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Inspection on 22/09/06 for Hebburn Court Nursing Home

Also see our care home review for Hebburn Court Nursing Home for more information

This inspection was carried out on 22nd September 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home offers its residents `care with a human touch` as one person described how they feel about the home. `The staff here care for the families as well as the residents, there is always a lovely atmosphere and a warm welcome` said another. Lots of interesting photos and information are available to everyone in the entrance, the hall and the lift. Information about what`s happening in the home and forthcoming events are all well advertised, well presented and easy to read. There is tea and coffee making facilities available for anyone to use in the front hall and a pleasant seating area. The food in the home is `second to none` said one resident, with a wide choice of meals every day. The home encourages families to come into the home to share a meal with their relative and visitors are welcomed at any time.

What has improved since the last inspection?

The newly developed unit in the home that provides nursing care for people with dementia needs posed many training challenges for staff. However all staff have improved their knowledge through attending training courses and have been motivated to learn different skills so that they can ensure the people who live there are well looked after. Dining rooms have been redecorated and now have new furniture, round tables and slide/glide chairs that are easier for residents to use. The home now participates in the Independent Visitors Scheme that is led by the local Primary Care Trust and visitors have commended the home for the care they give to their residents. Information is displayed in the entrance to the home.

What the care home could do better:

The home must develop care plans that truly reflect the care the staff give to the residents to meet their needs. Systems that safeguard residents, that are already available in the home, such as for administration of medicines, must be implemented correctly so that residents` welfare is promoted.

CARE HOMES FOR OLDER PEOPLE Hebburn Court Nursing Home The Old Vicarage Witty Avenue Hebburn Tyne And Wear NE31 2SE Lead Inspector Sheila Head Key Unannounced Inspection 09:30 22nd September 2006 & 11th October 2006 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 DS0000039411.V309237.R02.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. DS0000039411.V309237.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hebburn Court Nursing Home Address The Old Vicarage Witty Avenue Hebburn Tyne And Wear NE31 2SE 0191 428 1577 0191 483 5555 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) hebburncourt@schealthcare.co.uk Southern Cross Home Properties Limited Mrs Carole Ann Craig-Gilby Care Home 68 Category(ies) of Dementia (9), Dementia - over 65 years of age registration, with number (18), Old age, not falling within any other of places category (68) DS0000039411.V309237.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 12th January 2006 Brief Description of the Service: Hebburn Court Nursing Home is a purpose built home situated in a quiet and discreet residential area of Hebburn, at the site of an old vicarage. The rear of the building provides a pleasant garden view and ample privacy. The Home is registered to accommodate up to 68 older people who require personal and/or nursing care, including up to 15 people with physical disabilities. Recently the home has been registered to care for up to 18 people who have Dementia needs and who also require nursing care. A separate unit, named The Rivers, has been developed on the first floor of the home accessible by a passenger lift as well as stairs. The unit is divided in two parts, Tyne View and Wear View. In total throughout the home there are 44 single bedrooms, and 12 double bedrooms that are used for single occupancy. En-suite facilities are not provided but there are adequate toilets and bathroom facilities throughout the building. A large central reception area on the ground floor provides seating, in addition to the large lounge/dining areas, and is available to service users and visitors. A separate smoking lounge is provided. A large patio with seating facilities is provided to the rear of the ground floor lounge. Access for wheelchair users is available throughout the Home. The Home is within easy reach of public transport facilities, and the local shops and amenities. The Home is about one mile from Hebburn town centre and approximately two miles from the nearby town of Jarrow. Fees for this service range between £349 and £482 per person per week. DS0000039411.V309237.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out by one inspector and took a total of nine hours spread over two days. The home was visited on the 22nd September 2006 and finally on the 11th October 2006. The manager was present throughout both days. Before the inspection took place the manager had completed a questionnaire giving the inspector up to date information about the home. During the inspection residents, staff and visitors were spoken to and a tour of the building was carried out. The inspector shared lunch with residents on the first floor. A sample of records were examined including resident care files, medication documentation, staff files, training files and maintenance logs. The inspector used case tracking to follow through the care received for a sample of service users from admission through aspects of the care provided. What the service does well: What has improved since the last inspection? The newly developed unit in the home that provides nursing care for people with dementia needs posed many training challenges for staff. However all staff have improved their knowledge through attending training courses and have been motivated to learn different skills so that they can ensure the people who live there are well looked after. Dining rooms have been redecorated and now have new furniture, round tables and slide/glide chairs that are easier for residents to use. The home now participates in the Independent Visitors Scheme that is led by the local Primary Care Trust and visitors have commended the home for the care they give to their residents. Information is displayed in the entrance to the home. DS0000039411.V309237.R02.S.doc Version 5.2 Page 6 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. DS0000039411.V309237.R02.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 DS0000039411.V309237.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are given a good level of detailed information about the service provided before admission. This ensures that service users can make an informed choice. The quality of assessment information recorded varied and provided only basic details to inform the care plan. Comprehensive and completed assessments enable staff to prepare adequately for new people moving into the service, and ensure sufficient resources are available to cater for their needs. DS0000039411.V309237.R02.S.doc Version 5.2 Page 9 EVIDENCE: The home offers detailed information for prospective residents by way of the homes brochure and more specific information via the ‘Statement of Purpose’. When residents arrive in the home they are given a guide that tells them all about the home and what services and care they can expect to receive. Hebburn Court offers support to families from the staff team who have a philosophy of looking after residents, their friends and their families. ‘The staff were so good when my husband had to come here, it was a difficult time and they helped make it easier’ said one visitor. Information about the residents assessed needs is supplied to the home usually by a care manager from Social Services before the person comes to live in the home so that staff have information to begin developing a care plan. The care received by four people were case tracked. The first related to someone who had lived in the home for a long period of time and a pre admission assessment was not available. The other three were more recent admissions and although assessments had been carried out they were not always fully completed. There were gaps in the information and comments such as ‘need to shout’, although helpful, does not contain enough detail as to why and how this need is to be cared for. Assessments were not always signed and dated by those who took part in formulating them, or where the assessment took place. DS0000039411.V309237.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 AND 10 Quality in this outcome is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Care plans are in place but often do not fully demonstrate how residents’ needs are met, although residents confirm they are looked after well. Satisfactory medication systems are in place however some parts of the system were not implemented correctly so residents were put at risk. Residents are treated with respect and the staff ensure that their privacy is protected. DS0000039411.V309237.R02.S.doc Version 5.2 Page 11 EVIDENCE: Each resident has a care plan that has been developed with the help of information gathered before they came to live in the home. Some care plans are clearly set out and risk assessments are in place however the standard is not consistent. For example, although in one file a nutritional risk assessment had been completed well and identified the resident was at risk, this had not generated the necessary care plan that would instruct staff how to look after that residents’ nutritional needs so that the risk was minimised. In another a risk assessment relating to falls had been reviewed and updated in the correct timescale but the care plan that should have given new instruction was not complete. Some care plans have not been dated or signed so it is difficult to determine when reviews took place, or which member of staff has written the information in them. Families are sometimes included in regular reviews that are held to establish if needs of the resident have changed. However, where families are not involved this information needs to be noted and reasons documented so that there is a full picture of the resident that will to enable the correct decisions to be made. For residents that have transferred to the new unit it is important that as well as the social worker assessment, that the home completes a full assessment that identifies the changing needs of the resident. This is to ensure that the transfer is in the residents’ best interests and to ensure the unit can meet their needs. Some care plans were short on detail and some contained inappropriate wording so that instructions about how to care for people were not clear, especially around the area of self harm and suicidal thoughts. However, staff are receiving training and updating in how to complete an instructional care plan ready for the implementation of new documentation through the home. Comments by residents and relatives confirm that residents’ receive good care. ‘I never worry about her when I go home’ ‘The staff look after me as well! They let me come at any time and he is always looked after well’ ‘I like it here. The staff do everything I need them to do and never refuse me anything.’ ‘I am much better now that I have come to live here.’ The home uses a monitored dosage system for administration of medicines that are prescribed to residents. This system is designed to minimise the risk of any errors if it is used correctly. Medicines are put into individual blister packs by the pharmacy and sent to the home every month. The blister packs are marked with the day the medicine is to be given and different colours denote the different times of the day. Once the medicine is given to the resident, the member of staff then signs to confirm, on an individual resident record, that the medication has been taken. There are two trolleys used in the home, one for the residents downstairs and one for the residents upstairs. These trolleys were clean and medicines were securely stored in them. A DS0000039411.V309237.R02.S.doc Version 5.2 Page 12 random inspection of the medication administration record showed that there were discrepancies. For example, two different tablets were still in the blister pack but had been signed for as given. This means that the resident had not received their prescribed medication so was put at risk. Another recording sheet identified that one tablet had been given to a resident but there was a gap in recording of a second. When the blister pack was examined both tablets remained. This means that they had not been given to the resident, again putting them at risk. On part of the record one resident had a drug stopped on the 29th of the month yet on a different page the same drug had been restarted on the 27th, which did not make any sense. There was no documentation to explain why this was so residents cannot be confident that they are receiving their medication correctly. Care files relating to this resident were examined but no entries were found. Those nurses were not fully complying with policies and procedures for administration of medicines to ensure residents are safe. These instructions are available in the home and are also attached to the actual medication administration record. Before the inspection an audit had taken place but had only looked at one part of the system and this audit had not identified any problems. The medicines fridge was unlocked however, it was situated in a locked room. Cupboards were found to be clean and well organised. The controlled drugs record was found to be correct and reflected amounts of controlled medication held by the home. The home uses good practice to control access to controlled drugs. To gain access to the cupboard it is necessary for two nurses to check requirements together, as a nurse from each floor has a key and both are needed for access. There was an up to date list of signatures used by the nurses when recording medicines have been given, so that it is easy for the home to identify who has made any errors. Care is given in a discreet manner with staff knowledgeable about residents’ preferences. ‘The staff are always kind and know how to look after me’ said one resident. The staff appeared to be kind, polite and unhurried. Staff were knocking on doors before they entered and the home was filled with happy cheerful banter between staff, residents and visitors. DS0000039411.V309237.R02.S.doc Version 5.2 Page 13 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 and 15 Quality in this outcome is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are given good the opportunities to participate in a wide range of leisure and social activities. Links with families and friends are supported and encouraged. The residents’ day is flexible so they are encouraged to make choices and take control over how they spend their day. Residents are offered and receive varied, wholesome, nutritious and wellpresented meals of their choice. DS0000039411.V309237.R02.S.doc Version 5.2 Page 14 EVIDENCE: A full time activities organiser works in the home providing a varied activities and events programme for residents. Included in the care planning process, residents’ social interests, hobbies, religious and cultural needs are assessed and reviewed monthly. This information is obtained by the activities organiser through a combination of recording life stories and talking to residents and their families. This then identifies what the resident would prefer to do and also what interests residents wish to continue now they are living in Hebburn Court. On the dementia unit activities are usually organised in small groups or on a one to one basis to ensure individual needs are being met. The emphasis on resident centred care must be commended as not only what the resident has done is recorded but how they reacted and if they had a positive experience. Attention had been paid to making notices stand out and be colourful as well as easy to read. Lots of pictorial prompts are used to help residents find their way around the unit. Staff in this unit are eager to learn more and constantly listen to residents so that their changing needs are met. Lots of information is available throughout the home letting visitors and residents know what’s going on in both units. Activities and forthcoming events were all suitable and had been arranged in consultation with residents. Staff are included in the social programme so that residents receive their support, not only from the activities organiser. Visitors are welcome at any time in the home. The staff work hard to make sure they feel at home and part of the ‘caring’ package. ‘I would recommend this home to anyone, I feel such a part of it’ and ‘I can’t fault the care, and the staff are always interested in how I am as well, which is so nice’ were comments received. The inspector shared lunch with residents in the Rivers unit. There was a friendly but unhurried atmosphere with residents seated in small groups throughout the unit. This promoted concentration on the mealtime. The tables were suitably laid with condiments, menus, appropriate cutlery and napkins. There was plenty of space and quiet chatting was encouraged. There was a choice of tea, coffee, juice or water throughout the meal. Residents had a wide choice of meal. Battered cod, fish fingers, fish cakes, fried or poached eggs, omelettes, salads, scampi, chips, mashed potato and peas. Puddings offered were bananas, ice cream or homemade mousse. Meals were well presented, nutritious and well cooked. Residents enjoyed their lunch and some had second helpings. DS0000039411.V309237.R02.S.doc Version 5.2 Page 15 The cook visits the residents every day to ensure they have what they want to eat and will always make them something if they don’t fancy what’s on the menu. ‘She’s one in a million’ said one resident. Residents are asked to make their choices through the morning which is good practice and offers a realistic timescale, as residents can chose just before lunch, so they know what they fancy rather than having to chose the day before. Food is available through the day. Breakfast is available from eight o’clock and is freshly made when a resident decides to get up. Teatime is around four o’clock and on the day of inspection included homemade mince and onion pies, minestrone soup, sandwiches, spice buns and cakes. Residents who needed assistance were helped discreetly and with dignity. Special diets were catered for and soft diets were presented so that individual items could be recognised. Staff have access to the kitchen throughout the night in case a resident is hungry and wants a snack. ‘The food’s great’ and ‘It’s always lovely’ were comments received. DS0000039411.V309237.R02.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome is good. This judgement has been made from evidence gathered both during and before the visit to this service. A clear complaints procedure is in place which residents and their relatives can be confident that their concerns will be listened to and dealt with in an appropriate manner. Residents are protected by robust policies and well trained staff that ensure they are safeguarded from abuse. EVIDENCE: A clearly explained complaints procedure is available to residents and visitors in the home. The manager holds a complaints register. The philosophy in the home is to address any concerns straight away and make sure that they are sorted out quickly and to everyone’s’ satisfaction. The manager has an open door policy and visitors and residents alike confirmed they knew what to do if they had a complaint. Some comments included: ‘I would tell the manager or tell one of the staff and they would ask her to come to see me’ ‘I see her everyday walking about so I know who to tell but there’s nothing to see her about’ ‘I once had a problem and the manager sorted it out there and then which was a great comfort’ ‘I feel I can say anything so I would say if there was a problem’ DS0000039411.V309237.R02.S.doc Version 5.2 Page 17 Staff are adequately trained in Protection of Vulnerable Adults so can recognise abusive situations and would know what to do if they suspected abuse. The home has a policy of updating training on a regular basis for all staff. There is also written information and guidance, as well as policies and procedures available in the home for staff to look at if they need guidance. Residents and families can be confident that the staff group are well trained so that residents are safeguarded from abuse. DS0000039411.V309237.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is clean, warm, well maintained and suitably decorated so that the residents have a homely and safe environment to live in. EVIDENCE: The home was clean and odour free. The dining room downstairs has benefited from new round dining tables and chairs of the slide/glide type have been purchased so that residents find it easier to use and move them. The entrance hall is very welcoming with seating, a drinks machine, subtle music and plenty of information about the home, plus photographs of staff and residents taken during social activities. DS0000039411.V309237.R02.S.doc Version 5.2 Page 19 The housekeeping staff promote good practice in infection control techniques using aprons and gloves whilst correctly using provided materials and equipment. Bedrooms are personalised as residents wish. They are encouraged to bring small items of furniture, photos and ornaments with them when they come to live in the home. Some bedrooms are looking rather tired and would benefit from redecoration but they are homely and clean. The new ‘Rivers’ unit is well decorated and has some interesting features that promote residents well being. There is a ‘street’ with shop windows stocked with items relevant to the residents past, a ‘market place’ seating area, bedroom doors are brightly coloured to help residents recognise where they are and furniture is homely but suitable for the people who live there. There is a ‘bar’ area that the residents like to use as a focal point that evokes memories and a quiet area with armchairs is provided. The unit is bright, spacious, airy and clean. Maintenance log contained all the necessary checks to safeguard residents such as water temperatures, call bells, window restrainers, fire doors, emergency lighting and bed rail inspection. These were all completed recently and records showed that these checks were carried out on a regular basis. DS0000039411.V309237.R02.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome is good. This judgement has been made from evidence gathered both during and before the visit to this service. The staff recruitment procedure is operated in a robust manner safeguarding the residents from potential harm. The home is staffed to a level that ensures residents’ needs are met and staff are well trained to care for them. EVIDENCE: The rota reflected the staff on duty on both days of the inspection. There is a satisfactory number of staff throughout the home to meet the needs of the residents who live there. Four personnel files sampled were well organised and easy to follow. All contained evidence of a robust recruitment procedure that safeguards residents. All had application forms, equal opportunities monitoring forms, references, Criminal Record Bureau clearance, interview records, supervision and appraisal notes. All but ancillary staff had completed or was undertaking an on going induction programme. A formal induction for ancillary staff is being developed but is not available for use at the moment. The home ensures ancillary staff are given information so that they can work safely but this is not a substitute for a comprehensive induction programme to ensure they work effectively and to the benefit of the residents. DS0000039411.V309237.R02.S.doc Version 5.2 Page 21 The manager operates a training matrix that identifies training needs of staff and when that training needs to take place. On the first day of inspection two members of staff were taking exams for their NVQ level 2 in healthcare. Documentation showed training offered, such as Protection of Vulnerable Adults, Fire Safety, Moving and Handling, First Aid, COSHH, NVQ levels 2 and 3, Dementia Awareness, Managing Challenging Behaviour and Safe handling of Medicines. Staff are encouraged and supported to attend and records confirm that staff are well trained. Residents can be confidant that the staff looking after them are knowledgeable and well trained so that their well-being is promoted. DS0000039411.V309237.R02.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome is good. This judgement has been made from evidence gathered both during and before the visit to this service. The manager has appropriate knowledge, experience and qualifications to run the home competently. Clear systems are in place to monitor the quality of care the residents receive and to ensure the home is run in the best interests of the residents. Robust procedures are in place and ensure that residents’ personal finances are safeguarded. Staff usually follow safe working practices to promote and protect residents welfare and safety. DS0000039411.V309237.R02.S.doc Version 5.2 Page 23 EVIDENCE: The manager is registered with the Commission, holds the required nursing qualifications and has completed the Registered Managers Award. She has extensive experience in caring for elderly people and can successfully manage the home. Comments include ‘The manager encourages training and really cares for the residents’ and ‘You couldn’t get a better manager, I would recommend her to anyone.’ The Company’s’ quality assurance system includes internal monitoring of complaints, maintenance, catering and domestic services. Storage and administration of medication is audited monthly. Audits don’t cover both units at present and therefore, errors may go unnoticed for unacceptably long periods of time and residents may be put at risk. Care plans are also internally audited with a number being randomly selected each month. Due to the inconsistencies found during this inspection care plan auditing needs to be developed that ensures instructions on how to care for residents are clear so as to minimise risk to residents. The home constantly asks residents their views and opinions through questionnaires, the manager talking to residents every day and resident meetings that are held frequently. The majority of residents have their personal allowances held by the home and looked after by the administrator and manager. The system is computerised and only accessible with the use of passwords that are limited to the administrator, manager and deputy manager. Head office is alerted whenever the system is accessed and are able to block information if necessary. All residents have an individual balance record that is reconciled every week if any transactions have taken place. Monies are held in one joint non- interest making account. This practice is under review as some banks are now offering individual account facilities so that residents will then be able to gain interest on their money. The home holds an appropriate float and two signatures support transactions when a resident requires money. Each resident has a lockable facility in their rooms and are able to hold their own keys if they wish so that their independence is both supported and encouraged. Residents can be sure that their personal allowances are safely managed. Conversations with staff and examination of documentation confirm that they receive training in all areas of health and safety. Some training in fire safety has been held recently but although there is a list of attendees these are not confirmed by signatures. It is important that all staff sign to confirm they have received training so that non-attendees can be identified and then given missed training. This is to ensure that all staff are trained to ensure the safety of themselves, residents and visitors. Accidents in the home are recorded clearly and analysed for any trends every month by the manager so that risks to residents are minimised. DS0000039411.V309237.R02.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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 DS0000039411.V309237.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15(1) Requirement Service users care plans must reflect all known and changing needs and how they are effectively met. Timescale of 31/03/06 not met The accurate and consistent recording of medicines must be ensured at all stages of procedure. Timescale of 12/01/06 not met The Home must ensure that evidence is available to confirm that appropriate assessments have been carried out prior to service users moving into the Home to ensure their needs can be met. Timescale of 12/01/06 not met. Subjective and judgemental language must not be used in reference to the actions of individuals who have dementia needs. Timescale for action 31/12/06 2. OP9 13(2) 30/11/06 3. OP3 14(1) 30/11/06 4. OP7 12(3)(4) 30/11/06 DS0000039411.V309237.R02.S.doc Version 5.2 Page 26 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 OP35 Good Practice Recommendations Service user’s monies must not be put into an account unless the account is in the name of the service user. DS0000039411.V309237.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Shields Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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. 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