Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 20/07/05 for Home Of Comfort Nursing Home

Also see our care home review for Home Of Comfort Nursing Home for more information

This inspection was carried out on 20th July 2005.

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

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

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 has a strong Christian ethos and many of the service users were pleased to share their satisfaction and pleasure that they continued to be able to practice their faith. Staff appraisal and supervision is in place and documented in personnel records and training needs are identified readily. Staff reported that they receive the training they request to undertake which is discussed during supervision sessions. The staff expressed their satisfaction that the home is well managed and that the manager and trained staff are very supportive and approachable to discuss any issues they may have. The home`s repairs and redecoration is maintained to a good standard and the service users were keen to point out to the inspector the delightful gardens that surround the home. A high standard of cleanliness and hygiene is maintained throughout the home. Service users comments indicated that they are satisfied with the housekeeping standards in the home and that their rooms are cleaned daily. Service users commented on the good standard of food served and the cook keeps the kitchen area clean and well organised. Service users reported that the staff are `very kind` and that whatever they request is supplied and that staff are always there to listen to their concerns. The relative spoken with reported that she is very satisfied with the care her mother is receiving. The administrator has undertaken a service user satisfaction survey and has analysed the results and identified areas of concerns to the residents that affects the quality of their lives. Letters of testimonials are kept also as evidence of quality assurance.

What has improved since the last inspection?

Staff training has been well organised and the training matrix identifies the staff who need training and those who have undertaken training. It also identifies that the training being undertaken is appropriate to the client group the staff care for. A service user survey has been introduced which has been undertaken recently and will be periodically undertaken and complements the quality control audits that already take place in each department of the home. The heating system has now been extended to the rooms identified at the last inspection as needing fixed heating, and radiators have now been fixed to the walls in those rooms.

What the care home could do better:

Care plans need to be developed further and care staff should receive more training on the computerised system so that they can become more involved in how to use the care plans as everyday working documents. The flooring in the area used for hairdressing is stained and is in need of replacing. This should be identified and reported when the housekeeping person does quality audit of the environment. Care staff should become more involved and sit with the service users who are in need of feeding or assistance with their eating to promote the dignity of the resident and be sensitive to their need.Staff should respect service users` choice of what time they would like to be assisted to get into their night attire.

CARE HOMES FOR OLDER PEOPLE The Home of Comfort Nursing Home 17 Victoria Grove Southsea Address 3 PO5 1NF Lead Inspector Jan Everitt Unannounced 20 July 2005 10:00 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 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. The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Home Of Comfort Nursing Home Address Home Of Comfort Nursing Home Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 023 92 730063 023 92 730063 The Home of Comfort Charity Mrs Patricia Irene Evans Care Home with Nursing 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Terminally ill (8), Terminally ill over 65 of places years of age (30) The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: One male service user may be admitted to the home at any one time. This male service user must be a partner of one of the female service users. A risk assessment must be carried out prior to the admission of a male service user. Service users in the TI category must be at least 55 years of age. Date of last inspection 14/12/04 Brief Description of the Service: Home of Comfort is a care home providing nursing and personal care for 30 ladies over the age of 65 years. The home is also registered to accommodate service users with life limiting disease with the condition that only 8 may be accommodated between the ages of 55-65 years. The registration also has a condition that one male may be accommodated at any one time, providing he is the spouse of a service user. The home is owned and administered by The Home of Comfort Charitable Trust and is represented by a management committee, one of whom is the named responsible individual stated on the certificate of registration. The home is located in the pleasant residential area of Southsea, close to Portsmouth city centre and in walking distance from the sea front and local amenities. The home is two converted Victorian houses on three floors with a purposebuilt three-storey wing added in the 1960’s. A newer conservatory lounge has been added in recent years. The home has a well-maintained garden that surrounds the home and is accessible to service users who make use of it in the finer weather. All rooms are single accommodation. There are two shaft lifts installed The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of the Home of Comfort Nursing Home took place on the 20 July 2005 and was the first inspection of the home for the inspection year 2005/6. The inspection took 6.5 hours. Sixteen of the twenty core standards were assessed whilst also looking at the requirements from the previous inspection report. During the inspection 3 service users were spoken with individually and other service users in small groups. Three relatives were also spoken to at length. A number of comment cards from relatives and service users were returned to the CSCI and all made very positive comments about the home in general. These together with the analysis of the interviews with the service users and relatives indicated that there was high level of satisfaction with the care and services received in the home. The inspector assessed that given a number of the service users unable to verbalise their opinions, from observations of the care practices and interactions between service users and carers, the care and services received by the service users was of a good standard. A group of four staff were spoken with and from comments and the general conversation, the inspector concluded that there was a high level of motivation and job satisfaction within the staff group and a high regard for how the home was managed. All communal areas were seen as well as most of the service users’ rooms. The lunchtime meal was observed and care records examined. What the service does well: The home has a strong Christian ethos and many of the service users were pleased to share their satisfaction and pleasure that they continued to be able to practice their faith. Staff appraisal and supervision is in place and documented in personnel records and training needs are identified readily. Staff reported that they receive the training they request to undertake which is discussed during supervision sessions. The staff expressed their satisfaction that the home is well managed and that the manager and trained staff are very supportive and approachable to discuss any issues they may have. The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 Page 6 The home’s repairs and redecoration is maintained to a good standard and the service users were keen to point out to the inspector the delightful gardens that surround the home. A high standard of cleanliness and hygiene is maintained throughout the home. Service users comments indicated that they are satisfied with the housekeeping standards in the home and that their rooms are cleaned daily. Service users commented on the good standard of food served and the cook keeps the kitchen area clean and well organised. Service users reported that the staff are ‘very kind’ and that whatever they request is supplied and that staff are always there to listen to their concerns. The relative spoken with reported that she is very satisfied with the care her mother is receiving. The administrator has undertaken a service user satisfaction survey and has analysed the results and identified areas of concerns to the residents that affects the quality of their lives. Letters of testimonials are kept also as evidence of quality assurance. What has improved since the last inspection? What they could do better: Care plans need to be developed further and care staff should receive more training on the computerised system so that they can become more involved in how to use the care plans as everyday working documents. The flooring in the area used for hairdressing is stained and is in need of replacing. This should be identified and reported when the housekeeping person does quality audit of the environment. Care staff should become more involved and sit with the service users who are in need of feeding or assistance with their eating to promote the dignity of the resident and be sensitive to their need. The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 Page 7 Staff should respect service users’ choice of what time they would like to be assisted to get into their night attire. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 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 standard(s) 3. Standard 6 is not applicable to this service. A comprehensive pre-admission assessment of the service user is undertaken by the manager to ensure the home can meet their identified needs. EVIDENCE: The manager has devised a comprehensive pre-admission assessment tool that covers all aspects of health and social needs. The manager assesses potential service users in their current setting and reports that this is mainly from hospital or another care setting. This assessment forms the basis for the assessment and care planning process once the service user has been admitted and is maintained in the care planning records. Service users were asked about their experiences of being admitted to the home. One service user reported that she had known about the home for many years and was connected with the local parish that supports the home and therefore never thought of going anywhere else to live. Another service user said that she had been attending the home for respite care occasionally and therefore came to the home when she felt it time she needed more care. A service user relative reported that she had looked around various homes in the area and that together with the home’s reputation had chosen this one for The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 Page 10 her mother who was unable to make those decisions. The service user concerned said she was happy living in the home. The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 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 standard(s) 7, 8, 9 & 10 The care plans are not easily accessible to staff and do not guide the daily practices for individual service users. Service users health care needs are fully met. Service users are protected by the homes policies, procedures and the trained nurses practices for dealing with medicines. Support with the activities of daily living is offered to service users to promote their privacy, dignity and independence EVIDENCE: A sample of care plans was viewed. The system for care planning has been recently computerised and the inspector found it difficult to track care. The care plans cannot be easily accessed by all staff that deliver care and are mainly documented by the trained staff, therefore concluding that the plans are not working documents used daily by those who deliver the planned care. This was discussed with the manager who agreed that further development of the system is needed and staff need further training with the system. The deputy manager also agreed that it was difficult to access information quickly if someone made a phone enquiry about a service user. The manager reported that service users and their relatives do get involved with the planning of care but care plans are not signed or documented as evidence of this. The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 Page 12 A service user spoken with said the she was invited to be in involved with care planning but that she did not want to be and that she was very happy with the care she was receiving. Another service user said she had been consulted about her care plan, another said her niece got involved with her care. Service users have access to their NHS entitlements and the dentist, optician and chiropodist visit the home at regular intervals to offer their services. Service users spoken with confirmed that they have access to a range of healthcare services such as podiatry, dentist and optician. One service user spoken with reported that staff would push her in the wheelchair to the local opticians, which she chooses to use. The manager reported that there are a considerable number of outpatient appointments for service users to attend and these are undertaken with escort from the home or relatives. Service users reported to the inspector that the GP visits the home when needed and the manager reported that the home receive a good service from the local surgery. One service user reported that the nurse asks first if she wishes to see her GP and ‘he is very good’ but reported that she did not have a regular review by the GP. Nutritional assessments are undertaken routinely and service users are weighed at appropriate intervals. Service users are encouraged to mobilise around the home with assistance but many of them are unable to walk unaided. Medication records were viewed and were observed to be well recorded. Systems are in place to ensure medicines are ordered, stored and administered safely. Service users reported that they receive their medication appropriately and either the ‘matron or the nurse administer them. No service users were choosing to self-medicate at the time of this inspection. A service user spoken with said she was happy that home looked after her medication as she would not know what to do with them. The manager reported that one service user is receiving medication crushed and this has been recorded that it has been agreed with the GP and pharmacist as safe practice. Service users reported that they consider their privacy and choices are respected. Staff were described as ‘ wonderful’ and ‘they do all they can’ and ‘the matron is good if I need anything I get it, nothing is too much trouble’. One service user said that she did not mind what time she got up in the morning and always had breakfast in her room, and chose when she went to bed, but ‘I do not like getting into my nightdress too early’. This issue was discussed with the manager. Another service user confirmed that she prefers to stay in her room between meals and will socialise in the lounge when there are activities going on. The inspector observed staff interacting with the service users in a respectful quiet manner and knocked on doors before entering. From the conversations with service users and staff and observations by the inspector, it would suggest that the service users have their rights, privacy and independence promoted to the full and that staff are aware of the core values of care. The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 Page 13 The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 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 standard(s) 12, 14 & 15 Services users have the opportunity and choice to participate in social, cultural, religious and recreational interests that meet their chosen needs and match their previous lifestyles. Service users are supported to exercise control over their lives to the extent their mental capacity will allow. Service users are offered a balanced and nutritious menu with choices at every mealtime. Service users eat their meals in pleasant surroundings in the location of their choice EVIDENCE: Social care plans are in place and part of the admission assessment documents the service users’ social preferences and what they enjoyed doing before they came to live in the home. The home does have a planned activities programme but it is not advertised, the manager reports that this is because the service users would be unable to read it and that they are informed on the day by the lady that arranges the activities and she makes a note of who wishes to attend. A service user spoken with confirmed that activities do take place and consists of quizzes, bingo and other games that she reported ‘we all enjoy’. A relative spoken with reported that her mother really enjoyed the bingo twice a week. The inspector observed newspapers are delivered daily. The home has a volunteer from the committee that undertakes shopping once a week for those unable to get out and who have no relatives. The clergy The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 Page 15 visit the home monthly and many of the ladies attend their own local churches and are usually transported by relatives. A service user confirmed that she attends the local church whenever she can. The library visits the home three monthly to deliver large print books and talking tapes. Service users spoken with reported that they are supported by their families and friends that visit regularly and also the church people who are ‘always good’. Many of the service users spoken with commented that ‘the food is good’ and that they had ‘no complaints the food is excellent’ and ‘homemade cake is served with afternoon tea. A menu is displayed each day. The kitchen was visited and the cook was spoken with. She confirmed that likes and dislikes are observed and that the menus are planned around these but that there is always an alternative choice if the service users request it. The inspector observed that there were jugs of drink available and continually offered to the service users throughout the day. The inspector observed the lunch-time meal of lamb cobbler and three fresh vegetables being served and later the afternoon tea with homemade cakes, which confirmed that the standard of food served and the manner in which it is served is such that the service users receive nutritious well presented meals in the pleasant surroundings of the dining area or where ever they choose to eat their meals. The inspector discussed meals and menus with the service users. Comments such as ‘the food is good’ ‘food is well cooked’ ‘ we have a very good cook and it is all homemade with plenty to eat and a choice of what to have’. ‘The cook comes round to see what we want’. The inspector observed that a considerable number of service users needed assistance with their eating. This was being given on an individual basis but that the carer assisting was standing over the service user and not sitting participating in the occasion. A recommendation will be made. Service users’ rooms were homely and had been personalised with personal possessions and pieces of their own furniture. Service users reported to the inspector that they are well supported to maintain their independence and to do whatever they choose to do if it is within their capacity and that they feel safe and happy with their home. Service users consider they have autonomy and choices of how they spend their days, one service user commenting that ‘nothing is perfect but I live my life how I wish and if I have never requested anything that has not been supplied to me’. Another service user commented that ‘her wishes were respected ‘and that she chose to stay in her room with the door closed and decides daily whether ‘I wish to go into the dining room for meals’. The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 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 standard(s) 16 & 18 Satisfactory policies and procedures are in place for service users, staff and relatives to address any concerns or complaints that they may wish to raise. The registered manager ensures that service users are protected from every form of abuse. EVIDENCE: The home has a complaints policy that is displayed in the entrance hall informing people of their rights to complain and how they can go about this. This policy is contained in the Statement of Purpose. Service users spoken with said they would go to the matron or nurse if they should wish to raise an issue. No complaints have been logged in the records. Staff spoken with were also aware that the manager or nurse in charge would be the first person to go to if they or a service user wished to make a complaint. The home has the protection of vulnerable adults policy in place and staff spoken with were aware of the policy and how to report any allegations or witnessing of abuse and described that process to the inspector. The deputy manager has undertaken training from the city council and is the process of ensuring it is disseminated to all staff. Information and resource files are available to staff and a training video is shown to all staff followed by questionnaire to test their knowledge. The home is targeting a lot of training on adult protection, which the manager reports, has been requested as a training need at the staff appraisals. The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 Page 17 Bedrails are used following a risk assessment for their use and consent for their use sought from the service user or their representative and documented in the care plans. The inspector observed bumpers covering bedrails in use. The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 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 standard(s) 19, 25 & 26 Service users live in a safe, well-maintained environment. The home is clean and hygienic and service users live in comfortable surroundings. EVIDENCE: The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 Page 19 The home is well maintained by the full-time maintenance team. A new call bell alarm system has been installed with pendant call bells for the two lounges. The inspector observed that the carpet tile flooring on the first floor area where the hairdresser washes and does the service users hair as stained and lifting. This was discussed with the manager and the administrator as a potential hazard and the floor will be replaced imminently. The gardens are well maintained and were very colourful at the time of the inspection. Service users commented how lovely the garden looked with the new water feature having been recently installed. As the inspector arrived one service user was sitting in the garden enjoying the fine weather. The two rooms identified in the previous inspection as having freestanding heaters have now been fitted with wall-mounted heaters with less risk to the service users. The home was observed to be very clean and free from offensive odours. The cook must be commended for the standard of cleanliness and organisation of the kitchen at the time of the inspection. Separately contracted staff are employed to provide a housekeeping service. A service user spoken with reported that the home is ‘spotless’ and that her room is cleaned every day. Another service user also confirmed that she considered the home to be very clean. There is a laundry facility in the home and a designated member of staff undertakes these duties. Service users reported that they are satisfied with their laundry and that their clothes are returned to them promptly and put away. The relative spoken with also commented that her mother’s clothes were well laundered. The home has an infection control policy in place and is made available to all staff. Hand washing facilities and antibacterial hand wash and disposable towels are made available to all staff. Disposable gloves and aprons are available to assist in the prevention and control of infection. The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 30 Service users needs are met by the numbers of staff that are appropriately trained. EVIDENCE: The inspector viewed the staff rota that demonstrated sufficient staff were on duty each shift to meet the assessed needs of the service users in residence. Separately contracted staff are employed for the kitchen, housekeeping. The home does use agency staff on occasions and endeavours to request the same staff each time, which the manager reported, does happen. Service users were asked to comment if they considered there were enough staff on duty. They reported that the staff were very busy but that they were all ‘very nice’ and would answer the bell as soon as they possible could but it did depend who was on duty. Service users spoken to comment that they were given support and help with their daily hygiene at appropriate times for them. The inspector activated the call bell, which was answered promptly. Staff spoken with reported that they felt supported within their working environment and that they did have time to sit with service users. Observations of the morning routines, which appeared well organised and had taken place within appropriately time scales to suit the service users, would suggest that sufficient numbers of staff were on duty. The manager is very motivated to train her staff to a good standard. The induction programme and foundation training programme is TOPSS based and is undertaken over a six-month period. The inspector viewed the training matrix, which easily identified training that had taken place and forthcoming The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 Page 21 training. This demonstrated a wide spectrum of various training appertaining to the client base the home accommodates. All staff have appraisal and supervision records and staff are also offered to complete a questionnaire identifying what they consider their training needs are. A mixture of staff of long standing employment and some fairly recently employed were spoken to in a group and they reported that they consider they received good training and are supported by the manager and trained staff to carry out their roles. The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 38 The manager and committee strive to maintain the interests of the service users at the heart of the service. Staff are provided with appropriate training to ensure that the health and safety of both them and the service users is promoted and practiced. EVIDENCE: The home has a quality assurance system in place, which was viewed by the inspector. Housekeeping, catering, care and administration have audit tools appertaining to that department to monitor standards. A customer satisfaction survey has recently been completed and analysed with positive results. Comments and suggestions made for improving the quality of service users have been acted upon. The inspector viewed the results of the survey and such comments ‘this is an excellent home and I would recommend it to anyone’. ‘I cannot fault the staff’, ‘wish staff could have more time to chat to us but appreciate they are busy’. Other letters and cards from relatives and one from a local GP gave testimony of the level of satisfaction with the care and services delivered in the home. The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 Page 23 The inspector viewed the risk assessment for the environment. All health and safety policies and procedures are in place and available to staff. The training matrix evidenced that staff have received all the mandatory training required at appropriate intervals appertaining to health and safety, first aid, food handling and hygiene and infection control. The fire logbook was examined and systems for the fire safety of the home were being tested regularly and servicing of the systems was undertaken in May 05. The manager has now installed an accident reporting system on the computer, this was discussed with her as to the effectiveness of this system, which will be assessed over the coming months and will be reviewed at the next inspection. A copy of the report made under Regulation 26 visits, by the responsible individual is sent to the CSCI monthly. The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x 3 The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 Page 25 NO Are there any outstanding requirements from the last inspection? 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 Standard 7 Regulation Reg 15 (2) Requirement The care planning system must be further developed to ensure the information and care plans inform practice and that staff are given training to use the electronic care planning system. The flooring area on the first floor used as the hairdressing room must be replaced with new flooring. Timescale for action 30.10.05 2. Standard 19 Reg 13(4)(a) 30.9.05 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 12 Good Practice Recommendations It is recommended that the manager ensures that staff respect the choices and decisions made by service users in relation to the time of their being assisted into their night wear. It is recommended that when carers are assisting with the feeding of service users this should be done with the carer sitting down with the service user and giving them undivided attention during this time. 2. 15 3. The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 Page 26 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton SO15 1GW 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 The Home of Comfort Nursing Home H55-H03 S11514 Home of Comfort V220396 200705.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!