Inspection on 19/04/07 for John Wills House

This inspection was carried out on 19th April 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 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 Wills House 01/02/06

John Wills House 31/08/05

John Wills House 15/03/05

John Wills House 31/07/04

John Wills House 24/02/04

Similar services:

Manor Lodge

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE John Wills House Jessop Crescent Westbury Fields Westbury on Trym Bristol BS10 6TU Lead Inspector Vanessa Carter Key Unannounced Inspection 09:30 19 and 20th April 2007 th 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 John Wills House DS0000046239.V336607.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. John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service John Wills House Address Jessop Crescent Westbury Fields Westbury on Trym Bristol BS10 6TU 0117 3773700 0117 3773725 angela.healey@stmonicatrust.org.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) St. Monica Trust Mrs Angela Rosalind Healey Care Home 60 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (45), of places Physical disability (3) John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Fifteen older persons with dementia who require personal care only to be accommodated in `The Orchards` wing. Up to fifteen older people including two adults (aged forty years and over with a physical difficulty) requiring planned short-term care may be accommodated in the respite care wing. Of the fifteen, up to eight Service Users entering the Beeches Unit may be accommodated for a period of time not exceeding twelve months. This may include respite, intermediate and nursing care. Up to thirty older persons requiring nursing care to be accommodated in `The Willows` on the first floor. This may include one named person aged forty-six onwards, with a physical disability. This placement is specific for one individual and the condition will lapse if the placement ceases. 1st February 2006 3. Date of last inspection Brief Description of the Service: John Wills House is a purpose built care home, built and owned by St Monicas Trust. It is registered with the Commission for Social Care Inspection (CSCI). The home is situated in the Westbury Fields Retirement Village. In addition to the home there is a complex of sheltered housing, retirement apartments and bungalows - these do fall under the remit of CSCI. The home is well appointed and shares its building with a purpose built pub - the Cricketers. John Wills House is registered to provide different levels of care in each of the three units: • The Willows provides placement for 30 residents, both male and female who require nursing care. All rooms are for single occupancy, with ensuite facilities and ceiling fitted hoist mechanisms. • The Orchards provides placement for 15 residents, both male and female with personal care and dementia care needs. • The Beeches, is again for 15 male or female residents, but only on a short term/respite basis. A number of the beds are block booked by South Gloucestershire PCT and Bristol City Council. John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unplanned key inspection to the home that took place over two days. This was a full inspection with all but two of the standards being assessed. Evidence has also been gained from a number of other sources, namely:• Information provided by the manager in the pre-inspection questionnaire • 13 resident survey forms returned to CSCI • 8 relative survey forms returned to CSCI • 1 GP comment card returned to CSCI • a tour of the home • speaking with a number of the residents, • speaking with a number of relatives • speaking with the care home manager and deputy care home manager • speaking with registered nurses and nursing care assistants. The service provided at John Wills House continues to be of an excellent quality, with substantial strengths in many areas. From the Inspectors point of view it has been a pleasure to visit this home, and to meet with the staff who are totally committed to enhancing the lives of those in their care. What the service does well: What has improved since the last inspection? John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 6 The home continues to provide an excellent quality of care for those residents who live there and to those visitors who call to see their relatives or friends. 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. John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 7 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 John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 8 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, 3, 4, 5 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are given clear information about the home, and are assessed prior to admission, and this ensures that placement is appropriately offered. Intermediate care is provided in The Beeches, and residents are assisted to regain their independence and return home. EVIDENCE: The homes Statement of Purpose and Service Users Guide has not been changed since the last inspection and contains all the information necessary to enable a prospective resident and their representative, to make an informed choice about moving to John Wills House. 13 residents completed a CSCI survey form and all said that they had been provided with enough information about the home and had decided it was the right place for them. John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 9 One resident commented on the form “I heard it was the best place I could come to”. A copy of the homes Welcome Pack is placed in each bedroom, having been personalised to whichever unit, with staff details and photography. Each resident is provided with a statement of terms and conditions of residency upon admission. Some residents are privately funded whilst others are partly funded by the local authority or the primary care trust. The home will have also contracts drawn up with whichever relevant party. The home will always undertake an assessment of needs for all new admissions, prior to any placement being offered. They use a comprehensive document that covers all aspects of a person’s personal care needs, daily living, health and social care. This is to ensure that the home is able to meet the person’s needs. One resident commented on the CSCI survey form “ The manager visited me at home and I was delighted when I was offered a room”. The assessments of the most recently admitted resident was examined, evidencing that is had been completed prior to the admission date. The unit manager on The Orchards arranges for prospective residents to have a minimum of two assessment ‘visits’ to the home, prior to being offered a place, to assess suitability and compatibility with the other residents. This is good practice. Prospective residents where possible, and/or relatives, are asked to visit the home and have a look around so that they can sees what the home has to offer. “I visited the home before I chose to move her and I liked the look of it” and “I didn’t settle at first but staff have helped me” were comments made on the survey forms. The Intermediate Care Unit, the Beeches, has separate communal facilities from the rest of the home. South Gloucestershire PCT Intermediate Care Team have ‘block purchased’ five of the beds and staff on the unit will provide care for these residents, working in conjunction with the ICT staff to enable the people to return to their own homes. In addition two beds are funded by Bristol City Council who use them for planned respite. People can also make their own private respite arrangements directly with the home. The unit has a rehabilitation kitchen and a physiotherapy department. Most residents length of stay is 2 - 6 weeks, however the home does have a condition of registration that states that up to eight residents are able to remain on this unit for a maximum period of up to one year. John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 10 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, 10 and 11. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The homes care planning processes, the delivery of individualised packages of care and management of medications ensure that residents will be well cared for in respects of their health, personal and social care needs, in the way that they want. EVIDENCE: Eight care planning files were looked at, three from The Beeches, three from The Willows and two from The Orchards. The plans were each person-centred and had been written in conjunction with the resident and/or their family. Some residents had signed to say they had been involved in the care planning process. They included the resident’s name of choice and any information regarding their family and any other specific needs. The identified needs were set out in the care plans, with instructions for the staff in how these needs should be met. John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 11 The plans are reviewed on a monthly basis and amended as necessary, but the summary record made of the review should always indicate where changes have been made. Where equipment had been identified as essential to maintaining the residents comfort this was detailed upon the plan of care. The plans are supported with risk assessments in respects of the likelihood of developing pressure sores, nutritional needs, and manual handling assessments that then result in a safe system of work being devised. Some minor improvements were suggested, for some of the plans, which the staff and home manager acted upon before the end of the visit. This evidences that although the home have good processes in place, they are still open to suggestions to make things better. Daily communication sheets are maintained. The entries were detailed and provided a clear insight into what care the resident had received. Each entry was signed in line with good record keeping guidelines. The home maintains records for each resident showing their contact with other health care professional such as the GP, psychiatric services, dietetics and chiropody. One GP completed a CSCI comment card and stated, “the quality of care is very high. The staff are professional and helpful” and “staff have a clear understanding of the residents needs”. The medication procedures on one unit were looked at. The home has robust procedures in place for the ordering, receipt, administration and disposal of medications. Residents can be assured that they will receive their medications correctly. The home ensures that all medication storage areas are maintained at the right temperature – thermostatically controlled air conditioning units are installed. Residents are cared for with respect to their dignity and their privacy. The GP commented “I am able to see my patients in private”. Personal care is provided in private and staff were observed to be polite and courteous in their dealings with the residents. One resident commented on a CSCI survey form “people look after me – I couldn’t wish for better people to help me” – there were also very many other positive comments regarding the standards of care. The home always ensures it knows how residents want to be cared for if they have a sudden illness or deterioration in their health. This is a sensitive subject, however when appropriate they consult with the resident, their GP and any relevant family or representatives. Residents can be assured that the staff will look after them in the manner in which they wish, when it comes to ‘endof-life’ care. John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 12 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 excellent. This judgement has been made using available evidence including a visit to this service. Residents are able to spend their time as they wish and have the opportunity to participate in a range of different activities. They can maintain contact with family and friends and are provided with an excellent standard of catering. EVIDENCE: The home has a programme of activities each day that residents can choose whether or not to participate in. “Sometimes I am too tired to join in the activities” was one resident’s comment, whilst another said, “I go for a ride in the minibus, join in the music group and do gardening”. During the course of the inspection a number of activities were observed - three residents were doing a jigsaw puzzle with staff support, a Recall Session was well attended on The Willows, and later a group of staff and residents got together to celebrate a birthday. One resident commented on a CSCI survey form “when one of the carers is on duty, she arranges Chinese food for a few of us”. It is evident from discussions with residents that there is always plenty going on. John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 13 “We are having a lovely time here”. A weekly plan of activities is posted throughout the home and includes shopping trips, music sessions and religious worship. A number of residents go out on a regular basis to attend functions held in the sheltered housing complex, on the same Westbury Fields site. The home ensures that it can meet the cultural and religious needs of its residents. They will go to great lengths to find out the necessary information to ensure that they support they offer is appropriate for that person. Attached to the home there is The Cricketers Pub - this is well used by the residents, their visitors and those who live in the retirement apartments and sheltered flats in the Westbury Fields Village. A number of the residents have partners and friends who live in the village, and therefore this facility enables them to still be able to “go out for lunch”. The home has an open visiting policy and it is obvious that relatives and friends are seen as being essential to maintaining a resident’s well being. One visitor stated that she enjoyed visiting the home and added that her mother was provided with the best social life ever. Observations were made of positive and friendly interaction between staff and visitors. One visitor said there was always a happy positive atmosphere in the home. Another visitor said they were always offered tea and cake when they visited their relative each afternoon. Residents are encouraged to make decisions about all aspects of their daily life. This may include choosing where to take a meal, where to spend their time, or what time to get up in the morning and what time to retire to bed at night. One relative commented on a CSCI survey form that the spiritual care was excellent and that this was important to them. A choice of menu is offered at each mealtime and residents are able to choose what they want to eat at the start of the meal. A roast meal is served twice a week, and each day there is also a vegetarian option. The home is able to cater for other diets and the catering manager will visit any resident to discuss dietary requirements. The same meals are also served each day in The Cricketers Pub. Comments received about the meals include “the food is great”, “the food, it’s like home cooking” and “excellent catering”. Meals are either served in the dining rooms or in the resident’s own room. John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 14 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. Residents can be assured that any complaints or concerns they have will be listened to and acted upon. The staff ensure residents are safeguarded from harm, but need to be aware of agreed procedures to follow if concerns are raised. EVIDENCE: The homes complaints procedure is contained within their Statement of Purpose and the Welcome Pack placed in each person’s room. Those residents spoken during the inspection said that they were aware that the home had a complaints procedure, but that they had no reason to make any complaints. All residents who completed a CSCI survey form about the home stated they knew how to make a complaint. Comments on the forms included “If I grumble about something, they sort it out right away” and “ a concern I had was dealt with swiftly and appropriately”. The home has received four complaints since the last inspection – each had been handled appropriately and it was evident from the clear records maintained by the home, that the complainants were informed of the outcome and any actions taken. John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 15 The manager looks upon complaints positively and sees them as a means of reviewing any working practices that are brought into question and then looking for possible satisfactory solutions. This approach will ensure that the service remains appropriate for the needs of the residents. Staff who were spoken to during the inspection demonstrated awareness of adult abuse issues and stated what they would do if something unacceptable were observed. Junior staff would always report concerns to the home manager or the most senior member of staff on duty (the “duty officer”). Discussion with some senior staff, regarding what they would do if it was reported to them that a resident had been harmed, found them to be indecisive about what to do. The manager was advised to place information about the agreed protocols in the “duty officers” pack. All staff are expected to undertake adult abuse awareness training at the organisations training department. Information regarding ‘Protection of Vulnerable Adult (POVA)’ issues is displayed through out the home. Observations made of interactions between staff and residents, demonstrated that the residents are well cared for and safe. Residents spoken to during the inspection said that they were well cared for and were safe. John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 16 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, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable and safe home, that is fully equipped to meet their needs and is maintained to the highest of standards. EVIDENCE: The home was first opened in 2003 and complies with all the regulations for newly built care homes. Both inside and out the buildings are well maintained. The gardens surrounding the home are well tended. It is built within the “Westbury Fields” Village, in addition to retirement apartments and sheltered flats. To the rear of the home is a very nice landscaped garden, with plenty of seating provided for residents and their visitors. One resident spoken to during the course of the inspection said, “I am so very lucky to live here. I thank God every day for this beautiful place”. John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 17 Westbury Fields is entered via electronically operated gates. The console to contact the porters, is located on the left hand side of the driveway, meaning that visitors travelling alone would need to get out of their car to use the call bell. The company that installed the equipment have been contacted to relocate the unit but the layout of the road does not allow this. St Monica’s have displayed telephone numbers for visitors to ring, if they need assistance. Despite this being a problem identified by CSCI, none of the relatives who completed a CSCI survey form made comment about access into Westbury Fields. The home is a two- storey building, entered via a large and pleasant reception area. The reception area is staffed during ‘office hours’. The nursing unit (The Willows), on the first floor, can be accessed by one of two lifts, or a stairway, thereby it is fully accessible for older and disabled people. The Orchards unit (the dementia care unit) and The Beeches (the respite care/intermediate care unit) are both on the ground floor. There is access out into the garden area from the reception area. In order to prevent the residents in The Orchards from wandering off, the door into the unit is key padded and all other exits from the unit are linked into the alarm call system. Each of the bedrooms in The Orchards has a sensor system installed. This can be set differently for each resident dependent upon their specific needs. Sensor pads placed under the mattress will switch on lights when a resident gets up during the night and will alert staff if they do not return to bed within a specified time. This equipment enables the resident to retain their independence in safety. The three units each have their own lounge area and dining room. The furniture and soft furnishings are of a superior quality, making the rooms a very pleasant space in which to relax and take a meal. In addition, there is a large lounge area leading off from the reception area that is also used by the people who live in Westbury Fields. Attached to the home is “The Cricketers Pub” and this is used by many of the residents, particularly when entertaining their visitors and family. Each of the bedrooms is for single occupancy, spacious and with ensuite bathroom facilities. The ensuite rooms in the Beeches are fitted with facilities that can be moved to accommodate different residents needs. The rails can be raised and lowered, as can the wash hand basin and shower units. All bedrooms in The Willows and The Beeches are fitted with tracked ceiling hoists, thereby reducing the need for bulky manual hoists to be used – these tracks continue into the shower rooms. The home has an electric hoist for use in those areas where tracked ceiling hoists are not sited. In addition to the ensuite facilities, there are specialist bathrooms and toilets located throughout the home. John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 18 Residents are encouraged to bring in their own possessions and furniture. Each resident’s room is furnished with quality furniture and fittings. The majority of beds are specialist beds that will aid resident’s comfort and assist the care staff when giving personal care. One relative commented on a CSCI survey form “my Mum has been given a lovely chair to ensure she is comfortable”. In The Beeches, memory boxes are placed outside of the resident’s bedroom doors, and contain family photographs of other memorabilia. The home is centrally heated and well lit, and each room is well ventilated. The radiators are all of low surface temperature type. Fans are made available during the hot weather, and were already in use in a number of rooms due to the unseasonably warm weather. Following on from the hot summer last year the home has also installed air conditioning units in the lounges. All parts of the home are tastefully decorated and furnished throughout. In general the bedrooms are decorated in between residents. The home does not ever have vacancies for long and the two vacant rooms were already earmarked for new people and were being prepared for their admission. The home is spotlessly clean, tidy and odour free in all areas. Air freshener units are installed in the corridors and perfume the air without being overpowering. Comments received on CSCI survey forms completed by residents and relatives included the following “My bedroom is cleaned every day”, “everywhere is always nice and clean” and “the ladies that clean are very thorough”. There were some comments received about the quality of the laundry service. Several relatives said, “All laundry goes to the Cote Lane site and things can go missing or be spoiled”. A discussion with the manager evidenced that the home are aware of the problems and are continually striving to improve the service. St Monica’s Trust are in the process of revamping the laundry facilities, however the problem will not be resolved unless residents personal clothing is clearly marked, and is “non-delicate”. John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 19 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 excellent. This judgement has been made using available evidence including a visit to this service. Residents are cared for by staff who are skilled and competent to do their jobs, so they can be assured that their needs will be met. Robust recruitment procedures ensure that the right staff are employed at the home. EVIDENCE: The home continues to have near full occupancy at all times with a waiting list of prospective residents who want to live at John Wills House. The recent vacancies have already been earmarked for new residents. The appropriate numbers of staff were on duty to meet the resident’s needs. The manager maintains an overview of dependency levels on each of the three units, and will amend staffing levels accordingly. The home has unit managers for all three units, having recruited one for The Willows since the last inspection. The home has 14 registered nurses and 50 nursing care assistants, and each worker is ‘employed’ for a specific unit. The care staff are supported by 20 ancillary staff, in meeting the residents daily living needs. John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 20 The home does not use Agency staff as it has a number of bank staff who will work as and when required. Shifts are also covered ‘in-house’. This ensures consistency of care for the residents. Of the 50 nursing care assistants, 40 have already obtained at least, a National Vocational Qualification in Care, at Level 2 (80 ). From information provided by the home, 15 of the 40 also have an NVQ Level 3. One staff member said she was due to start NVQ level 2 in the next cohort. The commitment to providing trained members of care staff is to be commended and reflects upon the quality of the service provided. Residents commented on CSCI survey forms “there are some very skilled and caring carers” and “she goes well beyond the call of duty and makes a difference to people’s lives” The home has had very little staff turnover since the last inspection, but have previously shown that a robust recruitment procedure is followed. Prospective employees are expected to complete an application form and attend for interview. Two written references, CRB and POVAfirst clearance are obtained for all new recruits. The staff files of three recent recruits confirmed this to be the case. The homes procedures ensure that the right staff are employed at the home and that the residents will be cared for by staff who will safeguard and protect them. St Monica’s Trust has a specific training department, and other care providers can purchase the courses they run. They have an annual training and development plan and examples of training sessions include first aid, infection control, food hygiene, fire, manual handling, care of vulnerable people, principles of care and specific health related topics. Each staff member has a training file that evidences the training they have undertaken. One qualified staff member is in the process of collating all the files and arranging which staff member goes on what training course. A sample of files was checked and the information verified by the staff member. John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 21 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, 32, 33, 35, 36, 37 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is well managed, has clear and effective leadership, and is run in their best interests. Residents’ interests are promoted and safeguarded. EVIDENCE: The manager has been in post since the home opened in 2003. She is a registered nurse and has completed her Registered Managers Award. One relative wrote on the CSCI survey form “Angela Healey is a marvellous care home manager”. John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 22 Residents spoken to during the inspection were very complimentary about the manager and all the staff who work at John Wills House, with one adding, “I am privileged to live here”. A deputy care manager, unit manager and heads of department assist in the management of the home. Residents meetings, relatives meetings and staff meetings are held on a regular basis and ensure that the home is run in the best interests of those who live there. A look at the minutes of the various meetings, show that the views and opinions of residents are valued and are acted upon. The manager has a “hands on” approach to her job and maintains a visible presence in the home. Staff reported that they felt listened to and that their opinions were valued. The home undertakes regular ‘customer satisfaction survey’, and the results of the most recent one, provide clear evidence that the service is performing well. The manager said that they are just about to undertake a staff survey. In addition to this all residents leaving The Beeches, the short term care unit, are asked to complete an assessment of their stay. This evidences that the home look seriously at how they provide their service and want to ensure it remains appropriate and meets resident’s needs. The home holds personal monies for those residents who require the service. Good administrative procedures and record keeping evidenced that resident’s funds are safe. A random sample of resident’s funds was checked against the records and was correct. The home has a planned programme of staff supervision for all staff members. The manager supervises the qualified staff and cascades responsibility for the supervision of junior staff members to these staff. Staff confirmed that they have regular supervision with a senior member of staff, and that they discuss any training requests or work issues. Newly recruited staff are allocated a mentor who will assist them to settle into their job, ensure they work to the homes policies and procedures and standards, and complete the induction training programme. Those home records that were examined were all in order. CSCI have been notified throughout the year of all events that have occurred in the home, as they are required to do. St Monica’s Trust have recently employed their own Fire Officer, who will check all fire safety arrangements in the home. Risk assessments are carried out for all safe-working practices and records are maintained when any restrictive measures (use of bed rails) need to be taken to secure a residents safety. For one resident the risk assessment had determined that the use of bed rails was not appropriate to maintain their safety, and therefore alternative methods were used. The home has robust health and safety procedures to ensure that the home remains a safe place in which to live and to work. John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 23 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 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 4 4 4 3 4 3 3 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X 3 3 3 3 John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 24 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. Refer to Standard OP18 Good Practice Recommendations Place information about agreed protocols to follow in the event that “POVA” issues are raised, in the Duty Office file so that the duty officer can then respond promptly and with confidence. John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 John Wills House DS0000046239.V336607.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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