Inspection on 16/07/07 for Hayes Cottage

This inspection was carried out on 16th July 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

Hayes Cottage 04/09/06

Hayes Cottage 09/01/06

Hayes Cottage 22/08/05

Hayes Cottage 24/02/05

Hayes Cottage 02/08/04

Hayes Cottage 15/01/04

Hayes Cottage 05/08/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hayes Cottage Grange Road Hayes Middlesex UB3 2RR Lead Inspector Mrs Clare Henderson Roe Unannounced Inspection 11:45 16 & 17th July 2007 th 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 Hayes Cottage DS0000010933.V340100.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. Hayes Cottage DS0000010933.V340100.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hayes Cottage Address Grange Road Hayes Middlesex UB3 2RR 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) 020 8573 2052 020 8573 5593 hacott@aol.com HAYES COTTAGE NURSING HOME Limited Matthew Dean Nutt Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Hayes Cottage DS0000010933.V340100.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following category of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP 2. The maximum number of the service users who can be accommodated is: 52 4th September 2006 Date of last inspection Brief Description of the Service: Hayes Cottage Nursing Home was previously the Hayes Cottage Hospital. The building has been developed and extended to its present condition. The home provides accommodation for 51 service users. One unit is designated to the provision of palliative care. There are 49 single rooms and 1 double room. There are several sitting areas to include a conservatory, plus a main dining room. The garden is well maintained and has chairs, tables and parasols for the use of service users and their visitors. The home is situated in a residential area of Hayes. It is well maintained and has a good atmosphere. The Beck Theatre is within walking distance from the home. There are shops and local amenities plus Hillingdon Hospital close to the home. The home has a social activities policy, which lists many ideas for social activities throughout the year and also ideas for activities on a day-to-day basis. 49 service users were accommodated at the home at the time of inspection. The home fees range from £530 to £725 per week. Hayes Cottage DS0000010933.V340100.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 18 hours was spent on the inspection process. The Inspectors carried out a tour of the home, and service user plans, medication records, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 12 residents, 12 staff and 4 visitors were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home, plus comment cards received from service users, healthcare professionals, care managers and representatives/visitors have also been used to inform this report. What the service does well: Comments received from residents, relatives and healthcare professionals include: ‘Provides a caring home in a friendly atmosphere where a smile and a friendly word mean so much.’ ‘Hayes Cottage is a very caring establishment which should be proud of their staff in all areas. Nothing is too much trouble for staff and they welcome proactive relatives. Suggestions are listened to and management are always approachable.’ ‘next best thing to home’. ‘it feels just like being part of an extended family.’ Prospective residents are fully assessed prior to admission to ascertain that the home can meet their needs. Prospective residents and their families are encouraged to visit the home prior to admission and are provided with clear information about the home, to enable them to make an informed decision regarding living at the home. Staff care for the residents in a gentle, caring and professional manner, respecting their privacy and dignity. Bedrooms are very personalised and there is a very homely atmosphere throughout. The home provides an excellent standard of ‘end of life’ care and is to be commended in this. Activity provision is good at the home, taking into account individual interests and wishes. Information regarding advocacy services is available. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made very welcome at the home and offered refreshments. They also commented that staff are very supportive to them. The food provision at the home is good, offering variety and choice. Clear procedures are in place for complaints and safeguarding adults, and Hayes Cottage DS0000010933.V340100.R01.S.doc Version 5.2 Page 6 these are followed, thus ensuring any complaints or POVA concerns are correctly managed. The home is being well maintained with evidence of ongoing plans for redecoration and refurbishment. There are infection control procedures and practices in place and these are followed. The staffing is kept under review to ensure the needs of the residents can be met at all times. Staff receive training to keep them up to date in topics relevant to the needs of the residents and also areas of health & safety. Systems are in place for the recruitment and vetting of staff and these are robust. The Registered Manager is open and approachable and manages the home effectively. He has clear leadership skills and encourages the staff to contribute to discussions about the running of the home. Systems have been put in place for quality assurance and the Registered Manager is very proactive in this area. Residents personal monies held on their behalf by the home are being well managed. There are good procedures and practices in place for the management of health & safety in the home. 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. Hayes Cottage DS0000010933.V340100.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 Hayes Cottage DS0000010933.V340100.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 & 5. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each persons needs. Prospective residents and their families can visit the home prior to admission and are provided with information about the services the home provides, thus enabling them to make an informed decision about moving to the home. EVIDENCE: The home has a comprehensive pre-admission assessment document that provides a good picture of the resident and their needs. On the palliative care unit a thorough assessment is obtained from the palliative care team and if there are any specific issues that additional information is required for, the Registered Manager will also carry out a pre-admission assessment. This is only done where there are additional circumstances, to minimise the distress Hayes Cottage DS0000010933.V340100.R01.S.doc Version 5.2 Page 9 to the resident. The home also obtains a copy of the needs led assessment undertaken by social services. The home encourages prospective residents and their relatives to visit the home prior to coming to live there in order to view the home and ask any questions they may have. Relatives spoken with confirmed that they visited the home and that they were shown the bedroom and provided with information about the services provided by the home. Hayes Cottage DS0000010933.V340100.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 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the service user plans were being completed to provide staff with the information to meet each resident’s needs. Further training has been planned to improve individualising of these plans, to better meet each persons needs. There is evidence of input from healthcare professional, and shortfalls in the recording of some healthcare information should be easily addressed, to ensure a clear picture of healthcare needs is available. Although medication is being managed, shortfalls identified could place residents at risk. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. The home provides excellent end of life care, thus ensuring that residents and their families have their wishes and needs fully discussed, recorded and met. EVIDENCE: New service user plans have been introduced into the home since the last inspection. These are pre-written. Overall service user plans were being completed and there was evidence of monthly reviews and of input from residents and their representatives. The Registered Manager stated that the Hayes Cottage DS0000010933.V340100.R01.S.doc Version 5.2 Page 11 staff are adapting to the new care plan system and that further training has been booked for care planning completion. The dates for this training were given to the Inspectors. The need to ensure that service user plans are individualised was discussed and the Registered Manager said that this would be incorporated in the training. Risk assessments for falls had been completed and are reviewed monthly. At the time of inspection there were no pressure sores. Following the last inspection new wound record documentation has been introduced to provide a clear picture of each wound and record the treatment and progress. Pressure sore risk assessments are completed for each resident and reviewed monthly. Nutritional assessments are carried out and nutritional care plans formulated. For one resident with Entral feeding in place the care plan was very brief and did not contain all details regarding the management and administration of the feed. The start time of the feed had been recorded on the fluid balance chart, however no information regarding the batch number was recorded anywhere. The need to ensure all required information is recorded in detail was discussed with the Registered Manager and following the inspection a care plan for Entral Feeding has been formulated. Continence assessments are carried out and care plans for continence care needs were also in place. Moving & handling assessments had been carried out and the specific equipment to be used for any moving & handling manoeuvres had been clearly identified. The home has a range of pressure relieving equipment in use, appropriate to meet the needs of each individual. Written consents for the use of bedrails were in place, however the assessments to identify the suitability of their use were not available. A new policy and assessment document has been put in place following the inspection. The importance of carrying out such assessments prior to the use of bedrails was discussed. There was evidence of input from the physiotherapist, chiropodist, GP, Macmillan nursing team and other healthcare professionals. The palliative care Consultant runs an outpatient clinic at the home and carries out weekly visits to assess residents on this unit. The Registered Manager said that the palliative care team provide very good ongoing support to the home and the residents in their care. One Inspector viewed the medication management and records. The medications policy had been updated and further updates were discussed for clarity when reporting any errors. The home uses a monitored dosage system (MDS), plus some medications are supplied in boxes, all of which had been dated when opened. Medications are stored securely in the home. Receipts and disposals are all clearly recorded and the correct method of disposal is in use. There were some discrepancies in the dating of some of the medication administration record (MAR) charts and this was discussed with the Registered Manager and corrected at the time of inspection. The dispensing pharmacist has now provided blank MAR charts for use when hand writing prescription entries. The Inspector recommended that two registered nurses check and sign all hand written entries on the MAR and the Registered Manager implemented this immediately. One prescription cream had not been signed for on the MAR Hayes Cottage DS0000010933.V340100.R01.S.doc Version 5.2 Page 12 chart and it was not possible to ascertain if this was in current use. The frequency of use for two medications had not been recorded, and for another medication with very specific administration instructions, these were not recorded. For one boxed medication there was a discrepancy between the number of tablets available and the number signed for as administered. The Inspector asked that this be investigated and the Registered Manager said this would be addressed. The Inspector carried out some further stock checks and these tallied with the administration record. Fridge temperatures were within safe range and the Registered Manager explained that any increases in temperature were due to regular defrosting of the fridges. The Inspector recommended that when the fridges are defrosted this be recorded in the temperature book, to explain the increase in the maximum temperature recording for that day. The room temperatures were usually below 25° centigrade and the Registered Manager said that he would keep this under review during any hot weather. Controlled drugs records were viewed and correct procedures are followed for the recording of receipts and administration. It was noted that some of the liquid controlled drugs had not been dated when opened and the Registered Manager said that this would be addressed. All other liquid medications viewed had been dated when opened. Two letter codes being used to indicate omissions or refusals of medications were out of date and staff need to use the current codes to clearly identify any omissions or refusals, and also record the reason for omission. Staff were seen caring for residents in a gentle, caring and professional manner. Residents spoken with were very happy with the care they are receiving at the home and positive comments were also received from visitors and healthcare professionals. Bedrooms viewed were very personalised and looked very homely. Residents’ personal clothing is labelled and residents were well groomed and dressed, reflecting individuality. Residents can have their own telephone if they so wish, and mail is delivered unopened. Staff speak with residents using their preferred term of address. The home has a palliative care unit. The service user plan documentation viewed was very thorough and the home has implemented the Liverpool Care Pathway, and this documentation is completed for residents entering the end stage of their life. Information regarding all the care needs of the individual is recorded and updated every 4 hours and provides a clear picture of individual needs and how these are being met. The home has ongoing input from and access to the specialist palliative care team and it was clear that there is excellent teamwork to provide a high standard of care for residents. An ‘advanced care plan’ is completed detailing the wishes of the resident and their families with regard to their end of life care and this can be reviewed at any time. The home is just completing the refurbishment of a room to be used as a visitors room, which will provide accommodation for relatives of residents in their final days of life. Pain charts are completed and those viewed showed a clear record, to include action taken to relieve the pain and control it. Clear medication regimes are in place for each resident, to include ‘anticipatory’ Hayes Cottage DS0000010933.V340100.R01.S.doc Version 5.2 Page 13 medications, thus pre-planning for the event of a resident experiencing pain, which can then be managed promptly and effectively. Staff had received training in palliative care. The staff are very sensitive and respectful to the residents and their families and there was a caring, calm atmosphere on the unit. Comments received from the palliative care nurses and the palliative care consultant were very positive. Information leaflets specific to palliative care were available on the unit for residents and visitors. The home is to be commended for their high standard of palliative care provision. Hayes Cottage DS0000010933.V340100.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. The activities provision is good and information regarding individuals’ hobbies and interests is obtained, thus enabling the activities co-ordinator to plan a programme to reflect these wherever possible. The home has an open visiting policy, thus encouraging people to maintain contact with family and friends. Information regarding advocacy services was available, thus peoples right to individual representation is respected. The food provision in the home is good, offering variety and choice, thus meeting peoples’ individual needs. EVIDENCE: The home has recruited an activities co-ordinator who is due to start on 30/07/07. The previous activities co-ordinator still works at the home and has taken on a new role as support worker, which entails providing input and support as needed on each of the units. The home has an activities programme and has continued to arrange outings and offer a good range of activities. The annual Fete was being planned for 21/07/07 and residents were seen assisting in the preparations for this. This was a very social activity and it was clear they were enjoying themselves. On the second day of the inspection 6 residents were being taken to see a show at the Beck Theatre. A trip to Brighton had been planned for August. Comments received from residents and relatives said Hayes Cottage DS0000010933.V340100.R01.S.doc Version 5.2 Page 15 that the activities provision is good and residents are given the choice as to what they wish to join in and their choices are respected. The home has an open visiting policy and visiting is encouraged. Residents can receive visitors in their own bedroom or in one of the communal areas, as they so wish. The visitors spoken with said that they are always made very welcome at the home and are offered refreshments. Representatives are kept up to date with any issues. The Registered Manager said that if people wish to visit very early or late in the day, then this is fine and a telephone call to let the home know assists with security. The home has access to the local Age Concern Advocacy service. An advocate used to visit the home weekly, however due to funding cuts by Hillingdon the service is only provided if a specific issue occurs requiring input from an advocate. One Inspector viewed the kitchen, which was clean and tidy. Records were up to date and risk assessments for equipment were in place. There is a 4 week ‘summer’ menu and choices are offered. Residents spoken with said that the food provision is good and varied. On the second day of inspection the Inspectors sampled the meat and vegetarian options and the meals were well presented and tasty. Food and drinks are available throughout the 24 hour period and the Inspectors witnessed snacks being provided for residents to meet their preferences. The dietary needs of each resident are clearly recorded, and for anyone with swallowing difficulties clear feeding guidelines were available, with a qualified member of staff assisting with feeding as necessary. The dining room is well laid out and attention to detail is paid to provide an attractive environment at mealtimes. Condiments are available on the tables. For any residents with cultural or religious dietary requirements these are discussed and respected. Hayes Cottage DS0000010933.V340100.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): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place for the management of complaints and adult protection issues, and these are followed, thus safeguarding the residents. EVIDENCE: The home had received 3 complaints since the last inspection. These had been well managed and clear records maintained to show they had been investigated and responded to. The complaints procedure is on display in the home. The home has a POVA policy and also follows the Hillingdon Safeguarding Adults procedures. Staff spoken with were very clear to report any concerns and understood the ‘Whistle Blowing’ procedures. There has been one POVA concern which was ongoing since the last inspection, and this has been managed by the Hillingdon Safeguarding Adults Team. Hayes Cottage DS0000010933.V340100.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the home is being well maintained, thus providing a clean, homely and safe environment for residents to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: One Inspector carried out a tour of the home. Overall the home was being well maintained and there was evidence of ongoing redecoration and refurbishment. The Responsible Individual has a programme in place for redecoration and refurbishment with timescales for completion. This includes renewal of the carpets in the corridors, and it was noted that these are very worn in places. There is a well-maintained garden with furniture for residents and visitors to sit out in. Some issues had been identified with the call-bell system and the Registered Person said that this is due to be replaced. Any faults are addressed promptly. Hayes Cottage DS0000010933.V340100.R01.S.doc Version 5.2 Page 18 There are also plans for a wet room to replace one of the bathrooms that is currently not used. It was noted that the toilets for general use do not have locks. The Registered Manager confirmed that all residents require assistance to and from these facilities and staff would ensure their privacy is maintained. Locks are to be installed on these facilities and the Responsible Individual confirmed that this would be actioned promptly. The home was clean and tidy and smelled fresh throughout. The laundry room is situated on the ground floor and there are strict procedures in place for infection control. An external laundry company launders all bed linen and towels and the home launders personal laundry plus items such as tablecloths, napkins and protective covers. The laundry person also manages areas of health & safety in the home, to include some of the training. She has undertaken training in several areas of health & safety and also carries out the risk assessments for all the rooms in the home, and there was evidence these had been reviewed in April 2007. Hayes Cottage DS0000010933.V340100.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 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are kept under ongoing review, thus ensuring appropriate numbers of staff are on duty to meet the needs of the residents. Training provision is good, thus providing staff with the skills and knowledge to care effectively for the residents. Systems are in place for the vetting and recruitment of staff, thus safeguarding residents. EVIDENCE: At the time of inspection the home was being appropriately staffed to meet the needs of the residents. The Registered Manager has recently implemented a dependency monitoring tool to ensure that staffing meets the dependency levels of the individual residents in each unit. The geographical layout of the home was discussed in relation to staffing, as this is an additional consideration in a home of this size and layout. Since the last inspection the role of a ‘support worker’ has been created. This person can assist on whichever unit requires her input to support the residents and staff. Several comments regarding staffing were made on the resident and visitors comment cards, and this has been discussed with the Registered Manager. He said that he has recruited 4 more care staff and is very aware of ensuring all units are staffed fully at all times, so that resident care is not compromised. The home was clean and tidy and domestic, catering, maintenance and ancillary staff are employed in such numbers to meet the needs of the home. Hayes Cottage DS0000010933.V340100.R01.S.doc Version 5.2 Page 20 The Registered Manager said that 78 of care staff have attained NVQ level 2 in care, and of these 26 have also attained NVQ level 3 in care. 3 more care staff are undertaking level 2. This has enabled the home to have staff with a range of skills and abilities to meet the needs of the residents. Residents and visitors confirmed that staff provide a good standard of care and this was evident during the inspection. One Inspector viewed staff employment records and these included all the information required under Care Home Regulations 2001. The home has in place a staff induction programme that meets the Skills for Care common induction standards. As part of the implementation of a new supervision programme for all staff training and development needs are being identified with a view to planning more training in future. The home has a training matrix for 2006 identifying the training undertaken by each member of staff and the Registered Manager said that this would be updated for 2007. There was evidence that training had been carried out during 2007. Staff confirmed that they had received training appropriate to the work they perform. Hayes Cottage DS0000010933.V340100.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. 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. The Registered Manager has the experience to manage the home and is completing the relevant management qualification, and is open and approachable and manages the home effectively. Good systems for quality assurance are in place, thus providing an ongoing process of management and practice review. Monies held on behalf of residents are being well managed and securely stored, thus safeguarding them. New systems are in place for staff supervision thus providing a forum for individual and group discussion and reflection on practice. Systems for the management of health and safety throughout the home are good, thus safeguarding residents, staff and visitors. EVIDENCE: The Registered Manager is a first level nurse with qualifications that include palliative care, teaching & assessing and supervisory management. He is Hayes Cottage DS0000010933.V340100.R01.S.doc Version 5.2 Page 22 completing the Registered Managers Award NVQ 4. The Registered Manager has the relevant experience to manage the home and is doing so effectively. Staff, residents and visitors spoken with said that the Registered Manager is approachable and has an open door policy to discuss any issues. He has clear leadership skills and communicates well with the staff team, encouraging them to contribute ideas to the overall running of the home. The Registered Manager has a file with all residents listed, in which he records any communication he has with the resident or with others regarding their care, so that he maintains up to date information. He also has a file for communication with members of staff. Positive comments were received regarding the management of the home, to include ‘the new manager is very respectful and is a good example to staff’. The Registered Manager has developed a new Quality Assurance policy that will include a monthly inspection and audit of the home in addition to the audits for topics such as medications and care planning. Regular staff meetings and relative meetings take place with minutes kept. Positive comments were received on the relatives comment cards regarding the good communication between the home and relatives and the fact relatives are given the opportunity to have their say. A joint meeting for residents and relatives was incorporated with a luncheon. Residents can meet individually with the Registered Manager if they so wish. Satisfaction surveys are carried out as part of the ongoing quality assurance, and one Inspector recommended that a full survey for residents and relatives be carried out annually and the results collated. The Responsible Individual has been carrying out the monthly Regulation 26 inspections and copies of the reports from these visits were available to view. It was clear from discussion with the Responsible Individual and Registered Manager, plus from the information provided in the AQAA that the management of the home are proactive and planning ongoing improvements for the future of the home. The home holds personal monies on behalf of several of the residents. 4 records and money amounts were viewed and the records of income and expenditure were accurate and up to date. Receipts are kept for expenditure. The home has policies and procedures available for the management of monies. The Registered Manager has set up a process for staff to receive formal supervision and also an external supervisor attends the home regularly to facilitate group supervision with staff, providing a forum for discussion and review of practice. Servicing and maintenance records were sampled and those viewed were up to date. Fire drills take place at the required intervals and the need to ensure that drills are frequent enough to encompass all staff was again discussed. Risk assessments are in place for equipment and safe working practices. The Responsible Individual and Registered Manager were in the process of Hayes Cottage DS0000010933.V340100.R01.S.doc Version 5.2 Page 23 formulating a new fire risk assessment in line with the current fire safety legislation, which has been completed following the inspection. Staff had received health & safety training to include fire safety, moving & handling, food hygiene, first aid and infection control, plus other topics relevant to their work. The Registered Manager said that he is setting up an in-house Risk Management Group to review such items as policies and incidents in line with health & safety, so that there is ongoing review in this area. Regulation 37 notifications are made to CSCI in line with the Regulation requirements and associated guidance. Hayes Cottage DS0000010933.V340100.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 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X X X 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 3 X 3 X 3 3 X 3 Hayes Cottage DS0000010933.V340100.R01.S.doc Version 5.2 Page 25 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 OP8 Regulation 17(1)(a) Requirement Entral feeding regimes must be clearly recorded in the service user plan and full administration records maintained in order to clearly show the nutrition being received by the resident. Risk assessments for the use of bedrails must be completed prior to their use to identify the appropriateness of their use for each individual. The dating on the MAR charts must be accurate and correspond with the administration signatures. Full administration instructions must be available for all medications. Prescription creams must be signed for when administered. If they are no longer in use this must be clearly recorded. All liquid medications must be dated when opened. Codes used for any omissions, refusals or any other reasons for non-administration of medications must tally with the codes provided on the MAR DS0000010933.V340100.R01.S.doc Timescale for action 20/07/07 2. OP8 13 01/08/07 3. OP9 13(2) 17/07/07 4. 5. OP9 OP9 13(2) 13(2) 01/08/07 17/07/07 6. 7. OP9 OP9 13(2) 13(2) 20/07/07 17/07/07 Hayes Cottage Version 5.2 Page 26 chart. 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 Good Practice Recommendations Hayes Cottage DS0000010933.V340100.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Hayes Cottage DS0000010933.V340100.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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