Inspection on 14/08/06 for Henlow Court

This inspection was carried out on 14th August 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.

Other inspections for this house

Henlow Court 10/01/06

Henlow Court 02/08/05

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 Henlow Court Henlow Drive Dursley Glos GL11 4BE Lead Inspector Mrs Ruth Wilcox Key Unannounced Inspection 14th August 2006 08:45 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 Henlow Court DS0000064619.V299463.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. Henlow Court DS0000064619.V299463.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Henlow Court Address Henlow Drive Dursley Glos GL11 4BE 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) 01453 545866 01453 549949 The Orders of St John Care Trust Mrs Rachael Ann Harris Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Henlow Court DS0000064619.V299463.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate one (1) named service user under the age of 65yrs. Condition to be removed when the named service user leaves the home. 10th January 2006 Date of last inspection Brief Description of the Service: Henlow Court is a care home for older people over the age of 65 years, which provides nursing and personal care. It is situated in the town of Dursley, and is managed by The Orders of St John Care Trust. Residents who are admitted for personal care only, but who may need the services of a nurse, have the District Nurse service accessed from community resources. One room is available to provide respite care, and is contracted to Social Services for this purpose. The home is purpose built and provides easy access throughout, including access for wheelchairs. The home has two floors, with a shaft lift providing access to the first floor. There are two lounges, a lounge dining room, and a spacious dining room divided between the floors. Residents accommodation is situated on both floors, and are all single rooms, each of which has its own washing facilities. Only one room has its own full en-suite facilities. There are spacious and easily accessible bathing and toilet facilities conveniently situated throughout the home. Information about the home is available in the Service User Guide, which is issued to prospective residents, and a copy of the most recent CSCI report is available in the home for anyone to read. The charges for Henlow Court range from £483.00 to £667.00 per week. Hairdressing, Chiropody, Newspapers, Toiletries and Transport are charged at individual extra costs. Henlow Court DS0000064619.V299463.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. One inspector carried out this inspection over two days in August 2006. A check was made against the requirements that were issued following the last inspection, in order to establish whether the home had ensured compliance in the relevant areas. Care records were inspected, with the care of four residents being closely looked at in particular. The management of residents’ medications was inspected. A selection of residents and relatives were spoken to directly in order to gauge their views and experiences of the services and care provided at Henlow Court. A number of staff were also interviewed. Survey forms were also issued to a number of residents, visitors and staff to complete and return to CSCI if they wished. 100 of residents’ and 90 of relatives’ surveys, and 40 of staff surveys were returned; some of their comments are featured in this report. The quality and choice of meals was inspected, and the opportunities for residents to exercise choice and to maintain social contacts were considered. The systems for addressing complaints, monitoring the quality of the service and the policies for protecting the rights of vulnerable residents were inspected. The arrangements for the recruitment, training and provision of staff were inspected, as was the overall management of the home. A tour of the premises took place, with particular attention to health and safety issues, the maintenance and the cleanliness of the premises. What the service does well: Henlow Court is a well managed home, and provides a safe, clean and wellmaintained environment for the residents living here. Residents are admitted on the basis of an assessment, so that they can be assured the home can meet their individual needs. The home works well with community health care services, and ensures that each resident is afforded Henlow Court DS0000064619.V299463.R01.S.doc Version 5.2 Page 6 good access to all health services, with appropriate medical interventions when required, to assist in meeting their health needs. Residents themselves were generally very satisfied with the way in which they are looked after here. The home is welcoming, and adopts an inclusive atmosphere for visitors, with relatives confirming that they feel welcome here, and that they are consulted and kept informed appropriately. The food served is of a good standard, and residents say that they have plenty of choice, and that they enjoy their meals very much. Residents and their families can be assured that the home has a robust approach to addressing any complaints or concerns, and that the standard of care, services and facilities is regularly reviewed as part of good quality monitoring systems. Staff have good access to training opportunities, and are making good progress with the National Vocational Qualification (NVQ) training programme. Those spoken to had attended adult protection training, and were informed about potential abuse issues. Recruitment is carried out using rigorous employment procedures, with new staff appropriately supervised. The home offers a safe and transparent system for safeguarding personal monies or valuables for those residents wanting such a service. What has improved since the last inspection? Staff have evidently worked hard to improve the standard of care plan documentation. Residents’ care plans are now more comprehensively recorded, and give clear direction as to the needs and care of each individual. The range of social opportunities available to residents has been the focus of some attention since the last inspection, and staff now endeavour to provide more one to one contact with those residents who are unable to participate with group activities; this seems to be greatly appreciated by some of the residents. There has been considerable investment in this home recently, with many improvements to the environment. New windows, furnishings, décor, carpets and curtains have been provided in many areas. New pieces of equipment have also been purchased, and there are some improved safety features. The gardens are also receiving greater attention to improve their appearance. An additional member of care staff has been provided overnight, to improve safety and services, to take into account the widespread layout of the building. Henlow Court DS0000064619.V299463.R01.S.doc Version 5.2 Page 7 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. Henlow Court DS0000064619.V299463.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 Henlow Court DS0000064619.V299463.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 & 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have access to information about the home to assist them in making their choice about moving there, although some work to further improve this remains incomplete at this time. Assessments are carried out on all prospective residents, so that they can be assured prior to admission that the home can meet their needs. EVIDENCE: To date the home has been issuing information brochures (Service User Guides) to prospective residents and interested parties that have continued to contain information relevant to the previous Registered Provider. The review and implementation of updated information brochures has been slow, and an updated copy has not been supplied to the CSCI as was required, within the agreed timescale. However, work is near completion on this exercise, and the new brochures are about to be introduced. A draft copy indicated that the guide would be available in alternative formats if needed, such as Braille or audiotape. Henlow Court DS0000064619.V299463.R01.S.doc Version 5.2 Page 10 Written survey responses from residents or their relatives confirmed that they had access to information about the home prior to admission. Copies of assessments carried out on two of the most recently admitted residents were inspected. These had been conducted in hospital before the resident’s admission to the home was agreed. Appropriate care and health information from other health care professionals was also on file, as were copies of the placing authority assessments and care plans where applicable. Henlow Court does not provide intermediate care. Henlow Court DS0000064619.V299463.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A much improved care planning system adequately provides staff with the written information they need to care for the residents’ health and personal needs. The systems for the administration of medications are generally satisfactory and provide appropriate safeguards for residents when consistently applied. In the main care is offered in such a way as to meet residents’ needs in respect of their privacy and dignity. EVIDENCE: Residents have their own personal plan of care. Four plans were selected for a case tracking exercise, and were scrutinised in closer detail. Staff have done well to improve the overall standard of documentation, and recorded planning of care is much more comprehensive and detailed, and now provides staff with good information about how to meet each individual’s care and health needs. A personal profile is recorded for each resident. Henlow Court DS0000064619.V299463.R01.S.doc Version 5.2 Page 12 Care plans have been regularly reviewed and updated as necessary. They are personalised, and are reflective of individuals’ choices and levels of independence. Care plans are directly linked to assessments, including risk assessments where applicable; these included moving and handling, falls, nutritional and pressure sore risk assessments. Appropriate measures and equipment were in place to support residents as identified on assessment. Wound care plans were better detailed, and photographic evidence of the wound’s healing process was available. There was very good evidence of multidisciplinary working between the home and other health care services, with residents afforded regular medical reviews and consultations, and access to a range of health care services, either in the community or in the home. In one person’s case the daily record showed the Community Psychiatric Nurse was involved in the care of their mental health needs; this intervention had not been featured within the associated plan of care however. Care was being delivered in accordance with the care plans, and when interviewed, staff were able to demonstrate their understanding and awareness of individuals’ needs and their planned care. The home had a large amount of medications in stock due to a recent delivery following a monthly order. Generally all medications were stored safely and securely. Boxed and bottled items were dated on opening so that they are not used beyond their expiry date. However, there were at least four bottles of liquid medications that had just exceeded their expiry date, but which were not in actual use; these were pointed out for immediate removal. Items requiring cold storage were held securely in a designated refrigerator, and temperatures in here were regularly checked and recorded. Scheduled drugs are stored securely, and the associated register properly recorded. The supplying pharmacist prints the medication administration charts. Staff record the receipts of items on the charts, and a separate book of returned items is kept. The person responsible signs hand written entries on medication administration charts, and has a second signatory in some cases; there were some inconsistencies however, with only initials used in some places, and no second signatory in others. Staff have recorded directions for use of external creams on medication administration charts where necessary, however have not linked the use of these or ‘PRN’ (when required) medications to a relevant plan of care, as was previously recommended. Henlow Court DS0000064619.V299463.R01.S.doc Version 5.2 Page 13 Residents are supported to self-medicate if they wish and are able, and this is done on the basis of a documented risk assessment. There are accessible medication guidelines and policies for staff to follow, and nurses responsible for medication management have undertaken appropriate update training. Residents spoke positively regarding their care, saying they were very happy with the way staff looked after them. Some said staff were very caring; a visitor said that they ‘couldn’t fault the care here’. Written survey responses about standards of care were generally very positive, with one saying that care and support varied when the home was short staffed, or sometimes when agency staff were on duty. Care was being delivered in the privacy of individuals’ bedrooms or in bathrooms. Most staff were sensitive and respectful when dealing with residents. Unfortunately there were two occasions when two carers were witnessed being less than respectful and abrupt in their tone when responding to some residents’ requests. Residents generally said that staff were very polite and respectful to them. One person said that ‘the staff have the patience of angels’. Henlow Court DS0000064619.V299463.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 this service. The home makes efforts to ensure that the opportunity to engage in social activities is offered to all residents, and that they can exercise choice in their daily lives. Visiting arrangements are such that residents can keep close contact with their families and friends. Dietary needs are well catered for, with a selection of food available that meets residents’ tastes and choices. EVIDENCE: The social activities coordinator appears to work hard to organise a varied programme of events and opportunities to meet the differing needs of the residents. A programme of group activities is displayed, and visiting entertainers and outings feature as part of the programme. Records of residents’ hobbies and interests are contained in their individual care plan, and separate records of activities held and of individual participation are also kept. In addition to group activities staff endeavour to provide one to one contact, especially for those residents who are unable to participate on a group basis. Henlow Court DS0000064619.V299463.R01.S.doc Version 5.2 Page 15 One resident said that the staff help her with some things, so that she can join in fully. One particular written survey response said how much they appreciated the one to one social contact they received when they could not join in group activities. Another response commented on how well activities were organised. The home has sourced the local newspaper on audiotape, to assist those who are unable to read a paper. A small number of residents use the local shops, and one of these uses many of the local community facilities. There are no restrictions placed on visitors here, and they are obviously welcomed into the life of the home. Residents said that their visitors can come at any time, and that they are made to feel very welcome by staff. One visitor’s written survey response said that the staff were very supportive to him, as well as his relative living in the home. Other surveys confirm that visitors feel very welcome, and that they are consulted appropriately, and kept properly informed. One visitor spoken to directly was particularly appreciative of the reception she always received in the home. During the course of this visit, some of the residents were seen sitting quietly in the lounges, with little going on around them, although music was playing in one lounge, and television on in the other. Others were in their rooms reading, watching television or resting. Residents were evidently spending time how and where they wanted. Some were more dependent on staff however, and there were times when staff were less in evidence around these people. Residents’ choices are respected generally, with personal influences noted in individual bedrooms, with different meals, and with those who were freely moving around the home. Two residents said how much they appreciated their independence, and how staff respected this. Two others said that they ‘did as they liked’, and that they could have help whenever they needed it. Advocacy information, leaflets from advisory services, newsletters and the community magazine were available in the hallway for those who might be interested in this. At least three choices of meal were served at lunchtime. A list of the residents’ selections from the menu is given to the cook for her reference. The cook was very well informed about individuals’ particular dietary requirements and preferences. All residents said that they had a good choice of very good food, and that they had plenty to eat. At least six people regularly opt to have a cooked breakfast. Written survey responses were complimentary about the food in the home, although just one said that they had too much jelly and ice-cream in their opinion, with another saying that they would like a cup-a-soup as a starter to a meal, but that it was never offered; these comments were relayed to the cook. Henlow Court DS0000064619.V299463.R01.S.doc Version 5.2 Page 16 During the meal staff were helping where it was required, and eating aids were provided to those who needed them. As part of the case tracking, it was confirmed that one person was receiving a dietary supplement and the appropriate assistance, as was recorded in her plan of care. A home baked cake was prepared for afternoon tea, and snacks are available at other times of the day if wanted. The kitchen records were not inspected on this occasion, as they have just been subjected to an Environmental Health inspection. The home has received a ‘Good Food’ award from the local council for the good standards achieved. Henlow Court DS0000064619.V299463.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 this service. A suitably robust complaints system enables residents and their families to feel assured that their views would be listened to and acted upon. The home’s Adult Protection policies help to provide a safe environment for the residents. EVIDENCE: A copy of Henlow Court’s Complaints Procedure is clearly displayed in the home. The manager maintains a record of any complaints and concerns received; records contain evidence of any actions taken in response to issues raised, any statements taken, and any correspondence sent or received. The manager adopts a very open and proactive approach to addressing concerns, demonstrating the home’s commitment to dealing with any issues with all due seriousness. Resident and visitor written survey responses confirmed their awareness of how to make a complaint and of whom to speak to if they had any concerns; two visitors said they were unaware of the complaint procedure. Residents spoken to all indicated their complete confidence in the manager and staff to help them with whatever their concern or query might be. Henlow Court DS0000064619.V299463.R01.S.doc Version 5.2 Page 18 The home has written policies and procedures for the protection of the vulnerable residents. Staff have received training in the recognition and handling of potential abusive practices. When interviewed, staff demonstrated their awareness and understanding of their adult protection training, and confirmed that they would not tolerate any kind of abusive practice if they were to witness any in the home. With further reference to the issue regarding shortfalls in staff attitudes reported under standard 10, the names of the two carers concerned were given to the manager, who intends to address their attitude to residents on this occasion through individual supervision. There have been some instances where small amounts of money have gone missing in recent months. The home has taken all prompt and appropriate actions, and has involved the police. Residents are encouraged to use their lockable drawers for valuables, and the home also offers a main safe for secure storage. Henlow Court DS0000064619.V299463.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 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The improvements within the environment have helped to ensure that residents are provided with a comfortable and safe place to live. The home is clean, with appropriate and full observations regarding the control of infection. EVIDENCE: There have been a number of improvements in the home recently, with an ongoing programme of maintenance and refurbishment. Windows have been replaced, and new low surface temperature radiators have been installed throughout the building. A new sluicing disinfector and a new assisted bath has been installed; new dining room furniture, table wear and lounge furniture have been purchased. Four new profiling beds have been provided, and new bed linen is about to be purchased; some of the bed linen was quite flimsy and obviously well worn. Henlow Court DS0000064619.V299463.R01.S.doc Version 5.2 Page 20 The majority of the bedrooms and communal areas have been repainted, and a number of carpets have been replaced. Maintenance personnel are employed, and cyclical maintenance records are kept. A gardener has started work at the home, and is improving the appearance of the surrounding grounds. A contract window cleaner was present during this visit, washing the exterior of all the windows. The home is clean, and the air was fresh in the main areas of the home. A problematic recurring odour is now much better managed and contained. One bedroom had a slightly unpleasant odour, and staff endeavour to manage this through a range of means. There are good infection control measures here, with liquid soap, paper hand towels, hand sanitising gels, gloves and aprons widely available. Clinical waste is safely managed. The laundry room is well organised, and washing machines are capable of disinfecting any foul laundry. The laundry assistant was conversant in the proper infection control procedures for the laundry. Henlow Court DS0000064619.V299463.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 this service. Staffing provision is just adequate to meet the needs of the residents currently living in the home. Robust recruitment procedures ensure that suitable staff are employed for the protection of residents. The arrangements for the induction and training of staff are good, with the staff able to learn the skills necessary for their role. EVIDENCE: A staff rota is maintained, which allows for one registered nurse to be on duty at all times, with seven care staff in the morning, six in the afternoon and evening, and three overnight; night carers have recently been increased, due to the widespread layout of the building. The deputy manager now has one day each fortnight when she can work in a supernumerary capacity, and the manager works totally supernumerary. An ancillary team of cleaning, laundry, catering, maintenance and administration staff ably supports the care and nursing team. Staff are evidently very busy in this home, and appeared to be under some pressure to meet everyone’s needs in the most timely way on the first day of this inspection; things did seem better on the second day however. Staff interviewed indicated that things very much depended on the skill mix of the staff team on any given day as to how effectively they worked. Some said Henlow Court DS0000064619.V299463.R01.S.doc Version 5.2 Page 22 that it could be difficult at times to meet everyone’s needs as promptly as they would like. Residents themselves spoke well of the staff; a number confirmed that the staff were always available and ready to help. One person said ‘there are ups and downs like anywhere’, but that ‘usually things were ok’. Two written survey responses from residents raised their concern that there may not be adequate staffing, particularly in the morning. There are currently five care staff who are NVQ (National Vocational Qualification) qualified to at least level 2, with one of these being at level 3. One carer has completed the level 4 award; two carers have completed the level 2 award, one has completed level 3, and all are awaiting verification. Another two are on their final unit of study, whilst two others are actually on the programme this year. Although the home has not yet achieved the recommended target of at least 50 of qualified care staff, they are making excellent progress towards achieving this. Six staff files were chosen for inspection, on the basis of their recruitment to the home since the last inspection. Each record contained application forms, including a full employment history. Records of interviews were seen. Full and complete evidence of the required pre-employment checks was seen in each of the files, including medical checks, proof of identity, two written references, POVA checks and CRB clearances. Staff confirmed that they have good opportunities to attend ongoing training. A training events programme is made available from The Orders of St John Care Trust Training Manager, and comprehensive records show that staff have attended a variety of mandatory and optional training in issues relevant to their caring role. New staff attend formal induction training, comprising of two days structured learning at a training centre; certificates for some new staff were seen in their personal files. In addition to this, new staff are given in-house induction, more specific to the home. The induction list records the name of the instructor initially, and then new staff are given a named supervisor to mentor them during their induction period; the name of this supervisor is not consistently recorded, and should be identified somewhere, either on their personal file or on the rota as an example. Henlow Court DS0000064619.V299463.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 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are very good management systems in place here to ensure that the interests, health and safety of the residents are safeguarded. The home reviews aspects of its performance through a good programme of self-review and consultations, which includes seeking the views of residents and their relatives. EVIDENCE: The manager at Henlow Court is an experienced level one registered nurse, who is registered with CSCI for her role. She has completed the NVQ 4 Registered Manager Award, and is currently awaiting verification of the final unit of written work. She attends management and clinical training regularly to ensure her continued professional development. Henlow Court DS0000064619.V299463.R01.S.doc Version 5.2 Page 24 She works tirelessly for the benefit of the home and the residents, has provided good strong leadership to all, and has driven many improvements and changes here. One resident commented on how evident it was that the manager works alongside the staff out and about in the home. The home uses a range of quality monitoring systems to help evaluate and improve its services. Quality monitoring survey forms have been issued to residents and their families, and the completed forms are about to be sent to the Quality Assurance Manager, who will collate the results and return them to the manager for any action that may be necessary. In addition to this, the home undertakes a six monthly review with each resident, with their relative in attendance if they wish, so that they can offer their views about care, services, facilities and any concerns they may have. Meal monitoring forms are also regularly issued to residents chosen on a random basis, so that they can give feedback on their experiences with the food and drink provided for them in the home. Three monthly meetings are held for residents and their relatives, recorded minutes of which show that information is shared appropriately with people, with residents and visitors invited to offer comments and feedback about their views and ideas. The manager conducts a number of internal audits relating to record keeping and aspects of management within the home, and The Orders of St John Care Trust also conduct quality-monitoring visits at least monthly. Some residents have placed personal money and valuables with the home for safekeeping. Clear and transparent records for each person, which include transaction details, running totals, and receipts, are kept. Two random audits on residents’ monies proved to be correct, with no discrepancies seen. Residents or their representative sign to acknowledge some transactions, but where this is not possible in the majority of cases, two staff members sign the record to witness on behalf of the resident. There was evidence that health and safety issues are addressed well in this home, with written policies, procedures and risk assessments and provision of necessary equipment. Staff have received thorough training in fire safety, with the content of the training recorded each time. Staff have received training in first aid; three have undertaken the more comprehensive 4 day course. First aid equipment is provided in the home. A full fire safety risk assessment throughout the whole building has been undertaken by an external assessor, with due regard to revised fire safety regulations. An action plan to address the risk assessment findings is awaited at this time. Hot water temperatures are regularly checked for safe levels, and regular Legionella checks on the water supply are also carried out. New low surface Henlow Court DS0000064619.V299463.R01.S.doc Version 5.2 Page 25 temperature radiators have been fitted throughout the home since the last inspection. All necessary safety checks and maintenance of equipment is undertaken in a timely fashion, and meticulous records are kept in these areas. Henlow Court DS0000064619.V299463.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 1 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x 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 x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Henlow Court DS0000064619.V299463.R01.S.doc Version 5.2 Page 27 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 OP1 Regulation 4(2) 5(2) Requirement The home must send the revised copies of the Statement of Purpose and Service User Guide to the CSCI upon completion. This requirement has been repeated from the last inspection. The Registered manager must ensure that staff undertake thorough stock checks of medications, to ensure that all stored items remain in date. Timescale for action 30/09/06 2. OP9 13(2) 30/09/06 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 OP9 Good Practice Recommendations • • The directions for the use of ‘as necessary’ and/or external medications should be recorded and linked in to a relevant plan of care First and second signatories on medication administration charts should be recorded in full. Henlow Court DS0000064619.V299463.R01.S.doc Version 5.2 Page 28 2. 3. OP28 OP30 A minimum ratio of 50 of care staff qualified to NVQ level 2 should be achieved in the home. The name of all new staff’s supervisors should be recorded on personal files or on rotas. Henlow Court DS0000064619.V299463.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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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