Inspection on 23/05/07 for Hartisca House

This inspection was carried out on 23rd 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

Hartisca House 27/06/06

Hartisca House 15/09/05

Hartisca House 05/04/05

Hartisca House 02/12/04

Hartisca House 22/06/04

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

CARE HOMES FOR OLDER PEOPLE Hartisca House Hartwell Road Burley Leeds West Yorkshire LS6 1RY Lead Inspector Dawn Navesey Key Unannounced Inspection 9:25 23rd May 2007 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 Hartisca House DS0000001458.V339161.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. Hartisca House DS0000001458.V339161.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hartisca House Address Hartwell Road Burley Leeds West Yorkshire LS6 1RY (0113) 2426919 0113 2426871 hartiscahouse@schealthcare.co.uk www.schealthcare.co.uk Southern Cross Healthcare Services Limited 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) Care Home 26 Category(ies) of Dementia (26) registration, with number of places Hartisca House DS0000001458.V339161.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2006 Brief Description of the Service: Hartisca House provides care for older people with dementia. The home was purpose built as a care home, though not specifically designed for the care of people with dementia. Bedrooms meet the minimum size requirements and some have en-suite facilities. The ratio of double to single occupancy rooms is satisfactory. The home is built on two floors with passenger lift to the first floor. Each floor has a lounge and dining area with food and laundry services being provided from a central area on the ground floor. Sixteen people are accommodated on the first floor and ten on the ground floor. The building does not provide an area where residents can wander freely. A very small, enclosed patio area in front of the building has been made into a more secure area which can be used during the good weather. The home is situated in the Burley area of Leeds, within walking distance of shops, a day centre, church and park. The city centre is a short bus ride away. Because of the vulnerability of the client group external doors are alarmed and the front door can only be opened by staff. The current weekly fees charged by the providers is £423 to £465. Additional charges are made for hairdressing, taxis and private chiropody. This information was provided to The Commission for Social Care Inspection in May 2007. Hartisca House DS0000001458.V339161.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk One inspector between 9-25am and 5-30pm carried out this unannounced inspection. The purpose of this inspection was to make sure the home was providing a good standard of care for the people living there. And to monitor progress on the requirements and recommendations made at the last key inspection on 27 June 2006. The people who live at the home prefer the term resident; therefore this will be used throughout the report. The methods used at this inspection included looking at care records, observing working practices and talking with residents, relatives and staff. Information gained from the home’s service history records were also used. During the visit, survey cards were distributed and sent out to relatives and visiting professionals to the home. None of these have been returned in time for writing this report. Feedback was given to the manager who had only been in the post for two weeks and operations manager at the end of the visit. Thank you to everyone for the hospitality and assistance on the day of the visit. And to everyone who took the time to talk and express their views. Requirements and a recommendation made during this visit can be found at the end of the report. What the service does well: Hartisca House DS0000001458.V339161.R01.S.doc Version 5.2 Page 6 The staff team are committed to providing high standards of person centred care to residents with dementia. Staff said, “Its about concentrating on what people can do rather than what they can’t do”. Staff training in dementia care means that staff are familiar with good practice such as food being available 24 hours per day and life history work. Staff have a good knowledge of residents’ needs and respond well to them. The atmosphere in the home is warm, friendly and welcoming. Comments from residents included, “They are very good to you, nothing I don’t like, there is a nice atmosphere and people have a good attitude”, “I like it here, it is very good” and “They are nice when they get you up on a morning”. Pre-admission assessments are detailed and provide a good basis for residents’ care plans. Relatives and residents are involved in the care planning process. A relative said, “They always discuss the care plans with me”. What has improved since the last inspection? What they could do better: The statement of purpose would be improved by including information stating how the specialist needs of people with dementia will be met. This will make sure that people who may use the service have information they need in order to make a choice about the home. Care plans would be improved by giving staff clear and precise instructions about the level of care to be given. This will make sure care needs are not overlooked. The independence and nutrition of people who live in the home would be improved by making sure that residents are provided with aids and adaptations needed to enable them to eat an adequate diet. The toilet bowls in the en-suite bedrooms must be replaced as they are badly stained. This has been outstanding for several years. Hartisca House DS0000001458.V339161.R01.S.doc Version 5.2 Page 7 The manager must make sure that all staff receive training in infection control in order that staff maintain good practice in preventing the spread of infection. Staff communication skills could be improved, as it was apparent that people living in the home did not always understand what was being said to them. The organisation and manager should give some consideration to reviewing staffing arrangements to make sure residents’ social needs are being properly met. 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. Hartisca House DS0000001458.V339161.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 Hartisca House DS0000001458.V339161.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, 4 and 5 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can be sure that the home will meet their needs following assessment before moving into the home. However, written information about the home is not comprehensive enough for them to decide whether the home will meet their needs, which are specific to dementia. EVIDENCE: There is a Statement of Purpose and Service User Guide available. These are documents that give information about the home and the service and facilities they aim to provide. They have been produced in large print making them more accessible and easier to read. They would also benefit from some use of pictures or photographs. The Statement of Purpose does not state how the Hartisca House DS0000001458.V339161.R01.S.doc Version 5.2 Page 10 specialist needs of people with dementia will be met even though this service is registered for people who have dementia. The manager must review this to make sure that people who may use the service have information they need in order to make a choice about the home. Pre-admission assessments take place for residents before they move into the home. The home’s manager or senior staff do these. The level of detail is good and a preliminary care plan is developed from the assessment so that staff have some information on residents’ needs as soon as they move in. The resident and their relatives are fully involved in the assessment and it is clear that information is gathered from a variety of sources. This includes care managers, social workers and community psychiatric nurses. Residents and their relatives are given opportunity to visit the home prior to moving in. The manager said that introductory visits are part of the assessment process and based on individuals’ needs. A visiting relative said that visits had been part of the introduction to the home for his wife to see how she got on with others in the home. The deputy manager said the home is clear when needs cannot be met as it aims to provide a service to people who have low level dementia. He said that risk assessments and the homes dependency assessment tool can help to indicate where needs cannot be met. A resident who had recently moved into the home said she was settling in well. She said, “They are very good to you, nothing I don’t like there is a nice atmosphere and people have a good attitude.” Hartisca House DS0000001458.V339161.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 and 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Overall, residents health and personal care needs are met and their dignity and privacy is respected. However, the absence of some detail in the care plans creates the opportunity for care needs to be missed. EVIDENCE: Residents have care plans which have been developed from their preadmission assessment information. The care plans focus on residents’ strengths and abilities while providing information on what they need help with. The plans include life history work which staff said they find useful in getting to know residents as individuals. Some residents have life story picture boards in their rooms. Residents and their relatives have been involved in developing these, providing photographs and memories of their Hartisca House DS0000001458.V339161.R01.S.doc Version 5.2 Page 12 lives. One staff member said it was good to have this information to be able to talk to residents about their families and friends. This is good person centred practice. A visiting relative said he was aware of his wife’s care plans and that he had signed them. The plans are reviewed regularly. This involves the resident their relative and their key workers. Staff were able to accurately describe the care they give as detailed in the care plans and it is clear that staff have a good knowledge of residents’ needs. Staff talked about the importance of understanding the way in which residents communicate their needs and wishes. Residents look well cared for. They are dressed appropriately and it appears that attention is paid to detail. Residents who wear glasses have very clean glasses, nails are well manicured and those who like to wear jewellery are supported with this. However, some care plans need to be developed further to make sure that care needs are not overlooked. For example, a care plan on bathing said the person needed “assistance”, a care plan on falls said the resident must be “checked regularly”. This is not detailed and specific enough for staff. All care plans should give clear and detailed information on how and when care should be delivered. Risk assessments have been carried out for identified risks to residents. These include moving and handling, nutrition, falls, pressure ulcers and wandering. Some of these also need more detail in the risk management plans. A resident who is at risk from pressure ulcers has pressure relieving equipment in place but no instruction for staff on its use. This could also lead to needs being missed or overlooked. Staff were seen to be patient and kind when interacting with residents. They chatted and told residents what they were doing when carrying out any task. Staff said they feel it is important to give residents their independence so that they feel good about themselves. They also said that motivating residents to maintain their independence helped to keep their skills and abilities going. Staff provided care and support in privacy and in a quiet and dignified manner. The home is currently in the process of working with residents’ GPs to set up a weekly surgery at the home for residents so that health needs can be carefully monitored. The manager has also completed an audit of residents who are nutritionally at risk and are losing weight. From this, appropriate referrals have been made to GPs or dieticians and some community nurses are to come into the home and give further training to staff. The manager feels that this is a priority area of work at the moment. Staff are prompt to act if they think there is a health problem for residents and referrals are made to health professionals as needs arise. The home uses a monitored dosage, pre-packed system for medication. All senior staff have been trained to use the system. A record is kept in the home of medication ordered. This is checked against medication delivered and Hartisca House DS0000001458.V339161.R01.S.doc Version 5.2 Page 13 recorded as correct before any medicines are dispensed. Photographs had been taken of all residents, which made sure they are clearly identified on the medication records. Good practice was seen during the visit in the administration of medication. Hartisca House DS0000001458.V339161.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 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported to make choices about their lifestyle, however this could be further developed to include more opportunities for residents to be involved in day to day issues in the home. Appropriate activities are arranged but staff have limited opportunities for social interaction with residents. A good, healthy and varied diet is offered, however some residents need more support with their meals to ensure a good level of nutrition. EVIDENCE: Observation and discussion with some residents made it clear that they are able to exercise choice and control over some aspects of their daily life. Residents said they could get up whenever they liked. One resident said, “They are nice when they get you up on a morning”. Another said, “They will give me whatever I want to eat, if I don’t like what’s on they will get me something else.” Staff were prompt in their response to requests from residents such as closing windows or getting a glass of juice. Hartisca House DS0000001458.V339161.R01.S.doc Version 5.2 Page 15 Relatives meetings are held, where relatives can air their views about the home. It would be good practice to include residents in meetings too. There is an activities co-ordinator who works 25 hours per week at the home. A programme of activity has been developed based on the interests of residents. Activities include, baking, group discussions, arts and crafts, knitting and sewing, bingo, making hanging baskets, sing-a-longs, beauty treatments and outings. The home has the use of a minibus one day a week and outings are organised in small groups. Care staff often volunteer their time to accompany residents on these outings. Residents said they had been out to local places of interest, shopping, cafes and pubs. The activity organiser keeps records of who has done activities and whether they enjoyed them. Records are also kept if residents refuse to get involved in an activity. On the day of the visit staff were seen to be actively encouraging residents to take part in activities. The activities co-ordinator gets to know residents likes and dislikes by talking to them and their families and by working with the care staff and looking at residents care plans. If residents do not enjoy an activity this is noted and it is made sure that it is not offered again to residents. Staff said that a resident had said they didn’t like going to pubs anymore so this request had been respected. The manager said that it can be arranged for staff to accompany residents to family occasions such as weddings and parties. This information is displayed on a notice board in the home. He also said that there is opportunity for residents to go out to local shops or just for a walk in the area or to sit out on the patio garden. Some money has recently been donated to the home and the manager is planning to use this to develop a room that will be used for residents to meet in private with their families or friends. The manager and staff realise the importance of residents maintaining good family contact. The room will also offer a space where a shop can be set up a few times a week, selling toiletries and confectionary. This will give residents some independence in buying their own items. Some residents are also involved in purposeful activity such as assisting with table setting, tidying and talking to residents who may be upset. One resident who had a background in the caring profession said she enjoyed doing this and helping people. A relative said that he wished his wife had more opportunities for conversation with staff and other residents. He said that this was “The only thing missing”. Staff said that they have time to sit and chat with residents in between busy times particularly in the afternoon and evenings. One said, “We can play board games and have a chat”. During the visit, most interaction with residents was when some aspect of care was being given. There was not much evidence of care staff having time to sit in the lounge with residents. Hartisca House DS0000001458.V339161.R01.S.doc Version 5.2 Page 16 Menus are varied and nutritionally balanced. There is food available 24 hours per day. Meals are served in the dining areas and trolleys of food and drink go round every few hours. This makes sure that residents are encouraged to maintain their weights. Finger food is available for those who find that easier to manage. This is good practice in dementia care. Low calorie snacks are also available for those who need them. The staff have recognised that some residents benefit from eating in a smaller group setting so a second sitting system has been introduced to meet their needs. Staff can give 1-1 support for residents at these times, and encourage and support them to eat more. This is good practice, especially in the upstairs dining room which is quite a small room for the whole group. Meal times are not rushed and are seen as a social occasion. A choice of two meals is available. The cook said that menus are arranged based on likes and dislikes of residents. This information is gained from residents and their relatives and staff. It would be good practice for the cook to meet with residents to discuss food choices and have this information recorded. Due to cultural differences, staff were not always clear in their communication when offering food choices to residents. Some had a tendency to shorten and abbreviate what they were offering which meant that residents did not understand what was being said. During the lunchtime meal it was clear that a resident needed the assistance of some aids or adaptations to help with eating. Staff had not recognised this and the resident’s care plan said that they ate independently. This was discussed with the manager and must be reassessed. Hartisca House DS0000001458.V339161.R01.S.doc Version 5.2 Page 17 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 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and their relatives have their views listened to, taken seriously and acted upon. There are good systems in place to protect residents from abuse. EVIDENCE: The home has a clear complaints procedure that is made available to relatives and residents. It is also referred to in the Statement of Purpose and Service User Guide. Complaints have been investigated thoroughly and handled properly by the home. Detailed responses to complaints were seen, showing that the home takes them very seriously. A relative and friends of a resident who visited the home said they knew how to make a complaint. One resident, when asked about making complaints, said, “I would tell someone if I wasn’t pleased”. Another said, “I don’t have any complaints but would complain if I had to”. Staff, including cleaning and catering staff, are familiar with adult protection procedures and have received training on abuse and the protection of vulnerable adults. Staff spoken to are aware of the different types of abuse Hartisca House DS0000001458.V339161.R01.S.doc Version 5.2 Page 18 and how to report any concerns. All staff are very clear on their responsibilities to report any suspicions or allegations of abuse. Good records are kept of residents’ property and belongings. Residents can have a key and lock their bedrooms if they wish. Hartisca House DS0000001458.V339161.R01.S.doc Version 5.2 Page 19 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 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home offers an attractive, homely environment which encourages independence for residents. However, outdoor space for wandering and leisure is limited to a small patio area. Some staffs practice increases the risk of the spread of infection. EVIDENCE: Most of the communal areas have been redecorated since the last inspection. There has also been some refurbishment with new flooring, curtains and furniture in the dining rooms and lounges. Hartisca House DS0000001458.V339161.R01.S.doc Version 5.2 Page 20 The environment of the home has been designed in part, to enhance and compensate for the abilities of people with dementia. Corridors have been given familiar street names to help with orientation. Bedroom doors are painted in different colours and given letterboxes, doorknockers and pictures to make the more familiar to residents. Carpets are plain and lighting is good to assist with residents’ mobility and orientation. Signage is used to good effect, using words and pictures to identify rooms and areas. The upstairs lounge is arranged in small seating areas giving residents a choice of what to do, for example, sit with others, watch television or sit and read. Residents are encourged to personalise their rooms and to bring familiar pieces of furniture in with them. One of the bedrooms is shared, all others are single. Some rooms have an en-suite toilet and sink. The toilet bowls are very stained and must be replaced. The manager is aware of this and is currently working with the maintainence officer to plan work that needs doing. A resident said she liked her room saying, “It’s a lovely room, I can do my handwashing in here too”. There is a small patio garden area at the home. Residents can use this in the good weather. It has been attractively decorated with planting and hanging baskets. Residents have been involved in making these and have entered a gardening competition run by the organisation. There is good quality garden furniture and protective garden umbrellas to provide shade from the sun. the home has a no smoking policy but has provided a canopied area outside the home for smokers. The laundry, although small, is well organised and all residents have a personalised basket for their laundry. There are good systems in place for hand washing in all areas of the home where clinical waste or bodily fluids are handled, and good measures to prevent the spread of infection. However, staff were seen to be handling laundry without wearing protective clothing or disposable gloves. This increases the risk of infection. The manager said that staff training on infection control was needed and he was in the process of arranging this with another home manager. On entering the home and in some parts of it there is a slight malodour. The manager has recently arranged and is waiting for carpet cleaning using an industrial carpet cleaner to try and eradicate these odours. Air fresheners were being used in the meantime to try and reduce the odour. Hartisca House DS0000001458.V339161.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 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are protected by the home’s recruitment procedures and staff are, in the main, trained and skilled to meet the needs of residents. EVIDENCE: There are staff on duty throughout the day and night. Staffing is arranged over the two floors of the home. During the day shifts there are usually two staff on each floor and the manager of the home in overall charge. One day per week there is another care staff for a half day. In addition to this there is an administrator, domestic, laundry and cook on duty. At night there are two staff for the home, one of which is always a senior staff member. An on-call manager supports the night staff. All staff spoken to said they felt there was enough staff to meet the needs of residents properly and they didn’t feel rushed. A relative commented on how hard staff work and, as previously mentioned in the lifestyle section of this report, that they don’t seem to have much time for sitting down to have a conversation with residents. Other than staff volunteering to go out on trips in the community, there did not seem to be much opportunity for staff to do this within the current staffing numbers. It Hartisca House DS0000001458.V339161.R01.S.doc Version 5.2 Page 22 is recommended that the organisation and manager review staffing arrangements to make sure residents’ social needs are being properly met. Recruitment is properly managed by the home; interviews are held, references and CRB (Criminal Record Bureau) checks are obtained before staff start work and checks are made to make sure staff are eligible for work. References are verified through telephone calls to the people providing them. This is good practice. Staff’s training is mostly up to date. Records are kept of staff’s training and when their updates are due. A new computer system is currently in use which shows all of this information. As previously mentioned training in infection control is needed for all staff. Training specific to the needs of people with dementia is provided to all staff, including administrative, domestic, catering, laundry and maintenance staff. This is good practice. The deputy manager is trained in the delivery of a modular training course accredited by The Alzeimers Society. Over half of the staff team have undertaken this training and there is a rolling programme to make sure that the other half complete it. Staff said it had made them realise the importance of providing person centred, individualised care, specific to the needs of people with dementia. One staff said, “It has made me look deeper at communication with people, I always make sure that residents have their teeth in properly or their hearing aids switched on so as to make the most of their senses” . Another said, “Its about concentrating on what people can do rather than what they can’t do”. Staff who have not yet taken this course receive an introduction and awareness course in the needs of people with dementia as part of their induction. Almost half of the care staff have also completed their NVQ level 2 in care. Another six staff are also working towards this. Hartisca House DS0000001458.V339161.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 and 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and has a competent management team. This means that the interests of the residents are seen as important to the manager and staff and are safeguarded at all times. EVIDENCE: The manager of the home had been in post two weeks at the time of the visit. He is an experienced manager of residential services for elderly people. He has a social care and management qualification and will also be undertaking the Registered Managers award in the near future. He is also about to start Hartisca House DS0000001458.V339161.R01.S.doc Version 5.2 Page 24 the dementia training course which is accredited by the Alzheimer’s Society. The deputy manager is also undertaking the Registered Managers Award. This is good practice and will make sure he can deputise well for the manager. Staff said they feel the management team are approachable and offer them good advice and support. A relative spoken to said they were happy with the managers of the home. It was clear that the new manager is currently developing his relationship and rapport with residents as he gets to know them. The deputy manager showed warmth and enthusiasm in all his interactions with residents and relatives. Quality assurance systems are in place with satisfaction surveys being sent out to relatives on an annual basis. These are then reviewed by the area manager and any issues followed up on. Comments received included, “The care and attention have made the last two years happy and comfortable” and “Thank you for the kindness and new man you have made of ……….” There are arrangements in place for the monthly provider visits, as required, and reports of these visits are forwarded to the CSCI (Commission for Social Care Inspection). The operations manager was in the home carrying out this on the day of the inspection visit. The maintenance officer carries out monthly health and safety checks in the home, including fire safety. Maintenance records are well kept. The five yearly electrical wiring safety test has now been carried out. Accident or incident reports are completed. There is a section for follow up action to be taken after any accident or incident. The manager has a system in place where he can analyse accidents to see if there are patterns, trends or ways of avoiding future accidents. The home has a comprehensive range of policies and procedures in place to ensure health and safety. The manager makes sure staff are familiar with these and asks them to sign them when read. There are clear records of all residents’ money and the home is subject to external audit with a system of frequent in-house random checks carried out. Any money held is in individual wallets with a limited number of staff having access to it. Hartisca House DS0000001458.V339161.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 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 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 3 X 3 Hartisca House DS0000001458.V339161.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 4 Requirement The manager must make sure the Statement of Purpose states in detail how the specialist needs of people with dementia will be met, so that people who may use the service have information they need in order to make a choice about the home. The manager must make sure that care plans give staff clear and precise instructions about the level of care to be given. This will make sure care needs are not overlooked. The manager must make sure that residents are provided with aids and adaptations needed to enable them to eat an adequate diet. The manager must make sure that the toilet bowls in the ensuite bedrooms are replaced as they are badly stained. The manager must make sure that all staff receive training in infection control in order that staff maintain good practice in preventing the spread of infection. DS0000001458.V339161.R01.S.doc Timescale for action 30/07/07 2 OP7 15 30/07/07 3 OP15 16 30/06/07 4 OP19 23 30/08/07 5 OP30 19 30/07/07 Hartisca House Version 5.2 Page 27 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 OP27 Good Practice Recommendations The organisation and manager should give some consideration to reviewing staffing arrangements to make sure residents’ social needs are being properly met. Hartisca House DS0000001458.V339161.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Hartisca House DS0000001458.V339161.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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