Inspection on 05/10/06 for Hayleigh

This inspection was carried out on 5th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hayleigh 13/03/08

Hayleigh 25/11/05

Hayleigh 31/05/05

Hayleigh 30/11/04

Hayleigh 26/06/04

Hayleigh 27/01/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Hayleigh Myrtle Street Bedminster Bristol BS3 1JG Lead Inspector Sandra Garrett Key Unannounced Inspection 5th – 6th October 2006 09:30 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 Hayleigh DS0000036207.V314328.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. Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hayleigh Address Myrtle Street Bedminster Bristol BS3 1JG 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) 0117 9039983 0117 9039984 Bristol City Council Barbara Ann Cairns Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate one named person aged 64 years with Physical Disabilities. Registration will revert to OP when named person leaves. May accommodate one named person with Learning Difficulties. A specific condition is added to the Certificate of Registration for the Home in respect of this named person being accommodated there. The registration will be permanent, to lapse only when the named resident leaves the Home. Hayleigh care staff must undertake training in the care of older people with Learning Difficulties. This must be a rolling programme of regular training, to include any new care staff taken on after the service user is admitted. 25th November 2005 3. Date of last inspection Brief Description of the Service: Hayleigh is a purpose built care home registered with the Commission. It is operated by Bristol City Council Social Services & Health (SS&H). The home is capable of housing forty residents and is registered in the older persons category. A variation of its registration is in place in order to provide accommodation for one older person with learning difficulties. This resident now occupies the area that used to be the staff flat. Hayleigh is situated close to the busy shopping area of Bedminster. It is close to local bus routes and community facilities. The home is fully accessible with a lift to the first floor. The home has extensive mature gardens with trees and a patio. Fees for the service are £451.99 per week (full fee). It wasn’t clear how residents or their relatives are able to access inspection reports as no copies of the most recent one were seen around the home at this visit. Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one and a half days. A number of residents were spoken with and fifteen were assisted to complete surveys relating to the care they receive. Three residents’ care files were examined in detail and the quality of their care tracked. The manager was on duty for the first day of inspection and gave the inspector full access to care records, health and safety and staffing records among others, for examination. A tour of the premises was carried out and individual rooms seen. Prior to the visit the inspector examined documents requested and gathered since the previous visit in November 2005. These included: the pre-inspection questionnaire, notified incidences in the home, (under Regulation 37) and team manager visit reports conducted on behalf of the Registered Provider (under Regulation 26). What the service does well: Hayleigh gives residents choice, responds to their views and requests and enables them to have autonomy over their lives wherever possible. Satisfactory admission arrangements ensure residents’ needs can be met or action is taken quickly to find a more suitable placement. Residents are looked after well in respect of their health and personal care and are treated with dignity and respect. The home continues to provide residents with the opportunity to experience a stimulating and varied life where various formal and informal activities are regularly made available. Meals at the home are well managed and provide daily variation, good nutrition and social contact for people. Satisfactory complaints management and recording ensures residents can feel confident in raising concerns about any aspect of their care. Residents and staff benefit from having a qualified and experienced manager registered with the Commission, in control of the home. Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 6 Appropriate and robust health and safety procedures ensure residents are kept safe from harm. What has improved since the last inspection? What they could do better: Three new requirements and two good practice recommendations were made: An immediate requirement was made in respect of medication following observation of poor administration practice. Residents may not be kept safe from harm if correct procedures are not followed and kept up. End of life plans that show what residents’ wishes are in respect of their death and funerals were not in place. Information seen was brief and very basic. Residents’ wishes may not be respected when they come to the end of their lives if these are not discussed with them and recorded. The environment in some areas looked tired and faded at this visit. A number of bedrooms were found to be in need of re-decoration or re-carpeting. The overall effect of some rooms was dingy and unpleasant odours in the carpeting pervaded some of the main parts of the home. Residents do not live in a fresh smelling and pleasant environment that meets their needs and lifts their spirits. Two new good practice recommendations were made: A method of recording safeguarding adults training and a plan for a rolling programme of this training for all staff should be put in place. Residents may not be confident they will be kept safe from harm or abuse. Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 7 Whilst it was noted that half of the staff had recent photographs in their files the other half had not. Whilst it’s appreciated that photos had been taken, these should be developed and put on file to ensure residents are kept safe from risk of harm. 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. Hayleigh DS0000036207.V314328.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 Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Information about the home and rights and responsibilities is made available for all residents and their families. Satisfactory admission arrangements ensure residents’ needs can be met or action is taken quickly to find a more suitable placement. EVIDENCE: Copies of the home’s Statement of Purpose were seen in individual residents’ care file folders that are kept in their bedrooms together with the Service users guide. Some residents said that they had read the information. Individual contracts for care provided were also seen in the folders and were signed by the resident or their relative. Contracts contained room numbers and details of the fee payable. Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 10 Pre-admission social work and health needs assessments were seen in those individual files examined. The assessments contained personal information about the resident concerned and their needs. From these it was noted that care plans had been developed and information transferred from the assessments so that residents’ needs could be met. Care plans matched the assessment information and residents confirmed the needs that had been identified were being met. Personal history information was also seen that was transferred on to a personal profile at the front of each file. The home keeps and emergency respite bed but doesn’t provide intermediate care. Therefore this standard isn’t applicable. Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8,9, 10 & 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are looked after well in respect of their health and personal care needs. Poor medication administration practices must be immediately improved in order to protect residents. Residents are treated with dignity and respect and their privacy is respected wherever possible. End of life matters and plans must be put in place to show that residents’ wishes and needs can be met and choices respected. EVIDENCE: It was pleasing to note that a requirement made at the last visit in respect of care plan reviews, changes and ensuring care plans are put in place, was met. Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 12 Three care plans were examined in detail and a number of others reviewed. From this it was pleasing to note that a new system of recording monthly reviews had been put in place. A sheet had been added to the front of each plan that contained the date of each review, whether changes were made, the dates for the twice-yearly full review, plus any other relevant comments. This is good practice. Further, care plan changes were seen hand written on the care plans together with a copy of the six monthly review sheet signed by the reviewer, the resident where possible and their relative. Residents and relatives’ comments were also noted. Each resident has a copy of their care plan that they keep in their room and master copies are kept in the office. Residents were able to speak about their plans and whether their care needs were being met. Clear healthcare needs were documented on care plans and in daily records and showed regular visits from GP, district nurses and other healthcare professionals where necessary. It was noted that prompt action was taken if a resident was unwell. An incident was observed during inspection when a resident collapsed. It was noted that the assistant manager on duty took charge of the situation; comforted the resident concerned, called the emergency services and dealt with other residents’ needs in a calm and professional manner. This is commended. However it was disappointing to note that medication administration was poor at this visit. Issues included: medication being signed for before giving to the resident instead of immediately afterwards (despite this being contrary to the local authority’s own medication policy seen at the front of the Medication Administration Sheets), medication dropped on the floor not being discarded immediately; and poor recording and witnessing of controlled medication, leading to a continuing error with numbers of tablets. Further it was noted that oversupply of some individual medication had occurred and it was advised to return large amounts of medication to the pharmacy where necessary. The manager accepted that medication administration needs improvement. It was pleasing to note that an action plan to remedy the issues was received from the registered provider within a week of the visit. However the requirement will be reviewed again at the next inspection. Staff were observed speaking to residents in a respectful manner and not entering bedrooms unless invited. Assistance with toileting was given discreetly. Staff and residents showed that they have good relationships with each other. One resident spoken with said that s/he thinks ‘the staff are excellent’ and that her/his healthcare needs are met promptly. It was noted from the pre-inspection information sent to the inspector that a resident had been diagnosed with a potential terminal illness. This resident’s records were examined and it had been found that there had been a spontaneous and full remission. Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 13 However in this and other residents’ records there was little or no information about plans and wishes around their eventual death and dying. The manager said that information is gained about funeral arrangements and whilst evidence of this was seen in some records, the information itself was brief and not holistic. Apart from whether burial or cremation and the name of funeral directors to be appointed, no wishes in respect of the end of life and arrangements following, were seen. Hayleigh DS0000036207.V314328.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 at least once during a 12 month period. 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 the service. The home continues to provide residents with the opportunity to experience a stimulating and varied life where various formal and informal activities are regularly made available. Contact with the local community is maintained wherever possible and from residents’ own choice. Residents enjoy a good level of different choices in respect of their daily lives. Meals at the home are well managed and provide daily variation, good nutrition and social contact for people. EVIDENCE: It was noted from records of the team manager’s monthly visits to the home that a trip to Clevedon had taken place in August ’06 and another was to be arranged for residents who hadn’t been able to go. Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 15 It was also noted from the independent Quality Assurance Survey done in August ’06 that ‘the residents’ meeting had had an input into the planning of trips’. The minutes of the meeting were seen and showed that residents had discussed trips, entertainment, games and key time among other issues. Twenty-two residents had responded to the discussion and gave details of particular trips they would like to have arranged. From the survey it was noted that activities scored 79 although the survey showed mixed responses about these. Some residents prefer to spend time on their own and not join in and one relative surveyed commented on this i.e. ‘The staff do try to motivate residents but some just prefer to stay in their rooms which is their choice’. From our own survey, comments about activities included: ‘there is entertainment but it is very poor quality, third rate’, ‘There is plenty, they’ve got all sorts going on but it bores me stiff – I prefer my own music and TV’ and: ‘I go down when the keyboard players on and I know they do films, bingo and sometimes have a lady dancing’. The minutes however showed a different picture: ‘Entertainment on the whole good’ and ‘more bingo’ was requested. A large number of residents were seen in their bedrooms at this visit and it’s accepted that several residents choose not to take part in any entertainment that may account for the negative comments. Activities records were seen that showed the type of activity or entertainment, residents who took part and their enjoyment in them. A key worker system is in operation and some residents said they prefer to spend time individually with their key worker rather than in a group activity. The manager said contact with the community is maintained wherever possible. Some residents are able to go out into Bedminster and were seen doing so. A vicar from a local Church of England church visits regularly to take services and give Holy Communion. The manager said religious needs are met if requested. Students from a local school visit at Easter, Harvest festival and Christmas. Visitors are welcome at any time and were seen visiting during this inspection. Residents have a good level of choice within the home e.g. they have a choice of a number of lounges to use or can stay in their own rooms if they prefer. They can choose to attend activities, entertainment and outings. Residents are consulted over re-decoration both in communal areas and in their own rooms and can choose wallpapers etc. Residents can choose to have personal relationships with each other and these are respected. The manager gave information about one such relationship that is managed discreetly to give the couple privacy and dignity. One resident said that s/he chooses not to attend outings but can go out alone if s/he wishes. Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 16 Meals at the home have been found to be of consistently high quality over previous inspections and were maintained at this visit. Residents are given a restaurant style lunchtime meal with tureens of vegetables on each table, choice of two main courses or alternatives if requested and at least five choices of dessert. Further a pot of tea is put on each table after lunch so that residents can help themselves. This is good practice. From the home’s recent quality assurance survey and our own survey done immediately before this visit, positive comments were noted e.g. (for meals) ‘always lovely’, ‘they are superb’, ‘I always look forward to meals’ and ‘It’s quite good and we are always offered an alternative’. It was noted that food and drink scored 91 from the home’s own survey and the report stated: ‘Most residents thought the quality and quantity of the food provided was good, although one person said the meat was sometimes tough. There was said to be good variety of menu and that if there was nothing suitable for an individual an alternative would be found. One vegetarian resident found there was ‘still variety’. One resident described the meals as ‘exemplary… cooked well and well presented’ and added that ‘visitors are offered refreshments’. The comment about tough meat was also made in our survey and the manager said that she has planned a cooks meeting to discuss individual comments made and what can be done about them. It was noted that a negative comment had been made about a diabetic resident’s right to choose her/his own diet. The manager explained clearly the actions she had taken to address the issue that had resulted in the resident being more aware of the need to stick to the diet that s/he was now doing. Menu choices had been discussed at the recent residents’ meeting and residents were reminded that food and drink is available at any time of the day or night if they want to ask for it. Currently no residents from minority ethnic backgrounds are living at the home so cultural dietary needs are not highlighted. However residents are offered choices of pasta and curry dishes if they wish. Hayleigh DS0000036207.V314328.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 inspected at least once during a 12 month period. 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 the service. Satisfactory complaints management and recording ensures residents can feel confident in raising concerns about any aspect of their care. Safeguarding Adults training records don’t fully reflect staff ability in ensuring residents are kept safe from harm. EVIDENCE: It was noted from the pre-inspection questionnaire that two complaints had been made since the last inspection. One of these was substantiated and both were investigated within the 28-day timescale that is good practice. We had received no complaints directly and records examined at the home showed that complaints (about noise from nesting seagulls and a charge for a healthcare need) were well managed. From our own survey carried out before this visit comments ranged from: ‘ I wouldn’t have anything to complain about’, ‘I have seen a copy of the complaints leaflet’, ‘I have a copy of the complaints leaflet in my drawer’, to: ‘I think I’ve got a copy of the complaints leaflet somewhere, I don’t bother complaining it’s a waste of time and they’re always shortstaffed’. The manager was able to show clearly that all complaints are taken seriously and promptly investigated. Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 18 It was noted that complaints had been discussed at the residents meeting and residents were reminded of how to make a complaint and also that that we are informed. Residents spoken with said that they had seen the complaints leaflet and knew how to complain. No incidents of abuse had been notified to the Commission since the last inspection. The manager was able to demonstrate clear attitudes to what is or is not considered abuse i.e. in respect of sexual relationships between residents that are consenting and not regarded as abusive. Staff training records however didn’t altogether show that safeguarding adults training had taken place in the last two years although some staff said they had received such training. A good practice recommendation is made to ensure that safeguarding adults training is recorded for all staff and a rolling programme developed to ensure staff get regular updates in it. Hayleigh DS0000036207.V314328.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The internal décor within the home needs updating in several areas, as some residents don’t currently have comfortable, clean and fresh accommodation in which to live. EVIDENCE: It was pleasing to note that the main areas of the home had been re-carpeted since the last inspection. The new carpet was of good quality and looked clean and hardwearing. Some residents’ bedrooms looked well decorated, homely and fresh. Some rooms had been redecorated and the manager said that six more rooms were to be re-carpeted shortly. Residents seen and spoken with in their rooms said they were happy with the décor. Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 20 The home meets older and disabled peoples’ needs by having suitable equipment available and ensuring the premises are as accessible as possible i.e. a passenger lift to the first floor, disabled people’s toilet facilities and automatic front door opening, handrails around the home and in all toilets and bathrooms and accessible bathing facilities. The laundry room was in use and busy and despite lots of washing being done was clean and hygienic. However at this visit it was noted that the environment looked unkempt in some areas. A number of bedrooms looked ‘tired’, faded and outdated in respect of decor. In some bedrooms strong odours wafted out into the corridor making the whole home less than fresh smelling. The manager said that despite constant attempts to deep clean carpets these odours have become ingrained. A list of rooms for immediate re-decoration and/or re-carpeting was given to the manager. These included rooms: 2, 16, 20,21,22, 29 and 40. In some of these rooms large ceiling cracks were noted, caused by settling. In other rooms cobwebs were noted around the light fittings and ceiling. The floor of the medication room was dirty and covered with rubbish. The inspector required that this be cleaned and it was done by the following day. Hayleigh DS0000036207.V314328.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 at least once during a 12 month period. 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 the service. Care staff are well trained, supported and employed in sufficient numbers to meet residents’ needs. EVIDENCE: Staffing at this visit was adequate. The manager said that some vacant posts are being held due to the imminent closure of another home locally which impacts on staffing generally. However she said that fewer agency staff are used and this was confirmed by staff when spoken with. Staff prefer to do overtime and any gaps are covered by permanent staff. Rotas showed that sufficient numbers of care staff are on duty at each period of the day. Residents spoken with didn’t comment on staffing levels. Residents who completed the home’s quality assurance survey and our own survey were positive about staff availability and helpfulness. Staff said that they feel they work well with the agency staff that are used, either regular or new ones. They also said that they feel they manage well despite the care needs of several residents, by getting into clear routines and understanding each person’s needs. Although there is some incontinence that impacts on their time with each resident, staff said that they had found the continence advisor who visits the home very helpful and this further helped them manage the issue. Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 22 Staff spoke about some residents’ communication needs and demonstrated how they are able to communicate with them e.g. by developing ‘sign language’ and ensuring they speak clearly with those who lip-read. Staff also gave information about managing different behaviours and showed accepting attitudes to this. National Vocational Qualification in Care training continues apace with two staff achieving it in September. The manager said that two other staff who had achieved it had now left. This would have brought the home up to the 50 recommended standard but currently around 40 of staff have the level 2 qualification. A requirement made at the last visit in respect of staffing records to be kept at the home was partly met. The manager had developed individual staff files for each person that contained photographs, sickness, training, supervision and yearly appraisal records. This is good practice. However exactly half of the files contained photographs of each staff member and half didn’t. The assistant manager said she thought all photos had been taken but had not yet been developed. Since the last visit arrangements for examining staff records has changed and the inspector will be visiting the City Council’s human resources offices to look at individual records later in the year. Therefore the requirement in respect of proof of identity has lapsed. Training records were reviewed for each staff member. From these it was noted that statutory training such as health and safety, fire safety, basic food hygiene and moving and handling have been undertaken. Other training e.g. mental health, dementia awareness, recording skills was also seen recorded. Training identified and undertaken was highlighted in staff yearly appraisals, together with training they would like. Hayleigh DS0000036207.V314328.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents and staff benefit from having a qualified and experienced manager registered with the Commission, in control of the home. Quality assurance is given a high profile and residents’ views are sought, respected and acted upon. Appropriate financial procedures keep residents safe from risk of financial abuse. Supervision record keeping doesn’t reflect staff ability to discuss their work regularly and ensure residents are protected. Appropriate and robust health and safety procedures ensure residents are kept safe from harm. Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager Barbara Cairns has worked in local authority care homes for a number of years in a variety of posts. She has been manager of Hayleigh for five years and is registered with the Commission. She has National Vocational Qualification in Care Level 4 together with the registered managers’ award. Mrs Cairns operates an open and inclusive style of management that benefits residents. Staff said that they respect the manager and find her to be firm but fair. The inspector had received a copy of the recently completed independent quality assurance survey report commissioned by the City Council. Overall this was a very positive report with satisfaction levels of over 90 in several areas including management and staff. The manager was able to give clear information about dealing with some comments that needed further action i.e. around meals and activities. A random check of residents’ monies was carried out and all were found to correct. Cash sheets were accurately recorded, included receipts of purchases and, where applicable, residents’ signatures when money is given to them individually. Residents each have lockable facilities in their rooms for keeping money if they wish although the majority wish their money to be managed in the office. It was disappointing to note that a good practice recommendation in respect of regular supervision hadn’t been implemented. Whilst the new individual staff files had a section for these records, many only had one record for this year whilst others had 2-4. Staff spoken with however said that they had supervision at least every six to eight weeks. Further, some supervision records were brief and didn’t show that staff had been able to reflect on their working practice. All staff files seen had yearly appraisal records that gave information about what they felt had gone well, what needed to improve and training undertaken or needed. This is good practice. From information provided in the pre-inspection questionnaire and team manager visit records, fire drills were held on 15/06/06 and 01/08/06. Further to this a list of regular fire drills was seen in staff records and it was noted that some staff had taken part more than once or twice a year. It was noted that the Fire Safety Officer had last visited in November 2005. A regular programme of fire safety training is carried out and details of fire safety training updates were seen in each staff member’s file. Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 25 It was further noted that a visit from the Environmental Health Officer to do a kitchen inspection had taken place in August ’06. A copy of the report was given to the inspector and it was pleasing to note that actions had been taken to meet the requirements of the report well within timescales i.e. It was noted that a new refrigerator had been purchased and an appointment to deep clean the kitchen was made within a week of the report being sent to the home. Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 2 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 2 3 X X X X 2 X 2 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 2 X 3 Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 27 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 OP9 Regulation 13(2) Timescale for action All medication must be signed 05/10/06 for immediately after giving. Any medication dropped on the floor must be returned to the pharmacy. New supplies of Controlled medication must be counted and witnessed before entering into the controlled medication book. Further, controlled medication must be counted after each time of giving, witnessed and entered on to the record accurately End of life plans must be put in 31/12/06 place for every resident which clearly show that their wishes after death have been recorded and are to be respected The bedrooms itemised in the list 31/12/06 given to the manager must be re-decorated and where offensive odours persist, recarpeted Requirement 2. OP11 12(3) 3. OP24 23(2)(d) Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP18 Good Practice Recommendations A record should be kept of safeguarding adults training done by all staff and a plan to ensure regular training updates are given to each staff member. The remainder of staff photographs taken should be developed and added to their individual files OP29 Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hayleigh DS0000036207.V314328.R01.S.doc Version 5.2 Page 30 - 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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