Inspection on 11/05/07 for Harleston House

This inspection was carried out on 11th May 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

Harleston House 25/03/09

Harleston House 24/05/06

Harleston House 28/09/05

Harleston House 16/05/05

Harleston House 11/10/04

Harleston House 07/04/04

Harleston House 25/02/04

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

CARE HOMES FOR OLDER PEOPLE Harleston House 115 Park Road Lowestoft Suffolk NR32 4HX Lead Inspector Mary Jeffries Unannounced Inspection 11th May 2007 1:00pm 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 Harleston House DS0000058556.V339984.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. Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Harleston House Address 115 Park Road Lowestoft Suffolk NR32 4HX 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) 01502 574889 01502 516638 harleston@greensleeves.org.uk www.greensleeves.org.uk Greensleeves Homes Trust Post Vacant Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Last Key inspection 24th May 2006, Last inspection 29th November 2006 Brief Description of the Service: Harleston House is a 25 bedded residential home for older people situated in a residential area of Lowestoft. The home was first registered in 1950 and has over the years been extended to provide additional accommodation. All resident rooms are offered for single occupancy. At the end of January 2004, the ownership of the home transferred from the Church Army to the Greensleeves Homes Trust, a national organisation which owns two other residential homes within East Anglia. It is the intention of the organisation to extend the service and to upgrade the existing premises. The current charges are at three levels, depending on the assessed dependency level of the resident. They are £395:00, £ 435:00, £465:00. Chiropody, Hairdressing, Newspapers and toiletries are not included. Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during one afternoon and early evening in May, and took eight hours forty minutes. This includes two hours on the following morning, when the Inspector returned to see staff records that were not accessible on the previous day. The inspection was facilitated by the acting manager, and care staff participated. There were 22 residents at the home. Four were tracked. Two of these were sleeping and another some-what preoccupied, having been recently admitted. Two other residents were spoken with in some depth, one of which had lived at the home for some time. A random inspection took place on 29th November 2006. What the service does well: What has improved since the last inspection? Since the last Key inspection care plans have improved and are now of a very good standard. There was evidence that accidents occurring in the home are documented in detail and that a review of the existing risk assessment is triggered by this entry. A revised practice has ensured that the medication trolley is not left unattended whilst unlocked. The frequency and dosage of “as and when required” medication is now entered on Medicine Administration records. Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 6 Leaflets explaining the complaints procedure were available to all residents, families and visitors to the home, being displayed in the entrance hall. The document also included contact details for the Ombudsman or the CSCI. Staffing levels were found to be acceptable at the random inspection in November 2006, and also on this occasion. All required pre-employment checks and information was available for recently appointed workers. All opened packaged foodstuffs stored in the fridges within the kitchen had been marked with the date of opening. Financial transactions carried out on behalf of service users were supported by two signatures and amounts held tallied with records. Complaints were properly logged, including evidence of action taken. What they could do better: The home can accommodate 24 persons, whilst it is still registered for 25 persons. The home should consider making an appropriate application in order to bring the registration in line with the Registration and Statement of Purpose. Service User Guides must be distributed to existing residents. Medical Administration records must be signed immediately after administering medication. The home must ensure that communal areas are maintained to a good standard of decorative order. Update training for staff is required in manual handling and infection control and fire safety. Formal supervision must take place in line with the home’s policy, and regularly enough to support and monitor staff. Resident’s dignity must be promoted through appropriate storage of incontinence aids and in the quality of interactions with residents. Mops must be stored in accordance with good infection control procedures. The home must ensure that the lift s regularly maintained and evidence of servicing held. Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 7 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. Harleston House DS0000058556.V339984.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 Harleston House DS0000058556.V339984.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can be assured that they will be fully assessed prior to moving into the home and will be given information to enable them to make an informed choice. EVIDENCE: At the random inspection undertaken in November 2006, the Acting Manager was able to evidence that all prospective residents now receive an introductory pack which includes a copy of the home’s Statement of Purpose, an information leaflet about the accommodation and services provided, a copy of the home’s complaints procedure. It also included a copy of the Annual Report for the Greensleeves Homes Trust and a summary of any requirements made at the most recent inspection. A requirement was made that Service User Guides must be distributed to all residents. Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 10 Service User Guides were not seen in the three bedrooms entered. A resident was asked if they had a Service User Guide. The resident, advised that they did not know what this was. A member of staff was asked for a copy of the Service User Guide, so that this could be shown to the resident. Two staff members advised that these were given to people when they first came to the home, and that they would ask a recently admitted resident to borrow theirs. One of the Staff members returned with a Statement of Purpose. The staff members were not aware of any other document in residents’ rooms, and suggested that cleaners might dispense with “odd pieces of paper”. The home’s certificate of Registration states that it can accommodate 25 residents. This was discussed with the acting manager who advised that the home had 22 residents and none in hospital (at the start of the inspection). The acting manager confirmed that the home could only take 24 residents, and that a room that had previously been a residents’ room had been converted to a staff room “a long time ago”. The Statement of Purpose states that 24 persons are accommodated. Upon return to the office, the home’s previous certificates were inspected and it was found that the home had been and continued to be registered to accommodate 25 residents since prior to 2002. The files of three recently admitted residents were inspected. All three had assessments conducted by the home prior to admission. One also had a social care services assessment. The home’s acting manager advised that residents were visited prior to admission for assessment and confirmed they were given a Service User Guide at that point. The home does not provide Intermediate Care. Harleston House DS0000058556.V339984.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to have a comprehensive care plan that sets out their needs and regularly reviewed, and to be looked after well when they are unwell. EVIDENCE: The homes quality assurance exercise undertaken in February 2007 by independent consultants showed that residents and relatives rated the standard of care and health care higher than was the case in other homes owned by the organisation. At the random inspection undertaken in November 2006, care plans were inspected and found to be detailed and person centred, providing information on likes and dislikes of the residents and preferences, tastes and daily routines as well as levels of intervention required to meet identified needs. Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 12 On this occasion three care plans inspected and were found to be very clearly laid out and comprehensive. All inspected contained completed monthly review sheets which also raised the query as to whether the plan needed amending. The care planning process included risk assessments, mobility assessments, and pressure assessments. The care plans were person centred. Care plans contained brief life history/ backgrounds of residents and full records of contact with health care professionals. Residents care plans evidenced that they were supported to make informed decisions and express the manner in which they would like to be assisted with personal care. A carer spoken with advised that they thought basic care and personal care had improved. They and another carer spoken with had a good understanding of resents needs; the acting manager displayed a very good understanding. At the random inspection it was identified that whilst any accident involving a service user in the home was documented appropriately in the Accident Book, this did not necessarily trigger a review of the resident’s risk assessment in order to minimise the risk of a particular accident occurring again. One resident tracked on this occasion had fallen several times and had had their risk assessment reviewed after each occasion. A resident who was identified as having lost 4lb in weigh over a week had been referred to the speech and language therapist for assessment of dietary needs. . One of the residents checked was at risk of pressure areas developing; they had a special mattress in place and daily observations of their vulnerable areas was made. One resident with very poor sight had a very bright light positioned besides their chair and had a magnifying glass. Daily routine sheets contained useful observations and care notes, for example, “ when..… is asked what they want to eat they will always repeat the last choice. Action needed, make sure that…...doesn’t make the same choice each day.” A carer spoken with advised she now put the choices to the resident in a different order each time, rather than saying salad last, as they had previously chosen salad every day. A comment received by the home in it’s own customer satisfaction survey undertaken in February 2007 quality survey stated, “ The care and well-being of my friend since arriving at Harleston House by (all) has been outstanding. This has shown through, as (the resident) could not walk unaided on admission. She now walks, dresses and undresses herself.” Care plans evidenced that residents are enabled to access community health facilities such as district nursing services, chiropody, optician and dental Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 13 services. A resident spoken with advise that if they wanted to see a doctor they just asked, and staff would call one. They said that staff looked after them very well when they were unwell. At the random inspection undertaken in November 2006,it was found that the the Acting Manager had revised the systems used for the administration of medication. The home was able to evidence on that occasion that that the medication trolley is taken into the dining room where residents receive any medication whilst having their lunch. This revised practice has ensured that the medication trolley is not left unattended whilst unlocked. On that occasion a selection of MARS sheets the home were examined and the home was able to evidence that the frequency and dosage of “as and when required” medication is now entered. The administration of the teatime medication round was observed. Medication Administration records, (MAR) sheets, were inspected; only two days records were in the file as a new delivery had been received two days prior to the inspection. The carer administering the medication failed to complete the records for a number of the residents when administering the medication. The carer advised that they normally checked records for completeness in the evening. However, one gap was identified in the MARs sheet for the previous day and in a separate file maintained for records of prescribed creams there was also one entry was missing for the previous day. There was nothing to indicate these had been picked up. The controlled dugs book stated that there were no controlled drugs in the home, and the controlled drugs cupboard was empty. The acting manager advised that the carer who had given out the medication on this occasion and all of the seniors had undertaken an accredited medication course. She advised that the home was undertaking on- going audits of medication, and hat a recently recruited member of staff with training in and good knowledge of this area was going to oversee this, and they had introduced a policy that disciplinary action would be taken in the event of three incidents of mis-signing of medication. Two residents were in bed on the day of the inspection. Both were comfortable, and their windows were open to circulate air. Packs of incontinence pads were visible within both rooms, as was a cardboard bedpan in one and a urine bottle in the other. One residents spoke of staff sometimes some times talking to them in way they did not like, this was in terms of staff talking down to them, but said that they did not want to “make a fuss” about this; they described staff sometimes speaking to them as if they didn’t know anything. Another resident spoken with was asked about this and they advised that “some of them are a bit lacking.” Harleston House DS0000058556.V339984.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): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to be able to choose when to be able to exercise choice in their daily lives and also expect to be supported to maintain contact with family and friends. EVIDENCE: The homes quality assurance exercise undertaken in February 2007 showed that residents and relatives rated social activities less well than was the case in other homes owned by the organisation, although some recent improvements since the current acting manager took over were noted. This was highlighted as an area requiring further management attention. There are a number of different communal areas where residents can sit. One of the recently admitted residents spent most of the afternoon on a settee in the entrance hall area. They advised that they liked living at the home bit were Somewhat preoccupied with their thoughts about a relative. The acting manager was aware of the resident’s feelings, and spoke of her need to respect these but not to be judgemental towards the relative. Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 15 One comment received by the home in it’s own customer satisfaction survey undertaken in February 2007 quality survey was, “ Trying to look after (my relative) at the home was very difficult. Harleston House has been wonderful to my relative and to us…” A resident who was visiting one of the residents tracked for the inspection advised that they were always made to feel welcome. A list of residents with diabetes and a list of residents’ birthdays were pinned up in the kitchen. Food in the fried was seen to be dated when opened. Fridge and freezer temperature records evidenced that these were correctly maintained. The menus were seen and contained a good range of plan wholesome meals. A carer advised that breakfast can be taken anytime after 8am. Two residents spoken with said that they didn’t like the meals very much. One commented, “ you should just see how much is left on the plates at the end of a meal time.” A carer spoken with about this advised that it depended which cook was on duty, one tends to plate large meals which can over face residents, another carer said that a lot of food with sauces and more modern dishes were offered that that were not to everyone’s liking. Cool water is available at all times from a dispenser in the lobby area. At tea time residents had a choice of cheese and potato pie or sandwiches. This was taken round on trolleys and residents were seen enjoying their tea in a relaxed atmosphere. Activities are usually provided in the afternoon. On the day of the inspection a resident was ill and an emergency ambulance was called. Activities were cancelled on account of staff being involved with this event. Resources for activities were in the manager’s office, including a musical quiz, a reminiscence book and a book on group activities. The acting manager advised she was working on developing activities and that although the previous activities person had left that a new activities worker was on induction. A resident spoken with said that activities had dropped off a bit, but that this was improving. Religious services are held at the home on Wednesday evenings. Harleston House DS0000058556.V339984.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 good. This judgement has been made using available evidence including a visit to this service. Residents can expect to have access to a proper complaints procedure and for complaints to be properly investigated. EVIDENCE: On the day of the inspection, leaflets explaining the complaints procedure were available to all residents, families and visitors to the home, being displayed in the entrance hall. The document also included contact details for the Ombudsman or the CSCI. The CSCI received a complaint in October 2006. This was followed up at a random inspection and no requirements were made. At that inspection the home was able to evidence that it maintained a log of all complaints. The log did not show that the last two complaints received had been investigated, however the inspector was advised that they had been. The logbook had been completed since then. One further complaint to the home had had been entered in the log. This was upheld. At the random inspection it was noted that one complaint related to an allegation of the suspected abuse of a resident by an agency staff member. Whilst this staff member is no longer used by the home, and the allegation was reported to the agency, it was not reported in line with the home’s or local authority’s Procedure for the Protection of Vulnerable Adults. No further PoVA Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 17 matters had been identified since then. A staff member advised that they had received recent PoVA training. The home’s training action plan showed that PoVA training had occurred in March 2007 for the acting manager and twenty one staff. The acting manager advised that this had been provided by an external training company, and that the Suffolk Procedures were referred to in the training. Evidence of this training was seen on two seniors’ files. Harleston House DS0000058556.V339984.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): 19,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a comfortable home, however parts of the building require decoration and refurbishment. EVIDENCE: Harleston House is a Victorian building, which has been extended over the years to provide additional accommodation. Bedroom accommodation is sited on three floors, all of which are accessible by a passenger lift or stairway. All of the bedrooms are currently offered for single occupancy. Whilst none of the bedrooms have the benefit of en-suite facilities, the home has a sufficient number of communal assisted bathrooms and communal toilets. Hot water in bathrooms was checked and found to be at 43 decrees Celsius. The home has pleasant gardens to the rear of the building and a summerhouse for the use of residents. Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 19 The overall appearance of the home downstairs is that it is attractive and comfortable. One of the residents spoken with advised that they liked the high ceilings in the home, and that they made them feel better. The corridors on the upper floors, are in need of decoration and quite institutional in their appearance. Corridors appeared long and bare and poorly furnished. The condition of the building was identified as one of two key areas requiring improvement in the home’s quality assurance exercise. There has been a longstanding requirement that the corridor areas within the building are maintained to a satisfactory standard of decorative order. The front hall had been decorated but other corridors had not. This was due to be addressed as part of the home’s planned refurbishment of the premises. The Acting Manager advised the Inspector at the random inspection in November 2006 that occasion that the planned refurbishment work was due to start in the summer 2007. On this occasion the acting manager advised that this is now due to commence in October, following an architects meeting that had been held the previous week. Since the last key inspection there had been an outbreak of diarrhoea and vomiting at the home, and when this was responded to by a Health Protection Nurse, concerns were raised about inadequate infection control procedures. The policy on infection control had been revised, but not all staff had received training in infection control, (see the section on staffing.) On this occasion the home was clean and odour free. The relative survey complied in January 2007 indicated that relatives were satisfied with the cleanliness and the odour of the home, and also with the laundry service. On the day of the inspection, however, two damp mops were stored head down next to the kitchen. A tour of the premises undertaken at the random inspection evidenced that all communal toilets had been provided with liquid soap and paper towels and no tablets of soap had been left in any of these facilities. This was also the case at this inspection. In the home’s own survey, one person had commented that when the lift was not working they had had to have meals in their rooms. A carer spoken with confirmed that the lift was a periodic problem. Two carers were seen assisting a resident into the lift, and advising them to take care, as once it had arrived, the floor of the lift was raised in comparison to the external corridor floor level. The acting manager was advised that this was a tripping hazard and that a warning tape must be applied to the edge of the lift floor. This was done immediately. Evidence of lift servicing was requested. Paper work showing a repair had been carried out and the lift left in service on the previous day, and also in February 2006, but no record of servicing was provided. The carpet on the top flight of stairs was badly worn on a tread, and was a tripping hazard. A carer advised that all staff used the lift to this level, however Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 20 in the event of the lift being out of order or in a fire this would be a tripping hazard. Again, this was marked with safety tape on the day. Foodstuffs stored in the fridges in the kitchen within the kitchen wee checked; all opened packaged food had been marked with the date of opening. Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to be supported and cared for by experienced staff, although cannot be assured that all staff have had the necessary training updates to ensure that their needs will be safely and adequately met. Residents can expect that new staff to have been properly recruited and inducted. EVIDENCE: Staffing levels were found to be acceptable at the random inspection in November 2006, but it was noted that the level of staffing found, three on duty, was the minimum acceptable and this was dependent on levels of dependency within the home. On this occasion there was a senior carer and two carers on duty on the afternoon shift, which commenced at 2.15. It was the acting manager’s day off, although they had popped into the home and stayed to facilitate the inspection. The deputy manager was not on duty. A carer advised that the home never goes below three carers on duty, and that they are always busy. There were twenty two residents residing in the home. Staff appeared to be busy throughout the inspection; the only evidence of them not being able to cover all duties was that activities were cancelled that day. Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 22 The size and layout of the home presents a challenge. A carer advised that they carry walkie-talkies so that they can communicate across the home; they were aware of the need to maintain confidentiality when using these. The acting manager provided a staff training action plan for 2007. At the random inspection it was evidenced that manual handling training and infection control training had been provided to all working care staff, and that ten staff members had undertaken training in infection control, and the others had been booked into receive this training. The training action plan did not show any further training on infection control. Manual handling training had occurred in March 2007 for new staff, however the training action plan showed no update training for moving and handling since April 2006. A member of staff spoken with advised that update training was required. The acting manager, deputy manager and all four senior carers had received dementia awareness training since the last inspection. This had been a threeday course provided by the Alzheimer’s society. Two staff recruitment files were inspected at the random inspection and were found to be well organised and to include a checklist to ensure all required checks and documentation were in place before employment commenced. References were found to be in place prior to employment on the two files inspected at the random inspection. Three files were inspected on this occasion and were all found to be in order. New staff had received induction and manual handling training. Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can be assured that the home is actively working to improve standards and that they will benefit from the current ethos of the home under the current acting manager. EVIDENCE: A very thorough quality assurance exercise had been undertaken by independent consultants which made recommendations on areas needing improvement in the home. The satisfaction survey had been carried out and collated in February 2007. The survey was made of relatives’ opinions; 17 out of 22 next of kin responded. The survey was undertaken by consultants and identified issues that needed to be improved; the standard of care and social and recreational activities. It also compared the level of response in each Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 24 category with the current average score for all homes owned by the organisation, and made recommendations for improvement. A residents’ meeting had been held in April. At the random inspection it was noted that the Manager of the home had resigned their post on 23 November 2006 and the owning organisation had not informed the Commission, in writing, as required by regulation. One comment in the home’s relatives survey expressed dissatisfaction at the large number of managers and acting managers who had been in post in the last three years. The acting manager and the services manager both advised, separately that the post of Registered Manager was to be advertised the following week in Suffolk Press. The current acting manager displayed a very good knowledge of the residents needs. One comment included in the home’s survey stated, “Since. (the current acting manager) took over things have improved a great deal. Another comment received by the home in it’s survey stated, “. (the acting manager) has improved the overall atmosphere no end.” The acting manager advised that they were to commence their Registered Managers Award in June. At the random inspection, the Inspector examined the systems used for the administration of resident finances. The home was able to evidence that any withdrawals or transactions made on behalf of service users were supported by two signatures and that a regular audit of resident finances was carried out. Monies were kept for one of the three residents tracked, and they had a zero balance at the time of this inspection. Another resident with monies in the home was chosen at random, their records and balance was checked and found to be in order. Financial transactions carried out on behalf of the resident were supported by two signatures. Evidence of supervision on two staff files showed that one has none since January; the other had received supervision in March. The supervision record sheet was inspected and it showed that supervision was scheduled to take place on a bi monthly basis. A number of staff had missed two or three planned sessions. The home’s infection control policy had been reviewed in November 2006. A copy of the latest inspection report was available in the entrance hall. A copy of the homes public liability insurance was displayed. Fire extinguishers had been serviced within the last twelve months. The fire logbook included fire training to 13 staff including domestic staff since November 2006; this did not tally with the training action plan which had earlier dates for some staff who were listed in the fire logbook. Also three staff were not evidenced to have had it in the last two years. Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 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 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 5(1) Requirement Each resident must be provided with a Service User Guide, which provides the information as required under Regulation 5(1) of the Care Homes Regulations 2001. This is a repeat requirement from 24/05/06. Medical Administration records must be signed immediately after administering medication, and any gaps properly accounted for. Residents’ dignity must be preserved through practices such as appropriate storage of Incontinence aids and in staff interactions with residents. Corridor areas within the building must be maintained to a satisfactory standard of decorative order. This is a repeat requirement from 28/09/05. The lift must be services in accordance with good practice and manufacturer’s guidelines. Care staff must receive update training in moving and handling, infection control and fire safety. DS0000058556.V339984.R01.S.doc Timescale for action 31/07/07 2. OP9 13(2) 13(4) 11/05/07 4. OP10 12(4)(a) 31/07/07 5. OP19 23(2)(b)& (d) 20/12/07 6. 7. OP22 OP30 OP38 13(4) 18(1)(c) 31/07/07 30/09/07 Harleston House Version 5.2 Page 27 8. OP36 18(2) Formal supervision must take place in line with the home’s policy, and sufficiently regularly to support and monitor staff. 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations Menus and the serving of food should be reviewed and residents’ views sought. Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Harleston House DS0000058556.V339984.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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