Inspection on 12/06/07 for Hope Cottage

This inspection was carried out on 12th June 2007.

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

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

Other inspections for this house

Hope Cottage 14/10/08

Hope Cottage 19/05/08

Hope Cottage 21/06/06

Hope Cottage 06/01/06

Hope Cottage 24/06/05

Hope Cottage 22/09/04

Hope Cottage 20/04/04

Hope Cottage 05/11/03

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

CARE HOMES FOR OLDER PEOPLE Hope Cottage 5-7 Pilkington Road Southport Merseyside PR8 6PD Lead Inspector Mr Daniel Hamilton Key Unannounced Inspection 12th June 2007 08:50 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 Hope Cottage DS0000051273.V337317.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. Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hope Cottage Address 5-7 Pilkington Road Southport Merseyside PR8 6PD 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) 01704 536286 01704 543222 Hope Cottage Limited Mrs Joan White Care Home 26 Category(ies) of Dementia - over 65 years of age (26) registration, with number of places Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 26 DE (E) The service should employ a suitably qualified and experienced Manager who is registered with the CSCI. 21st June 2006 Date of last inspection Brief Description of the Service: Hope Cottage is a residential care home that specialises in caring for older people with dementia. The home is Registered for 26 residents and is owned by Hope Cottage Ltd. The Responsible Person is Mr T Yilmaz. The Manager is Joan White. Hope Cottage is situated within a suburb of Southport and is within easy reach of the town centre [1 mile]. The home has been extended to include a conservatory and further bedrooms, bathrooms and toilets. The facilities are spread over 2 floors with a passenger lift serving the first floor. All communal space is on the ground floor and includes lounge, conservatory and dining room facilities. There is an enclosed garden to the rear of the building and parking space at the front. A ramp has been added to provide disabled access. 3 of the bedrooms can provide for residents to share. The current fees at the home range between £394.50 - £405.00 per week. Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced ‘key’ inspection took place over one day and lasted approximately 9.5 hours. 25 residents were living in the home at the time of the visit. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The inspector met with the Deputy Manager, care staff, residents and relatives who were visiting the home during the visit. Care Home Survey forms were also distributed to a number of residents and / or their relatives prior to the inspection, to obtain additional feedback about the home. All the core standards were assessed and action taken in response to previous requirements and recommendations from the last inspection in June 2006 was reviewed. What the service does well: Hope Cottage presented as a warm and relaxed environment. Feedback received from residents and their representatives was positive and confirmed that the people using the service were generally satisfied with the standard of service provided. Staff spoken with were knowledgeable about the daily living needs of the people living in the home and the support required to assist them. Comments received from residents included: “I like it here. They are kind to me”; “There is no favouritism. We are all treated exceptionally well which I think is wonderful” and “I am happy here. They care for me.” A relative reported; “My brother seems very content at Hope Cottage and so far as I can see, all is well with him”. The home had developed a ‘Service User Handbook’ and a Contract / Statement of Terms and Conditions in a standard format, to provide prospective residents and / or their representatives with key information on the service. One relative stated; “I visited three times beforehand. Staff were helpful and informative.” Senior staff at Hope Cottage and Social Workers (where applicable) had completed assessments, to ensure the home was able to meet the needs of prospective residents before they moved in. Healthcare needs were managed well and evidence was available on personal files to confirm that residents had received the medical support they needed. Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 6 The home had a programme of activities that had been updated since that last visit, to improve the range of activities provided to residents. A monthly events calendar was also displayed in the home for people to refer to. Records showed that a selection of three activities were facilitated each day for residents to participate in. The standard of catering was good and residents were able to select an alternative choice for most mealtimes. Mealtimes were observed and residents appeared to enjoy their meals with support available from staff. Comments included; “Very nice food”; “I can’t complain. The food is presentable and nice” and “I think the meals are very good.” Staff had access to Induction, National Vocational Qualification, Safe Working Practice and general training that was relevant to their role. Training records were up-to-date and showed that the outstanding learning needs of staff were closely monitored. Staff spoken with confirmed they received support from the management team and the relative of one resident stated; “I find the management and staff excellent.” Sufficient numbers of staff were on duty on the day of the visit to meet the needs of residents and feedback received from staff was generally positive. Comments included; “The staff are nice”; “I like it here. They [staff] are kind to me” and “The carers really are lovely.” Complaints received and referred to the home had been logged and acted upon, to confirm the views of people were taken seriously. Likewise, the home had a quality assurance system in place to monitor the standard of care provided to the people using the service. What has improved since the last inspection? Since the last visit, the home had received ongoing maintenance and investment. Two rooms and the ground floor corridor had been redecorated, one bedroom had been fitted with new furniture, sash windows had been installed over both the front doors and windows had been fitted to two lounges to improve visibility. Thermostatic valves had also been installed to three bathrooms as required at the last inspection, to prevent residents from being accidentally scalded. The programme of activities had been reviewed and developed in accordance with the recreational needs of the people using the service and best practice. Over 50 of the home’s Care staff had completed a National Vocational Qualification in Care at Level 2, to ensure residents were supported by appropriately trained staff. Reports / records were available to account for accidents / incidents within the home, including the action taken. Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 7 What they could do better: Hope Cottage had developed a ‘Service User Handbook’, which contained key information on the home. This should be displayed in the home at all times as previously recommended, to ensure residents and their representatives have access to key information on the service, including details of the Complaints Procedure. The home had adopted a detailed assessment and care planning system however some care plans viewed did not provide sufficient detail of the action required by staff to meet individual needs. This issue was also noted at the last visit. Care Plans must be updated to address this issue so that record keeping is improved and the welfare of residents is fully protected. Records showed that the majority of the staff working in the home had completed training in the Protection of Vulnerable Adults however some staff spoken with lacked awareness of adult protection referral procedures. This should be addressed to ensure an appropriate response to suspicion or evidence of abuse. Medication Administration Records did not provide an audit trail to account for medication received into the home, as details of the date, quantity and the designated staff member responsible for receiving medication into the home had not been recorded. Furthermore, there was evidence that medication was not being given in accordance with the prescribed instructions. Medication records and practice must be reviewed, to ensure the health of the people using the service is safeguarded. Records showed that one member of staff had commenced employment in the home without a Protection of Vulnerable Adult check and two written references. This practice has the potential to place vulnerable people at risk and must stop. The home looked after the personal money of three residents at the time of the visit. Some financial transaction records were not up-to-date and the cash balances did not correspond to the written records. This issue must be addressed to provide evidence that the financial interests of residents are fully protected. The Registered Manager had completed a Management Qualification and a range of training relevant to her role. Arrangements should be made for the Manager to also complete a National Vocational Qualification in Care at level 4, to ensure the Manager has the necessary qualifications for her role. Hot water temperature check records could not be located at the time of the visit and one outlet checked exceeded 50°C. All outlets should be regulated to 43°C and / or risk assessed, to protect the health and safety of residents. Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 9 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 Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, and 3 [Standard 6 is not applicable]. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home undertakes preadmission assessments and provides residents and / or their relatives with information on the service. This assists people to make an informed choice as to whether the home is able to meet their needs. EVIDENCE: The home had developed a ‘Service User Handbook’ to provide prospective residents and / or their representatives with key information on the service provided at Hope Cottage. The handbook was not being displayed in the home on the day of the inspection as previously noted. Feedback received from residents and / or their representatives confirmed they had received sufficient information on the home prior to moving in. For example, a relative reported; “ I visited three times beforehand. Staff were helpful and informative.” A copy of a letter was available on each resident’s file to confirm that a copy of the Service User Handbook and Contracts had been issued to each resident or their personal representative prior to admission. Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 11 The personal files of three residents were viewed during the visit. Preadmission assessments of need had been undertaken for each resident by senior staff, which included information on each resident’s mental health. Additional information on health needs, functional ability and risk assessments was also on file. Copies of assessments completed by social workers had been obtained for residents referred via care management arrangements. Records showed that the manager had written to residents and / or their representatives following an initial assessment, to confirm the home was able to meet the needs of prospective residents, the proposed admission date and room number. Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home manages the personal care needs of residents satisfactorily, however care plans and medication records are in need of attention, to safeguard the health and welfare of residents. EVIDENCE: Three resident’s files were viewed during the visit. Each file contained a care plan together with range of personal information including risk assessments, daily report sheets, accident records and health care records. Care Plans were based upon a model of care called ‘Activities of daily living’. This model provides a framework for staff to assess and plan care around routine daily activities such as washing, eating and self-care. Staff spoken with during the visit were able to give examples of how they provide person-centred care to the people using the service. Some care plans viewed were vague and did not set out in detail the action required by staff to meet the individual needs of residents. For example, one Care Plan identified “Mental State” as an assessed need, the “Aim of Care” section had not been completed and the “Key Worker Instruction” section did Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 13 not provide information on interventions required from staff. Other examples were discussed with the Deputy Manager during the visit. Similar findings were noted at the last visit. Care plans viewed had been kept under monthly review and relatives had been invited to attend review meetings on a regular basis. A new review form had been introduced since the last visit, to improve monthly review records. Feedback received from residents and / or their representatives confirmed the people in the home received the medical support they needed. Evidence of doctor, district nurse, chiropodist and optician appointments were available on files viewed. The home had medication policies and procedures in place. Staff spoken with confirmed they had read the policies and completed medication training. Due to issues of mental capacity none of the residents living in the home were selfmedicating at the time of the visit, although there was a procedure available if required. Medication was found to be appropriately stored and separate storage facilities were available for controlled medication. An identification system had been established to enable staff to check the identity of residents prior to administering medication. Medication Administration Records were checked. Records viewed did not provide an audit trail for Medication received into the care home as the date, quantity and details of the person responsible for checking medication entering the home had not been recorded. No other audit records had been established. Other issues were also brought to the attention of senior staff. For example, the staff member responsible for administering medication reported that 84 Ibuprofen 200m/g tablets were received on the 15/05/07. Records showed that the medication had been signed for 35 times which should have left a balance of 49 tablets. The actual balance was 54 tablets. Advice was also given on additional matters such as PRN [give when required] medication. Feedback received from residents and their representatives confirmed they were generally satisfied with the care provided in the home. Residents were observed to be clean and appropriately dressed. Staff spoken with demonstrated a commitment to meeting the diverse needs of the people using the service and an awareness of the need to promote social care values into practice. Comments received from residents included; “I like it here. They are kind to me”; “There is no favouritism. We are all treated exceptionally well which I Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 14 think is wonderful” and “I am happy here. They care for me.” Likewise, a relative reported; “My brother seems very content at Hope Cottage and so far as I can see, all is well with him”. Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to maintain their independence and exercise choice in relation to daily life, social activities and meals. This enables the people living in the home to lead a lifestyle that satisfies their needs and expectations. EVIDENCE: Feedback received from residents and their representatives confirmed the home provided a range of activities, which generally were organised in the afternoons. A list of weekly activities and a monthly events calendar was displayed in the home for residents to refer to. The programme had been reviewed / updated since the last visit. Activities organised by the home included: reminiscence cards; ball, card and board games; quizzes; building blocks; chair exercises; relaxation; conversation; dominoes; bingo; hand and eye coordination; soft toys; reading; crafts; foot and nail care; bible reading and music / films. The deputy manager reported that no ministers of religion or church representatives visited the home at the time of the visit and confirmed that the religious / spiritual needs of residents were closely monitored as part of the assessment and review process. Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 16 The personal exercise of choice and control over each resident’s daily life in the home is a difficult balance to achieve given the lack of mental capacity of the people living in the home. The general atmosphere in the home was warm and friendly and residents were observed to be able to follow their preferred routines and receive visits from relatives. Staff spoken with demonstrated a good understanding of the rights and diverse needs of the people living in the home. The home had a four-week rolling menu, which was displayed for residents to view. This showed that residents received a selection of wholesome and nutritious meals. Daily choices were available for breakfast and lunch-time meals however some tea time meals only offered one option for residents. Meals were served in the home’s dining room, which was furnished to a good standard. Tables were laid with tablecloths and fresh flowers and staff were available to provide support and assistance for residents who found it difficult to eat their meals independently. The cook reported that meals were generally freshly prepared and that the special dietary needs of current and prospective residents would be catered for, subject to individual need. Feedback received from residents and their representatives confirmed the people living in the home enjoyed the meals. Comments included; “Very nice food”; “I can’t complain. The food is presentable and nice” and “I think the meals are very good.” Hope Cottage DS0000051273.V337317.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and / or their representatives were able to express their concerns via a complaints procedure so that their rights were upheld and their concerns acted upon. Some staff required refresher training in abuse awareness, to ensure they understand how to recognise and respond to suspicion or evidence of abuse. EVIDENCE: The home had developed a ‘Complaints, Suggestions and Compliments’ policy in a standard format. Information on the home’s complaints procedure had also been included in the home’s ‘Service User Handbook’. A copy of the procedure was not being displayed at the time of the visit however staff were able to explain how complaints are managed and feedback received from residents and / or their representatives confirmed they were aware of who to speak to if they were unhappy and how to make a complaint. The home’s record of complaints was viewed during the visit. This showed that three complaints had been received since the last inspection. Two of the complaints had been received by the Commission for Social Care Inspection and referred to the Provider for investigation. The nature of the complaints were as follows. The first complaint concerned injuries sustained by a former resident following two falls. The second complaint concerned a number of issues including: the standard of personal care offered to a resident; activities in the home; the attitude of management Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 18 and staff and the cleanliness of the environment. The third complaint concerned some missing facecloths. The pre-inspection questionnaire received from the home did not detail whether the complaints had been substantiated however, records viewed provided evidence that complaints received by the home had been investigated and acted upon by the home. Policies and procedures had been developed to provide guidance to staff on how to respond to suspicion or evidence of abuse. Some staff spoken to were not entirely clear about how to complete referrals. This issue was also noted at the previous inspection. The home’s training matrix showed that 14 staff had completed training in the Protection of Vulnerable Adults since the last inspection. Some gaps were noted however the inspector was informed that the full staff team would complete the training. Hope Cottage DS0000051273.V337317.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment was generally well maintained and this provided residents with a safe, comfortable and homely environment in which to live. EVIDENCE: Hope Cottage had access to one part-time and one full-time handypersons who were responsible for maintaining homes within the Cedars Care Group. Maintenance sheets were in place to record work in need of attention and an annual maintenance plan had been developed, to ensure the home received ongoing investment and maintenance. Pre-inspection records showed that the home had continued to receive ongoing maintenance and investment since the last visit. Two rooms and the ground floor corridor had been redecorated, one bedroom had been fitted with new furniture, sash windows had been installed over both the front doors and windows had been fitted to two lounges to improve visibility. Thermostatic valves had also been installed to three bathrooms. Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 20 A tour of the premises was undertaken during the visit. The home is not purpose built for people with dementia, as the bedrooms are situated over three floors and therefore not immediately accessible. Areas viewed appeared well maintained and the home was warm and welcoming. Residents had personalised their rooms with pictures and other memorabilia and the fabric and decoration was in good order. The deputy manager reported that the home was in the process of ordering name / picture plates to aid residents’ orientation around the home using signs and photographs. Only six of the twenty-six rooms in the home were equipped with en-suite facilities however a choice of bathing facilities, both assisted and unassisted, were available for residents to use including a walk in shower. Previous inspection records confirmed that shared rooms had been fitted with curtain screens to ensure privacy. Please refer to the ‘Brief Description of the Service’ section for more information on the premises. Feedback received from residents and their representatives confirmed the home was kept clean and fresh and no unpleasant odours were noted during the visit. Two ‘Housekeepers’ were on duty at the time of the visit. Staff spoken with confirmed they had access to Infection Control and Control of Substances Hazardous to Health (COSHH) Policies and Procedures. Some staff reported that they had not completed training in infection control to date, as scheduled training had been had been cancelled by the training provider. Hope Cottage DS0000051273.V337317.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff were deployed in sufficient numbers and received training to ensure the needs of residents were appropriately met. Recruitment practice required attention, as it did not consistently protect the welfare of residents. EVIDENCE: On the day of the visit the home had 25 residents. Direct observation and examination of rotas confirmed that the home was staffed with a senior carer and 3 care assistants from 8.00 am to 8.00 pm. The Deputy Manager reported that changes had been made to the night staffing during January 2007 in response to the changing dependency levels of the residents. Staffing levels had increased from two waking night staff and a sleep-in to three waking night staff. Rotas viewed did not clearly identify whether a waking night staff or sleep-in was being provided for the third staff member. The deputy manager agreed to address this. The Manager worked Monday to Friday each week or as required by the service and ancillary staff were employed for working in the kitchen, cleaning and laundry duties. Feedback received from residents and their representatives was positive about the staffing team and confirmed the people living in the home received the care and support they needed. Comments included; “The staff are nice”; “I like it here. They [staff] are kind to me” and “The carers really are lovely.” Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 22 Pre-inspection records showed that the home employed 13 care staff (including the deputy manager). Examination of training certificates showed that 6 staff (46.15 ) had attained a National Vocational Qualification in Care at level 2 or above. The deputy manager reported that a further two staff (15.38 ) had completed the training and were awaiting certification and four staff were in the process of working towards the award. The home had appropriate policies and procedures in place for the recruitment of staff. Records showed that two staff had commenced employment at the home in different capacities since the last visit. Only one of the two files viewed contained all the necessary documentation required under the Care Home Regulations 2001. One of the staff members had started work in the home without a Protection of Vulnerable Adult (POVA) check and only one reference. Arrangements were made to obtain the POVA check during the visit. The deputy manager confirmed that new care staff would be inducted in accordance with the Skills for Care ‘Common Induction Standards’. Staff spoken with confirmed they had received and / or were in the process of completing an induction and received training relevant to their role and responsibilities. The home’s training matrix showed that staff had access to a comprehensive range of training including; dementia awareness, equality and diversity and Safe Working Practice topics e.g. Health and Safety, Fire Training, Moving and Handling, First Aid, Food Hygiene and Infection Control. Some minor gaps were noted for some training topics however records provided evidence that the outstanding training needs of staff were being monitored and addressed in partnership with the Organisation’s ‘Training Coordinator’. Pre-inspection records detailed that Induction, Safe Working Practice, Protection of Vulnerable Adult, Dementia Awareness, Medication Management and National Vocational Qualification training had been completed since the last visit. Hope Cottage DS0000051273.V337317.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration of some key records is in need of review, to demonstrate that the welfare of residents is adequately safeguarded. EVIDENCE: The manager, Mrs Joan White, was registered with the Commission for Social Care Inspection and had managed the home for approximately 4 years. Mrs White was not available during the inspection as she was on holiday. Training records detailed that the Manager had completed the National Vocational Qualification (NVQ) level 4 in Management but did not have a NVQ level 4 in Care. Certificates were available to confirm that the manager had continued to update her skills. Since the last visit the Manager had completed Moving and Handling, Fire Prevention in the Home, Medication Management and Adult Protection Awareness training. Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 24 Staff spoken with reported that they felt supported in their duties by the manager and her deputy. Likewise, the relative of one resident stated; “I find the management and staff excellent.” The home continued to receive an external audit on an annual basis. This assessment was commissioned by the Owner in order to monitor and improve quality. Records were available to confirm that the Owner / appointed representative had also undertaken monthly visits and produced reports in accordance with Regulation 26 of the Care Home Regulations 2001. The manager had developed her own objectives, which were displayed in the office. The objectives were linked to both the audit and CSCI inspections. The Deputy Manager reported that ‘Service User Satisfaction Surveys’ were sent to the personal representatives of residents every 6 months to canvass views. This was last completed during February and March 2007. The results of the survey had been collated but they had not been displayed for interested parties to view. A suggestion box was located near the main entrance to enable residents and their representatives to share views anonymously. Pre-inspection records detailed that the manager acted as an appointee for one resident only. The deputy manager reported that all the other residents looked after their finances with support from family members, social workers and / or personal representatives. The Organisation’s head office was responsible for invoicing and administering fees. The home looked after personal money for three residents. Records of financial transactions checked were not-up-to-date and did not correspond with balances checked. Money had not been pooled together and receipts had been obtained for expenditure. The home had a ‘Health and Safety’ Policy and Procedure and a number of Health and Safety audits and risk assessments had been developed. Preinspection records detailed that maintenance and associated records were upto-date. A selection of key records were viewed during the visit. These included; insurance, fire safety, water testing / cleaning, portable appliance testing, gas safety, electrical wiring, passenger lift and hoisting equipment. Records / Certificates were available to confirm equipment in the home received regular tests / servicing. The Deputy Manager reported that the handyperson undertook monthly water temperature checks on the water. These could not be located at the time of the visit. The home was advised to review the installation / temperature settings of thermostatic regulator valves as one outlet tested in the presence of the deputy manager exceeded 50°C. Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 25 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 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 Score 3 3 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 3 Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 26 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 Requirement Care plans must contain all care needs and detail particular interventions in greater detail. [Previous timescale of 01/08/06 not met]. The date received, quantity of medication and the initials of the person receiving / checking medication into the home must be recorded on the Medication Administration Records, to ensure an appropriate audit trail is maintained. Medication must be administered in accordance with the Prescribed Instructions, to ensure the health and wellbeing of residents is maintained. Staff must not commence employment in the home until a Protection of Vulnerable Adult check and two satisfactory references have been received, to protect the welfare of the people using the service. Timescale for action 12/09/07 2 OP9 17 (1) (a) Schedule 3 (i) 12/07/07 3 OP9 13 (2) 12/07/07 4 OP29 19 (1) (b) 12/07/07 Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 27 5 OP35 17 (2) Schedule 4 (9) Up-to-date records of all money deposited / received on behalf of service users must be maintained at the home, to provide a clear audit trail and confirm the financial interests of residents are safeguarded. 12/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP1 OP15 OP18 Good Practice Recommendations The home’s ‘Service User Handbook’ should be displayed in the home at all times, for prospective residents and their representatives to view. The menu should be updated to offer an alternative choice for all tea-time meals. All staff should complete Protection of Vulnerable Adults training and refresher training should be arranged as required, to ensure staff understand how to recognise and respond to evidence or suspicion of abuse. The Manager should complete a National Vocational Qualification in Care at level 4 or equivalent, to ensure she has the necessary qualifications for her role. The regulation of all hot water outlets should be closely monitored, to ensure they do not exceed 43°C. 4 4 OP31 OP38 Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hope Cottage DS0000051273.V337317.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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