Inspection on 08/05/08 for John Joseph Powell Memorial Care Centre

This inspection was carried out on 8th May 2008.

CSCI found this care home to be providing an Adequate service.

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.

Other inspections for this house

John Joseph Powell Memorial Care... 05/06/07

John Joseph Powell Memorial Care... 27/09/06

John Joseph Powell Memorial Care... 08/11/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE John Joseph Powell Memorial Care Centre McKenna`s Court 11A High Street Prescot Merseyside L34 3LD Lead Inspector Mike Perry Key Unannounced Inspection 8th May 2008 10:00 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 DS0000065162.V364673.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. DS0000065162.V364673.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service John Joseph Powell Memorial Care Centre Address McKenna`s Court 11A High Street Prescot Merseyside L34 3LD 0151 431 0247 0151 431 0247 jjp@meridiancare.co.uk 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) Meridian Healthcare Ltd Mrs Dorothy Pye Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places DS0000065162.V364673.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - Code PC, to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 45 Date of last inspection 5th June 2007 Brief Description of the Service: John Joseph Powell Memorial Nursing Home is registered to provide nursing care for forty-five older people. The homes registration is for thirty-eight older persons over the age of sixty-five and seven persons under pensionable age. The home also provides seven beds for palliative (terminal) care. Intermediate care is no longer provided. John Joseph Powell is located in the Prescott area of Liverpool, close to local shops and road links. The home is purpose built over two floors. There is a passenger lift to access all areas and handrails are in place in the main corridors. Recreational space comprises of a dining room, lounges and conservatory. These rooms are bright and attractively decorated. Bathrooms have suitably adapted equipment and a call system with an alarm facility is operational for the residents. The home has garden areas, a large pond and a secure entrance to the car park. The home was acquired by Meridian Healthcare Limited in July 2005. Meridian Healthcare owns other care homes in the area, Leeds, Tameside and Scunthorpe. Mrs Dorothy Pye is the registered manager. The current fees are £515.39 - £530.00 DS0000065162.V364673.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 1 star. This means the people who use this service experience adequate quality outcomes. The inspection was a ‘key’ inspection for the service and covered the core Standards the home is expected to achieve. The inspection took place over two days and took a total of 10 hours. The inspector met and spoke with a number of residents and a number of relatives and visitors who were visiting over the two days. There were additional conversations with care professionals by phone before and following the visit. This was mainly in the context of a safeguarding investigation that was being undertaken at the time – the details of which are in the report. The inspector also spoke with members of care staff on a one to one basis and the deputy manager and senior nurses. Comment cards asking about standards in the service were also given out and collected and many of these were returned from both staff and residents and relatives. A tour of the premises was carried out and this covered most of the home including some of the resident’s rooms [not all bedrooms were seen]. Records were examined and these included four of the resident’s care plans, staff files, staff training records and health and safety records. Although all core standards were reviewed the inspector was guided by the two previous inspections and more particularly the random inspection in March 2008, which [again] highlighted that care was not of a consistent standard and this was related to fluctuating staffing levels. What the service does well: All residents are assessed prior to admission to the home. Appropriate social care and health care assessments are completed. Following admission there are further, more detailed, assessments carried out covering areas such as manual handling, falls, and nutrition so that a plan of care can be drawn up. Residents felt that health care generally is well monitored and that they are in safe hands. A relative spoken with also agreed: DS0000065162.V364673.R01.S.doc Version 5.2 Page 6 ‘They are brilliant. Cant do enough for my relative and they always keep me informed’. Over the two days in the home there was much activity in terms of visitors and staff interacting with residents and receiving ongoing support. The home was very lively and the general atmosphere was positive and friendly. The residents interviewed felt that staff were approachable and helpful. Residents were observed to be interacting with each other and where easy to engage in conversation. Relatives interviewed reported that they were always welcomed and could visit at any time. Other comments received were generally positive and evidenced a good rate of satisfaction amongst residents: ‘Care is good when there is enough staff on duty. I am generally happy with the support’. ‘The standard of hygiene and emotional care is excellent. Nurses and carers always find time to listen. Sometimes all I need is a hand to hold’. ‘My RGN is [X]. She is conscientious regarding any problems I have. The staff will help if I’m upset at any time’. Meal times were observed to be relaxed and a social affair with staff on hand to assist some residents as needed. Tables are set and flowers are placed on them. The portions of meals were very good and were commented on by the residents who said that they enjoyed the food. Staff reported that training is ‘excellent’ and that ‘there are always courses to go on. Staff files evidenced certificated training. The home has over 90 of care staff trained to NVQ level. A lot of the carers are doing NVQ 3 and 6 staff have been put forward for level 4. This evidences very high standards of training. Over the past year the home has developed positively in many areas. Progress is good and evidences that the manager and the company can make steady progress and deal with regulatory requirements. The manager commented that she feels issues are dealt with on a pro-active basis rather than previously simply reacting to events. The home is subject to some external Quality Assurance processess. The company carry out their own quality audit on a yearly basis. It contains the results of a resident / relative survey and the overall satisfaction was noted to be high which corresponded with the survey returns from this inspection. The quality assurance systems in the home should identify further improvements. DS0000065162.V364673.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: There is a lot of handwritten medication recording by staff on the administration [MAR] record and these were still found not to be signed by two staff and in one case not signed at all. Two staff should sign handwritten medication records so that there is a reduced risk of any error in the recording and this ensures that residents receive the correct medicine. The controlled drug book was inspected with respect to one resident and the stock of medication was found to be correct. The record was slightly confusing however in that some medicines had been carried over to a new book but the date was not recorded so additional backtracking was needed to clarify the audit trail. Management do not ignore issues of concern raised by residents and do try to deal with them but there needs to be more consistency around referring DS0000065162.V364673.R01.S.doc Version 5.2 Page 8 incidents through safeguarding at an earlier stage so that professionals can get involved as necessary. Also the openness and transparency of written replies to complaints needs to be addressed so that complainants feel all of the issues have been addressed. Staff files seen contained clear records for the purposes of recruitment and these are audited on a regular basis. There were two concerns however that need to be addressed: • On one file both references were from non-care jobs and a previous employment listed on the staffs application form was from a care organisation. In this instance the home must access a reference and this must be satisfactory. Two of the staff files seen were of staff with past criminal records. There was no written reference to this on any of the recruitment documents by management to say whether this had been considered and as to the rationale for employing these persons. The manager is responsible for ensuring standards are maintained here and that residents are suitably protected by the homes recruitment procedures. • 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. DS0000065162.V364673.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 DS0000065162.V364673.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): Standard 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents admitted are assessed prior to admission so that care needs can be met. EVIDENCE: The home has written information [Service User Guide] and this is available for residents and relatives. A copy is kept in each of the resident’s rooms and residents interviewed were aware of the guide and that it also contained the complaints procedure. Residents had found the information useful and it had assisted them in both choosing and settling into the home. All residents are assessed prior to admission to the home. Four care files were reviewed and appropriate social care and health care assessments had been completed. There were copies of referral assessments from health and social care professionals to compliment the homes own assessments. Following admission there are further, more detailed, assessments carried out covering areas such as manual handling, falls, and nutrition so that a plan of DS0000065162.V364673.R01.S.doc Version 5.2 Page 11 care can be drawn up. These are also completed on a routine basis during the stay in the home. All of these were up to date in the care files inspected. DS0000065162.V364673.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home manages the health and personal care of resident’s with appropiate care interventions and referral made for specialist input if needed so that residents can be assured that care needs are being met. EVIDENCE: All of the residents have a written plan of care. Four of these were reviewed and the quality of the documentation has improved since the last inspection. The care plans seen were up to date, clear and had the necessary detail so that care could be followed easily. For example, one resident with complex care needs had clear records in the care plan about special observations that staff need to be aware of in case of a specific health risk and what to do in case of emergency. The resident concerned signed the care plan. Also highlighted were more social issues concerning relationships with other people and how this may affect daily life. DS0000065162.V364673.R01.S.doc Version 5.2 Page 13 Evaluations are recorded at least monthly and useful in that they are a description of any progress made so that this was easy to follow. The care plans cover all of the activities of daily living. There is also an index sheet which lists the main care needs for ease of reference for care staff who can complete daily entries around these needs. Other care plans covered wound care and again the progress of the wound was easy to track. It included reference to and input from tissue viability nurses. One resident has a stoma and again the need for review by stoma specialists was highlighted. The manager reported that the care planning documentation is now audited and this process has assisted in continual improvement. The medication administration in the home was reviewed. The inspector observed the nursing staff giving out medication and also inspected records. There have been improvements since the previous inspection by the pharmacist and the requirements made at that time have mostly been met. There is a lot of handwritten medication recording by staff on the administration [MAR] record and these were still found not to be signed by two staff and in one case not signed at all. Two staff should sign handwritten medication records so that there is a reduced risk of any error in the recording and this ensures that residents receive the correct medicine. The controlled drug book was inspected with respect to one resident and the stock of medication was found to be correct. The record was slightly confusing however in that some medicines had been carried over to a new book but the date was not recorded so additional backtracking was needed to clarify the audit trail. Other records were satisfactory. Again the medicines are now subject to both internal and external auditing and this has helped maintain standards. The personal care of the residents was found to be also improved in that there is now more consistent standards in this area which is possibly linked to better over all staffing. Residents were observed to be appropriately dressed and those spoken to said that staff were attentive and provided assistance when needed. On resident said: ‘Staff are ‘fabulous. They cant do enough. Even if they are mad busy they always find time for me. Staffing has improved. More bodies and they are more consistent’. This resident felt that health care generally is well monitored and that he is in safe hands. A relative spoken with also agreed: DS0000065162.V364673.R01.S.doc Version 5.2 Page 14 ‘ They are brilliant. Cant do enough for my relative and they always keep me informed’. Some residents still felt there could be more consistency and although in the minority are included here as further feedback to the managers: ‘Visiting the toilet is a problem as often staff are busy’. ‘Care is good when there is enough staff’ ‘Slightly less staff weekends and bank hols. Very busy with residents and may be delay in answering call button’. DS0000065162.V364673.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. residents are supported to be involved in the social life of the home which helps ensure a good quality of life. EVIDENCE: The AQAA for the service tells us that: ‘We employ an activities co-ordinator and an activities assistant who provide both group activities and individual interaction. Due to the diversity of our clients we have found that this ensures each individual has a wider choice of social interaction. A monthly plan is in place which is given to clients so they are able to choose which activities they would like to join in’. Over the two days in the home there was much activity in terms of visitors and staff interacting with residents and receiving ongoing support. The home was very lively and the general atmosphere was positive and friendly. The home has been completed refurbished since the last inspection and the morale of both staff and residents has been lifted by this. The residents interviewed felt that staff were approachable and helpful. Residents were observed to be interacting with each other and where easy to DS0000065162.V364673.R01.S.doc Version 5.2 Page 16 engage in conversation. Relatives interviewed reported that they were always welcomed and could visit at any time. The two activities persons were seen engaging with residents. There is now a planned but flexible programme of events and activities and all residents spoken with felt this had improved. One resident said that he enjoyed the art sessions and had been able to discover and develop a skill he had hitherto been unaware of. Each resident receives a sheet with forth coming activities listed. Other comments received were generally positive and evidenced a good rate of satisfaction amongst residents: ‘Care is good when there is enough staff on duty. I am generally happy with the support’. ‘The standard of hygiene and emotional care is excellent. Nurses and carers always find time to listen. Sometimes all I need is a hand to hold’. ‘My RGN is [X]. She is conscientious regarding any problems I have. The staff will help if I’m upset at any time’. Meal times were observed to be relaxed and a social affair with staff on hand to assist some residents as needed. Tables are set and flowers are placed on them. The portions of meals were very good and were commented on by the residents who said that they enjoyed the food. These were seen as well cooked and presented well. There is now some choice available and staff were observed to canvassing residents during the morning for any preference that they may have. DS0000065162.V364673.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): Key standards Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service tries hard to manage complaints and allegations of abuse but there needs to be more consistency around the referring of allegations at an early stage and the transparency of written replies to complainants so that residents can be further assured they are protected and the service will act in their interests. EVIDENCE: Those residents and relatives interviewed felt that they were able to approach staff and that their concerns would be listened to. There is a complaints procedue and this is in all of the service user guides which are in bedrooms. Since the last key inspection for the service in jJne 2007 there have been a series of complaints, some of which have been investigated through safeguarding procedures and others by the service or through ‘random’ inspections by the Commision [CSCI]. Overall there appears to be a lack of consistency in managing some complaints and particularly in deciding whether incidents need to be reported through the safeguarding procedures which ensure that allegations of abuse can be investigated thoroughly with input from social services and regulatory bodies such as the Commission for Social Care Inspection [CSCI] and police. Examples of these complaints / allegations are: DS0000065162.V364673.R01.S.doc Version 5.2 Page 18 • A relative of a resident who complained to the home regarding care issues. The home investigated these and the manager replied within the time scale of the complaints procedure. The complainant was not happy however, as the written reply did not address all of the issues concerned. The areas of concern included the lack of informing the GP when required, personal care, care of the deceased and lack of staff to attend to toileting of residents and staff attitudes. The manager was open about some communication issues and did speak to the relative following the letter. An anonymous caller complained to the Commission about poor standards on night duty. This involved poor management of continence, poor access to the kitchen, and the general attitude of the manager. A ‘random’ inspection was undertaken by the Commission [unannounced] and none of the issues were evidenced. There were issues around staffing consistencies on nights. A safeguarding issue dealt with appropriately by the home. Alleged that a night nurse had been leaving residents wet. The nurse resigned but the home followed up with appropriate referrals. There was good liaison with social services. A safeguarding referral was made by the home regarding alleged behaviour of a resident towards a staff member. This was managed sensitively by the home – again in liaison with social services. An incident of alleged verbal abuse by two staff members was investigated internally and both staff dismissed and referred to the Protection of Vulnerable Adults [POVA] register. On this occasion there was no referral through the safeguarding procedures. This is important because other agencies such as the police may have wished to get involved. It is noted that the manager was on holiday at this time and the issues were dealt with at a higher management level. There is a recent [ongoing at the time of inspection] incident involving alleged poor management of a resident’s personal property. The relatives have complained under the homes complaints procedures and although they have been responded to, the complainants remain unhappy and cite the tone of the response and the lack of openness by senior managers in the company as an issue. The social worker involved was not made aware at the time and felt that a referral under safeguarding could have been made. • • • • • Overall it is clear that the home certainly do not ignore issues and do try to deal with them but there needs to be more consistency around referring incidents through safeguarding at an earlier stage so that professionals can get DS0000065162.V364673.R01.S.doc Version 5.2 Page 19 involved as necessary. Also the openness and transparency of written replies to complaints needs to be addressed so that complainants feel all of the issues have been addressed. The AQAA completed by the manager states: ‘Meridian Care has a designated POVA manager who will co-ordinate any investigation. Details on how to contact her are available to clients on admission and is distributed throughout the home’. The inspection evidenced that the manager has worked hard to liaise with social services around safeguarding and has sourced some good training. Further input is needed however as there appears to be some confusion amongst staff as to the role of the above person and their role in reporting incidents through at an early stage. For example a nurse interviewed was unclear as to the reporting and felt that ‘somebody in management would do this’. The local safeguarding contact number was not known by any of the staff interviewed and this needs to be made immediately available. The manager was told of these observations and feels that the home has come a long way in reporting and dealing with these difficult issues but there is a lack of formal auditing of safeguarding issues and complaints so that lessons can be learnt and this needs to be addressed at company level. Residents interviewed did feel safe in the home and felt that staff had their interests and safety at heart. All of those interviewed felt that the management team and staff were approachable. DS0000065162.V364673.R01.S.doc Version 5.2 Page 20 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): Key standards Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home presents as well maintained and bright and homely with required aids and adaptations made available so that residents can live comfortably with regard to any disability need they may have. EVIDENCE: The AQAA completed by the manager states: ‘The home presents as being clean, tidy and well decorated. Bedrooms reflect the client who occupies it and their taste. Garden and patio areas are well maintained. There are records of regular maintenance’. This was found to be the case on the site visit. The company have totally refurbished the home over the past year and facilities are of a very high standard. Residents and relatives and also staff were pleased to live and work in such an environment and this reflected in the comments received. DS0000065162.V364673.R01.S.doc Version 5.2 Page 21 Bedrooms for example were personalised and residents said that they felt comfortable and at home. All areas seen were clean and well presented and there are also good external gardens for residents to enjoy if they wish. There is also very good provision of disability aids and adaptations and all areas are accessible. DS0000065162.V364673.R01.S.doc Version 5.2 Page 22 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): All key standards Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are recruited and well trained to work in the home and therefore are able to maintain a more consistent level of care. There needs to be some further tightening of recruitment processes so that management decisions are transparent and residents can be seen to be protected at all times. EVIDENCE: The staffing of the home has been a key issue in terms of maintaining consistent care standards in the home. for example the ‘random’ inspection visit earier in the year cited inconsistent staffing numbers on night duty. There are signs that the home are now in a better position than previously. The manager feels that the home is now more ‘pro active’ in terms of recruitment and the quality and attendance of staff has improved. The AQAA states ‘we are maintaining staffing levels at a more acceptable level. We have recruited hard and spent valuable time on training’. For 41 residents in the home at the time of the inspection the staffing was 2 trained nurses and 9/10 care staff. Appropriate ancilliary staff are also employed on cleaning and in the kitchen and laundry. The manager is usually supernumerary to these figures and is supported by an administrator and deputy. DS0000065162.V364673.R01.S.doc Version 5.2 Page 23 Residents and relatives comments were generally very supportive of the staff who were seen as helpful and kind. Some residents still felt that not enough staff were around at times and stated that this was because call bells were not always answered quickly enough. These comments were generally less than previous however and most staff and residents spoken with said that staffing levels overall had improved. This was borne out by observation and also by examination of the duty rota for the home. Staff training is organised well. Staff reported that training is ‘excellent’ and that ‘there are always courses to go on. Staff files evidenced certificated training. The home has over 90 of care staff trained to NVQ level. A lot of the carers are doing NVQ 3 and 6 staff have been put forward for level 4. This evidences very high standards of training. Nursing and care staff have palliative care training (care of the dying person) Staff generally felt supported by the managers and felt that they were approachable. All felt that training in the home was very good. Staff also talked about being supervised and supported by more senior staff and this is currently a formal process every 4 months. The manager said that these sessions were supported by ‘group supervision’. It would be recommended that the home should aim for more regular one to one supervisions. Staff files seen contained clear records for the purposes of recruitment and these are audited on a regular basis. Required checks are carried out so that residents can be protected and quality of staff monitored. There were two concerns however that need to be addressed: • One staff has given references of previous employment and these have been accessed and were on file. Both references were from non-care jobs however and a previous employment listed on the staffs application form was from a care organisation. In this instance the home must access a reference and this must be satisfactory. Two of the staff files seen were of staff with past criminal records. One was fairy recent [last 3 years]. There was no written reference to this on any of the recruitment documents by management to say whether this had been considered and as to the rationale for employing these persons. A risk assessment needs to be developed and formal rationale listed on the interview [or elsewhere] form giving the reasons for any management decision to employ in these circumstances. • The manager is responsible for ensuring standards are maintained here and that residents are suitably protected by the homes recruitment procedures. DS0000065162.V364673.R01.S.doc Version 5.2 Page 24 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): All key standards Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good systems in place to gauge resident’s views and to further improve standards so that the home is run in the best interests of the people who live there. EVIDENCE: Dorothy Pye is the manager of the home. She is very experienced and is involved in the processes of introducing new auditing and management systems into the home in liaison with senior management in the company. She has very good experience in the clinical field working as a Registered Nurse [RN] for many years. She has a qualification in health and social care at degree level and is able to provide evidence of continual self-development for example in palliative care – care of the dying person. DS0000065162.V364673.R01.S.doc Version 5.2 Page 25 All staff and residents / relatives were supportive of the managers approach and she was known to all of the residents, relatives and staff spoken to. Most commented on her personal approach and were appreciative of the time she spent with them. Over the past year the home has developed positively in many areas. More specifically there has been more consistent staffing and there has been increased liaison with social services around safeguarding issues. Although both these areas need further work the progress is good and evidences that the manager and the company can make steady progress and deal with regulatory requirements. The manager commented that she feels issues are dealt with on a pro-active basis rather than previously simply reacting to events. The home is subject to some external Quality Assurance processess such as Investors in People award and the yearly audit of quality under the RDB . The company also carry out their own quality audit on a yearly basis. It contains the results of a resident / relative survey and the overall satisfaction was noted to be high which corresponded with the survey returns from this inspection. Areas identified as needing improvment have been dealt with.The quality assurance systems in the home should identify further improvements. Health and Saftey records were seen [fire records and accident records] and all were up to date and provide evidence of good ongoing management in this area. DS0000065162.V364673.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 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 2 17 X 18 2 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 DS0000065162.V364673.R01.S.doc Version 5.2 Page 27 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 OP18 Regulation 12(1) Requirement All allegations of abuse or mistreatment must be reported through to safeguarding at an early stage so that appropriate action can be coordinated under agreed protocols. The manager must ensure that all staff recruitment includes two written references, including were applicable, a reference relating to the persons last period of employment, which involved work with children, or vulnerable adults of not less that 3 months duration. All staff employed must have any criminal record clearly highlighted and addressed as part of the risk assessment process followed by the management so that this is seen to be transparent and accountable and helps ensure that residents are suitably protected. Timescale for action 01/07/08 2 OP29 19(1) and schedule 2 part 3 01/07/08 3 OP29 19(1) 01/07/08 DS0000065162.V364673.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations Dose changes should be clearly recorded and signed by two members of staff, so that residents receive the correct dose of medication. Where possible, changes should be confirmed in writing by the prescriber. Any carried over medication in the controlled drug register should be dated for clarity. 2 OP16 The managers should introduce a system of formal evaluation following the outcomes of each complaint and allegation so that any areas for improvement can be identified in terms of current policy. Written replies to complainants need to be open and transparent and cover all of the issues in question. DS0000065162.V364673.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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