptations and equipment were available throughout the Home. Fire equipment was inspected and seen to be serviced and up to date. It was noted that several extinguishers had been left on the floor, free standing, awaiting maintenance. Remedial action was taken immediately. The home presented a clean and pleasant, odour-free atmosphere, much to the credit of staff. Hampton Court Care Home DS0000022329.V334603.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The quality in this outcome area is good. Staffing levels were seen to be adequate to meet an expected demand, the daily care staffing rota showed adequate balance between skills and qualifications although because of sickness numbers fall short at times to provide a good standard of care. The Provider and Care Management have established an improved procedure for interview, selection and appointment of staff, which requires continual reinforcement in ensuring the protection of service users. Staff training records complement the effort placed into staff training. EVIDENCE: Hampton Court Care Home DS0000022329.V334603.R01.S.doc Version 5.2 Page 20 There were 47 service users in the home on the day of the inspection. Off-duties for week commencing 26/03/07 through to 14/04/07 were provided and examined; staffing levels were seen to be satisfactory. The daily care staffing rota showed adequate balance between skills, experience and numbers to provide a good standard of care. The staffing establishments were examined and found to be satisfactory in meeting the CSCI staffing notice. An average coverage was seen to be: a.m shift – 2 trained 6 carers p.m shift – 1 trained 5 carers n.d. shift – 1 trained 3 carers Shortfalls are usually made up with flexible rostering and overtime. The Registered Provider works full time in the home. The Care Manager (designate) is supported by a deputy, who each contribute to the rota. There are sufficient laundry and domestic staff over a seven-day period. There is a cook and an assistant in the kitchen daily. There is an administrator/receptionist for the home who works full time, and two handymen/gardeners available. The staffing compliment on the day of the inspection was found to be satisfactory. The home reported that 7 staff had obtained at least NVQ level 2, and 6 staff were reported to be enrolled on NVQ training. Documentary evidence confirmed an improvement in the quality of staff selection, recruitment effort and practice. Three staff files were sampled and found to be generally well organised. Each staff file would be more informative with a copy of job description, interview record to support the letter of appointment, and a suitable photograph of each staff member. Four members of staff were spoken with, each being pleased and satisfied with the professional foundation offered to them through effective management. All staff have a statement of terms and conditions. Service users are supported and protected by these practises and all new staff goes through an induction process that will ensure that they are going to be the right person for the home. The Care Manager (designate) is steadfastly committed to a learning environment. Staff induction programmes are meaningful and well established, forming the base upon which in-service supervision and training are planned. Overall the evidence shows a satisfactory account of a training programme and record that offers a full understanding of training needs. This would be enhanced with a more focussed, date specific planning element to the schedule. Hampton Court Care Home DS0000022329.V334603.R01.S.doc Version 5.2 Page 21 On going personal and training records were kept secure in accordance of the Data Protection Act 1998. Policy clearly states an equal opportunity position. Evidence showed a diligent attention to on-the-job clinical supervised training, involving a shared aspect of responsibility between staff and trainer, with the involvement of mentor trained staff. However there is a continuing need to extend this process by involving general working arrangements to offer a more substantial commitment to the supervision and appraisal process. Hampton Court Care Home DS0000022329.V334603.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): 31,32,33,34,35,36,37 and 38 The quality in this outcome area is good. The influence of the Care Manager (designate) has been significantly enhanced over the past 6 months, and also from the last inspection. This accountability has resulted in a much-improved level of performance through a broad avenue of issues, especially in improvement of standards, staff management and the supporting infrastructure of services. The Care Manager (designate) of the home accompanied the inspector for the day. Maria Guest has demonstrated her capacity as suitably qualified and experienced to manage the day-to-day care needs of service users. The inspector was impressed by the openness and confidence in the observed interactions of staff, relatives and service users. The relationships were seen to be of mutual trust and respect. Hampton Court Care Home DS0000022329.V334603.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Registered Provider and Care Manager (designate) have developed a formal approach to monitoring quality across a wide range of activities. This includes a care plan review process that is recorded at least once a month, a staff training programme and a risk assessment programme. This includes the setting of objectives, effective budgeting of plans and target dates to aim for. Ms Guest has been able to influence the planning in setting objectives on the planning process. Evidence was secured to acknowledge achievements, ongoing and planned objectives, confirmed at case tracking and informal discussion. Social Workers’ review meetings are often a vehicle for assessing quality. Each service users has a personal file containing contractual, financial and personal information. Three files inspected evidenced a satisfactory standard of maintenance and security. Care plans were drawn up, implemented and reviewed on a monthly basis. This process would be enhanced with the inclusion of service users and relatives whenever possible. Case tracking and informal discussion provided evidence that participation is encouraged on an informal level. A sample of administrative, maintenance and care records were examined and found to offer an accurate reflection of a service committed to providing a safe and comfortable environment for elderly service users. These included procedures on abuse, fire training, and pressure care management. Service records for water supplies; gas, PAT testing, and fire equipment were examined. Routine maintenance ensures that essential services linked to utilities and safety, are monitored and serviced on a regular basis. Accidents were seen to be addressed, risk assessed, actioned and recorded in an effective way, with access to Riddor if needed. No serious accidents have been reported. A three-month analysis was advised, with added security on filing and recording accidents. The administration and management of the home have achieved a substantial level of improvement from previous inspections. It has demonstrated that with effective and committed care management and a resource management released from external constraints, a good standard, effective, uncomplicated, and very sensitive to the needs of service users. Hampton Court Care Home DS0000022329.V334603.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 2 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 18 3 3 3 3 3 4 4 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X X 2 3 3 Hampton Court Care Home DS0000022329.V334603.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 Standard OP32OP32 OP9 OP36 Regulation 8 13 18(2) Requirement The Care manager is registered with the CSCI. The Homely Remedy procedure be up dated Ensure all staff are appropriately supervised every two months. Timescale for action 01/07/07 01/05/07 01/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard 1. OP30 2. OP38 3. OP12 4. OP30 Hampton Court Care Home Good Practice Recommendations A training matrix was recommended to easily identify individual team member training needs. Accident sheets should be filed following inspection and a l3-monthly analysis log created for auditing purposes. To circulate up to date information about activities throughout the home. A photograph would enhance all staff file records DS0000022329.V334603.R01.S.doc Version 5.2 Page 26 5. 6. 7. A re-furbishment plan be drawn for 2007/08/09 The practice of storing items on toilet pedestal lids cease Fire equipment be maintained safely Hampton Court Care Home DS0000022329.V334603.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: 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. 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