CARE HOMES FOR OLDER PEOPLE
Hope Cottage 5-7 Pilkington Road Southport Merseyside PR8 6PD Lead Inspector
Daniel Hamilton Key Unannounced Inspection 19th May 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hope Cottage DS0000051273.V365054.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.V365054.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 hopecottage@cedarscaregroup.co.uk 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.V365054.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. 12th June 2007 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 £415.00 - £510.00 per week. Hope Cottage DS0000051273.V365054.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes.
This unannounced ‘key’ inspection was carried out over one day and lasted approximately 9 hours. 21 people 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 viewed and the Registered Manager, Deputy Manager, care staff, residents and relatives were spoken with during the visit. Survey forms were also distributed to a number of staff, residents and / or their relatives prior to the inspection to obtain additional feedback about the home. All the key standards were assessed and progress / action taken in response to the previous requirements and recommendations from the last key inspection in June 2007 was reviewed. Full feedback was given to the manager on conclusion of this inspection. What the service does well:
Residents and relatives spoken with during the inspection were complimentary of the staff team and the care provided at Hope Cottage. Comments received from people using the service included: “The staff appear to be OK and are generally helpful”; “I have no concerns about the way I am cared for”; “The carers are there when we need them” and “I could not grumble. They [staff] are so good to me.” Likewise, a relative reported; “I am of the opinion that my mother and the other residents are properly cared for.” The environment was generally well maintained and this provided the people living in Hope Cottage with a pleasant and comfortable home. Areas viewed during the inspection appeared generally well maintained, clean and hygienic and the owner had continued to invest in the upkeep of the home. The home had developed a range of information in a standard format to provide prospective residents and / or their representatives with key information on the service. The information available included a ‘Service User Handbook’ and a Contract / Statement of Terms and Conditions.
Hope Cottage DS0000051273.V365054.R01.S.doc Version 5.2 Page 6 Residents, staff and visitors spoken with confirmed the people in the home had access to health care professionals as and when required. Evidence of doctor, district nurse, chiropodist and dietician appointments were available on files viewed A weekly programme of activities and records showed that a selection of three activities were facilitated each day for residents to participate in. Records of the date, type of activity and participants were available for reference and individual records were available on personal files and a resident confirmed that; “Activities are provided each day for anyone that wishes to join in.” Some residents expressed an interest in community based activities and this interest should be further explored. A three-week rolling menu had been developed and the standard of catering was good. Residents were able to select an alternative choice for each mealtime and confirmed they were satisfied with the standard of catering. Comments included; “The food is pleasant and we get a choice at each meal”; “The meals are nice and well prepared” and “I can’t complain. The food, drink, people and carers are all wonderful.” 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 inspection, Medication Administration Records (MAR) had been updated. The date, quantity and initials of the staff member responsible for receiving medication into the home had been recorded in order to provide an audit trail. Furthermore, MAR viewed provided evidence that medication had been administered in accordance with the prescribed instructions and this safeguarded the health of the people using the service. Staff had been correctly recruited and Protection of Vulnerable Adult (POVA) and two satisfactory references had been received for new employees. This protected the welfare of the people using the service. Arrangements had been made for family members or appointed personal representatives to assist residents with the management of their personal finances as required, in order to safeguard the financial interests of residents. Spending money was no longer managed by the manager or senior staff in the home. A copy of the ‘Service User Handbook’ had been displayed in the reception area of the home for people to view and the menu had been updated to offer an alternative choice for all tea-time meals.
Hope Cottage DS0000051273.V365054.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. The summary of this inspection report can be made available in other formats on request. Hope Cottage DS0000051273.V365054.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 Hope Cottage DS0000051273.V365054.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 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. Pre-admission assessments are undertaken and information on the home has been produced to enable prospective residents and / or their relatives to make an informed choice as to whether the service is able to meet their needs and expectations. EVIDENCE: A ‘Service User Handbook’ had been developed in a standard format to provide prospective residents and / or their representatives with key information on the service provided at Hope Cottage. A copy of the document was displayed in the reception area for people to view and a letter was available on residents’ files to confirm that a Service User Handbook and Contracts had been issued to each resident or their personal representative prior to admission. Hope Cottage DS0000051273.V365054.R01.S.doc Version 5.2 Page 10 The personal files of three residents were viewed during the visit. Each file contained a pre- admission assessment of need, which included information on each resident’s mental health. Additional information on health needs, functional ability and risk assessments were also available on files as previously noted. Gaps in assessment information were noted for each file viewed and examples were discussed with the manager during the visit. For example, one file viewed lacked information on medical history, past life course, history of falls, sight hearing and communication and oral health. Furthermore, some equality and diversity information had not been obtained as part of the assessment process i.e. cultural and religious needs. Despite the absence of some key information, staff spoken with demonstrated a satisfactory understanding of the diverse needs of the people living in the home. Furthermore, copies of assessments completed by social workers or health professionals had been obtained for residents referred via care management arrangements. Hope Cottage DS0000051273.V365054.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems have been established to ensure the health and personal care needs of residents are identified and planned for. This ensures the people using the service remain healthy and that they receive the level of care they need. EVIDENCE: Three care files were randomly selected to view 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. Care plans viewed outlined the ‘assessed need’, ‘aim of care’ and ‘key worker instructions’ for a range of areas including: Maintaining a Safe Environment; Communication; Breathing; Eating and Drinking; Elimination; Personal Hygiene; Controlling Body Temperature; Mobility; Sleeping; Mental state, Work and Play and Miscellaneous issues.
Hope Cottage DS0000051273.V365054.R01.S.doc Version 5.2 Page 12 The information contained within care plans was brief and records showed that only two of the three plans viewed had been kept under regular monthly review. These issues were discussed with the manager during the visit and advice was given on how the information could be further improved. Residents, staff and visitors spoken with confirmed the people in the home had access to health care professionals as and when required. Evidence of doctor, district nurse, chiropodist and dietician appointments were available on files viewed. The manager was advised to also include information on the promotion of health care within care plans. Due to issues of mental self-medicating at the Assessment (AQAA) for place for the Control, Medicines. capacity none of the residents living in the home were time of the visit. The Annual Quality Assurance the service confirmed policies and procedures were in Storage, Disposal, Recording and Administration of Staff spoken with confirmed they had read the medication procedures for the home and that they had completed external medication training. No system had been established to review the competency of staff responsible for medication at the time of the visit and advice was given to the manager on how to address this matter. 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 as previously noted. A sample of Medication Administration Records (MAR) were checked during the visit. Records viewed had been correctly completed to account for medication received into Hope Cottage and for medication administered to residents. Only one issue was noted with a MAR. This concerned the use of a code ‘M’ on a MAR sheet. Staff spoken with were unable to explain why the code had been used as there was no explanation on the reverse side of the MAR sheet. The manager was advised to remind staff to always account for the use of codes on the rear side of the MAR sheet, to ensure a clear audit trail. Feedback received from residents and their representatives confirmed the people living in the home received the care and support they needed. For example, a relative reported; “I am of the opinion that my mother and the other residents are properly cared for.” Likewise, a resident stated; “The staff support me to look after myself.” Staff were observed to communicate and interact with residents in a positive manner during the visit and demonstrated an awareness of the principles of care and the needs of the people they cared for.
Hope Cottage DS0000051273.V365054.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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. Overall, meals and social activities are varied and offer the people using the service the opportunity to exercise choice and control. EVIDENCE: Feedback received from residents and their representatives confirmed the home continued to provide a range of activities, which generally were organised in the afternoons at approximately 2.00 pm. One resident stated; “Activities are provided each day for anyone that wishes to join in.” A list of weekly activities and a monthly events calendar was also displayed in the home for residents to refer to. The Annual Quality Assurance Assessment for the service detailed that outside entertainers also visited the home at least once per month. The home’s activities coordinator was spoken with during the visit and confirmed that no significant changes had been made to the programme since the last visit. The majority of activities continued to be coordinated within the home. Hope Cottage DS0000051273.V365054.R01.S.doc Version 5.2 Page 14 The activities on offer 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. Records of the date, type of activity and participants were available for reference and individual records were available on personal files. No ministers of religion or church representatives visited the home at the time of the visit. The activities coordinator reported that the religious / spiritual needs of residents were closely monitored as part of the assessment and review process and that efforts had been made to engage the input of local church representatives from different denominations. Residents spoken with confirmed they were generally satisfied with the activities in the home however two residents spoken with expressed an interest in community-based activities during the inspection. This should be explored in order to fully satisfy the recreational needs and expectations of the people living in the home. 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 majority of residents spoken with confirmed they were able to follow their preferred routines however the inspector was informed that it was normal practice for some residents to be assisted to prepare for going to bed from 6.30 pm. This information was discussed with the manager during the inspection and the manager confirmed that she would stop this practice immediately. The general atmosphere in the home was warm and friendly and residents were observed to receive visits from relatives. One resident reported; “I receive visits from my son and he is always welcome.” Since the last visit the four-week rolling menu had been replaced with a three week rolling menu. The cook confirmed that the menu plan was reviewed every three months and that the health, religious and / or cultural dietary needs of residents would be catered for. A copy of the daily menu was displayed in the dining room and laminated menus were available on each table for residents to view. Examination of menus confirmed that residents continued to receive a selection of wholesome and nutritious meals. Since the last visit the menus had also been updated to include an alternative choice for tea-time meals as recommended at the last visit. Hope Cottage DS0000051273.V365054.R01.S.doc Version 5.2 Page 15 A number of comments were received regarding the standard of catering. These included: “The food is pleasant and we get a choice at each meal”; “The meals are nice and well prepared” and “I can’t complain. The food, drink, people and carers are all wonderful.” Hope Cottage DS0000051273.V365054.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems have been established to ensure an appropriate response to complaints and suspicion or evidence of abuse. This ensures that the views of people using the service are listened to and acted upon and that people are offered protection from abuse. EVIDENCE: A ‘Complaints, Suggestions and Compliments’ policy had been developed in a standard format to provide information for the people using the service and/or their representatives. The manager was advised to update the procedure in order to include the new contact details of the Commission for Social Care Inspection and to explore the possibility of developing the Complaints procedure in alternative formats. Information on the complaints procedure for Hope Cottage had been included in the home’s ‘Service User Handbook’, a copy of which was displayed on the notice board in the reception area. Letters were also available on files to confirm that a copy of the ‘Service User Handbook’ been sent to residents or their personal representatives /family. Residents and relatives spoken with during the visit reported that they had no complaints about the service and confirmed they were confident that the management team would address any issues of concern. Residents also confirmed that they felt safe living at Hope Cottage. For example, one resident stated; “I’m happy and have no worries.”
Hope Cottage DS0000051273.V365054.R01.S.doc Version 5.2 Page 17 The complaints record for Hope Cottage was viewed during the visit. This showed that two complaints had been received by the manager since the last inspection. One of the complaints had been received by the Commission for Social Care Inspection and the other by Sefton Council. Both complaints had been referred to the Provider for initial investigation and one had also been referred to the local authority safeguarding adults team. Records viewed provided evidence that complaints received by the home had been investigated and acted upon by the home. The first complaint concerned the general care provided to a resident and the other concerned the level of care / supervision provided to a resident during the night and an unexplained injury. The Annual Quality Assurance Assessment for the service detailed that the outcome of the complaints was not known and the manager confirmed this at the time of the visit. Policies and procedures had been developed to provide guidance to staff on how to respond to suspicion or evidence of abuse. The policies included an ‘Avoidance of Abuse’ and a ‘Whistleblowing’ procedure. A copy of the City of Liverpool and Borough of Sefton adult safeguarding adults procedure was also in place. The home’s training matrix showed that 10 of the 19 staff had completed training in the Protection of Vulnerable Adults. The manager reported that arrangements would be made for all new employees and outstanding staff to complete this training as a matter of priority in order to protect the welfare of the people using the service. Overall, the manager and staff spoken with were able to demonstrate a good understanding of the different types of abuse, reporting procedures and their duty of care to protect vulnerable adults from abuse. Only one employee spoken with lacked knowledge and understanding in this key area and the manager agreed to address this important learning need as a matter of priority. Hope Cottage DS0000051273.V365054.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. 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 is generally well maintained and provides residents with a safe, comfortable and homely environment, which meets their specific needs. EVIDENCE: Hope Cottage had access to one part-time and one full-time maintenance personnel 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 as and when required. Health and Safety audits and risk assessments were also undertaken and reviewed periodically, to monitor the condition of the environment and to control potential / actual risks. Hope Cottage DS0000051273.V365054.R01.S.doc Version 5.2 Page 19 The Annual Quality Assurance Assessment (AQAA) for Hope Cottage detailed that the environment had received ongoing maintenance of the interior and exterior parts of the building. Since the last visit, the conservatory had been redecorated and refurbished and new laundry equipment had been purchased. Furthermore, the dining room had been redecorated and new flooring fitted and new flooring had also been fitted in the hallway leading to the conservatory. A visual recognition system had also been introduced and pictures of residents had been fitted to their bedroom doors to aid residents with orientation. A tour of the premises was undertaken during the visit. As previously noted the home is not purpose built for people with dementia, as the bedrooms are situated over three floors and therefore not immediately accessible. Rooms viewed were personalised and residents were observed to have access to personal mobility aids, subject to individual needs. 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. Two ‘Housekeepers’ were on duty on the day of the visit and areas viewed appeared generally well maintained, clean and hygienic. No unpleasant odours were noted. A resident reported; “The place is always clean and tidy.” The Annual Quality Assurance Assessment (AQAA) for Hope Cottage detailed that a policy for preventing infection and managing infection control was in place. Records showed that 7 staff required training in infection control and the manager agreed to address this issue as a matter of priority. The manager was also recommended to review the installation/temperature settings of thermostatic valves throughout the building as previously recommended, as one hot water outlet in a bedroom exceeded 50°C when tested. The manager was also advised to purchase pressure alarm mats to assist night staff in monitoring residents who wander and/or at risk of falling during the night. Hope Cottage DS0000051273.V365054.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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 are correctly recruited however gaps in induction and care specific training are in need of review, to ensure the welfare of the people using the service is fully safeguarded. EVIDENCE: On the day of the visit the home had 21 residents. The manager reported that staffing levels had been changed since the last inspection to reflect the lower occupancy levels. Direct observation and examination of rotas confirmed that the home was staffed with a senior carer and 2 care assistants from 8.00 am to 8.00 pm. During the night the home was staffed with three waking night staff. Residents spoken with were complimentary of the staff team. Comments included: “The staff appear to be OK and are generally helpful”; “I have no concerns about the way I am cared for”; “The carers are there when we need them” and “I could not grumble. They [staff] are so good to me.” The manager was advised to utilise a dependency assessment tool in order to provide evidence that the revised staffing levels during the day were adequate to meet the needs of residents at all times of the day. Hope Cottage DS0000051273.V365054.R01.S.doc Version 5.2 Page 21 The manager continued to work Monday to Friday each week or as required by the service (up to 18 hours per week). Ancillary staff were also employed for working in the kitchen, cleaning and laundry duties. Pre-inspection records showed that the home employed 13 care staff (including the deputy manager). Examination of training records and discussion with the manager confirmed that 6 staff (46.15 ) had attained a National Vocational Qualification in Care at level 2 or above. The manager reported that a further four staff (30.76 ) had also completed a NVQ level 2 in Care or equivalent and were awaiting certification. Two additional staff were in the process of working towards the award at the time of the visit. The Annual Quality Assurance Assessment (AQAA) for Hope Cottage detailed that policies and procedures were in place for the recruitment and employment of staff including redundancy. The manager reported that four staff had commenced employment at Hope Cottage in different capacities since the last visit. The recruitment files for the four staff were viewed and each file contained the necessary documentation required under the Care Home Regulations 2001. Evidence of staff induction was available on files viewed however induction records were not fully compliant with the required Skills for Care Induction standards. This issue was also noted at the last inspection. A copy of the Skills for Care Induction paperwork was available in the home for the manager and staff to reference. The manager was advised that staff must be inducted in accordance with the ‘Skills for Care’ Common Induction Standards within a 12 week period of commencing employment and that a progress log and certificate of successful completion should be retained on file to provide evidence that staff are competent and ‘Safe to leave’. Staff spoken with confirmed they had received an induction, ongoing supervision sessions and training relevant to their role and responsibilities. The home’s training matrix showed that staff had access to a comprehensive range of training however significant gaps were noted for abuse, infection control, health and safety, equality and diversity and care specific training i.e. pressure area care, continence awareness, optical awareness etc. The manager reported that the training needs of staff were monitored in partnership with the Organisation’s ‘Training Coordinator’ and confirmed the outstanding training needs of staff would be addressed. Hope Cottage DS0000051273.V365054.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. 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. Systems have been established to monitor the operation of the service and to ensure it is run in the best interests of service users. EVIDENCE: The manager, Mrs Joan White, is registered with the Commission for Social Care Inspection and has managed the home for approximately 5 years. Previous inspection records confirm the Manager had completed the National Vocational Qualification (NVQ) level 4 in Management and a range of training specific to her role. The manager did not have a NVQ level 4 in Care as noted at the last inspection. Hope Cottage DS0000051273.V365054.R01.S.doc Version 5.2 Page 23 Prior to the inspection the manager completed a document known as an Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service and provides some numerical information about the service. The information in the document was brief but sufficient to inform the inspection process. Feedback received from staff confirmed the manager was approachable, supportive and provided clear leadership and direction to the team. Records were available to confirm that the Responsible Individual or his appointed representative had undertaken monthly visits and produced reports in accordance with Regulation 26 of the Care Home Regulations 2001. The home continued to also receive an external audit on an annual basis. This assessment was commissioned by the Owner in order to monitor and improve quality and was last undertaken during March 2008. Furthermore, questionnaires / Surveys had also been sent by the manager to residents or their personal representatives every 6 months to canvass views. This was last completed during February 2008. The results of the survey had been collated but they had not been displayed for interested parties to view as previously noted. The manager agreed to address this matter. Care plan records showed that meetings had been coordinated with residents and their relatives periodically and a suggestion box was located near the main entrance to enable residents and their representatives to share views anonymously. The manager reported that she did not act as an appointee for any of the people living at Hope Cottage and that personal and spending money was no longer managed by herself or senior staff in the home. The Organisation’s head office was responsible for invoicing and administering fees and family members or appointed personal representatives assisted residents with the management of their personal finances as required. The Annual Quality Assurance Assessment (AQAA) for the service detailed that the home had a ‘Health and Safety’ Policy and Procedure in place for staff to reference as previously noted. Furthermore, the AQAA detailed that equipment within the home had been regularly maintained and serviced. Fire records were checked during the visit. The records showed that alarm system was tested on a weekly basis and that the emergency lighting and fire extinguishers were inspected on a monthly basis. A fire risk assessment had been completed during January 2008 and records of fire instruction training were available for staff. Hope Cottage DS0000051273.V365054.R01.S.doc Version 5.2 Page 24 The manager was advised to specify the capacity of care staff on the records i.e. day or night staff and to ensure that day staff received training at least every six months and night staff every three months. Furthermore the manager was requested to obtain copies of the service certificates for the fire alarm system, extinguishers and emergency call system as they could not be located at the time of the visit. Records were in place to confirm Health and Safety audits and risk assessments had been undertaken and reviewed periodically, to monitor the condition of the environment and to control potential/actual risks. Hope Cottage DS0000051273.V365054.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 Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 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 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Hope Cottage DS0000051273.V365054.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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. 4. 5. Refer to Standard OP3 OP7 OP7 OP22 OP30 Good Practice Recommendations All sections of the Pre-admission assessment should be completed, to ensure a holistic assessment of need is undertaken. All care plans should be kept under monthly review to provide evidence that the changing needs of residents are monitored. Care plans should provide more detailed information on how the needs of the people using the service are to be met. Pressure alarm mats should be purchased to assist night staff in monitoring residents who are at risk of wandering and / or falling at night. Staff should complete the ‘Skills for Care’ Common Induction Standards within 12 weeks of commencing employment in the home, to provide evidence that they are competent and ‘safe to leave’. Hope Cottage DS0000051273.V365054.R01.S.doc Version 5.2 Page 27 6. OP30 7. 8. OP31 OP38 Action should be taken to ensure that all care staff complete; abuse awareness, safe working practice, care specific and equality and diversity training to ensure they are sufficiently trained for their role and responsibilities. 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. Copies of the most recent service certificates for the fire alarm system, extinguishers and emergency call system should be obtained and available on the premises for inspection, to verify the information contained within the Annual Quality Assurance Assessment. Hope Cottage DS0000051273.V365054.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North West Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 0LG 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
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