Inspection on 10/09/08 for Kathleen Chambers

This inspection was carried out on 10th September 2008.

CSCI found this care home to be providing an Good 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

Kathleen Chambers 19/09/06

Kathleen Chambers 19/01/06

Kathleen Chambers 04/08/05

Kathleen Chambers 15/03/05

Kathleen Chambers 22/06/04

Similar services:

Fairfields Country Rest Home

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Didsbury Court Rest Home

Honeybourne House

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Extracts from inspection reports are licensed from CQC, this page was updated on 23/11/2008.

CARE HOMES FOR OLDER PEOPLE Kathleen Chambers 97 Berrow Road Burnham On Sea Somerset TA8 2PG Lead Inspector Barbara Ludlow Unannounced Inspection 10th September 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 Kathleen Chambers DS0000031544.V372205.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. Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kathleen Chambers Address 97 Berrow Road Burnham On Sea Somerset TA8 2PG 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) 01278 782142 01278 782673 Royal National Institute of The Blind Mrs Margaret Main-Reade Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (10), Sensory impairment (3), Sensory of places Impairment over 65 years of age (40) Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to three persons between the ages of 55 and 65 years of age with a sensory impairment Up to ten persons, over 65 years, may receive personal care. Overall registered beds must not exceed forty. 19th September 2006 Date of last inspection Brief Description of the Service: Kathleen Chambers House is registered with the Commission for Social Care Inspection (CSCI) to provide care for up to 40 people who have a sensory impairment. The Royal National Institute for the Blind ( RNIB) which has been renamed The Royal National Institute of Blind People, owns the home. The registered manager is Mrs Margaret Main-Reade. The home itself is modern, it has been purpose built and equipped to meet the needs of people with a sensory impairment. All service users accommodation has en suite bathroom/shower facilities and a small kitchen area. The fees range from: £466.00 for single en-suite accommodation, one and two bedroom flats £535.00 to £566.00 (depending on occupancy) Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection visit was to inspect relevant key standards under the CSCI ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection, which took place over one day. The CSCI inspector was assisted by an Expert by Experience from Help the Aged. Both were well received at the home. The Expert by Experience was asked to make observations about the quality of daily life at the home and the outcomes for people living at the home. The Registered Manager was not available; the deputy manager was in charge and made herself available for the duration of the inspection visit and to receive feedback. A tour of the home took place and a sample of the bedrooms was seen and all communal areas of the home. At the time of the inspection there were 33 people residing at the home. The home is registered for forty places, at the inspection one single room and two double flats were empty. One single room is used as a guest room and one is used as a staff sleep in room. The home had sent CSCI their completed AQAA (Annual Quality Assurance Audit); this provides details of all aspects of the home and a data set of information. As part of this inspection, the inspector surveyed the opinions of people using the service and staff members. Good levels of responses were returned, six from people living at the service and six members of staff. Comments received from the surveys and following discussion with people using the service at the inspection visit are included in this report. The Expert by Experience and the inspector spent time talking to people at the home, members of staff, the deputy manager and administrator. Lunch was taken in the dining room with the people in residence. A selection of records relating to care including care plans, staff recruitment files, finances, health and safety records, were sampled and examined. Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 6 The inspector and expert by experience would like to thank all the staff for their help and cooperation with the inspection process. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: What has improved since the last inspection? Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 7 There has been ongoing maintenance at the home. Some new carpets have been purchased. Fire and danger signs now have directions in Braille. A review of activities has been undertaken and a new programme is in place. Volunteers are being actively recruited to help with activities. 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. Kathleen Chambers DS0000031544.V372205.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 Kathleen Chambers DS0000031544.V372205.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): 2,3, 6 is N/A Quality in this outcome area is good. There is detailed information about the service, which available in a range of formats for people looking to choose a place at this care home. People coming into the home on a permanent basis have their needs assessed, pre admission. Information is gathered from other sources to ensure care needs can be met at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 10 The Statement of Purpose had been updated April 2007; a copy of this document was supplied for inspection purposes. The service user guide has been developed as an amalgamated document with the statement of purpose for future use. This document was also seen for inspection purposes and was found to have much useful detail about all aspects of the service provision and quality information. The Annual Quality Assurance Assessment informed CSCI that the statement of purpose has also been reviewed to ensure appropriate language is used to promote equality and diversity within the service. The home can provide Braille, tape recording or large print copies of the homes ‘Welcome Pack’, to suit individual people. Six surveys were returned from people who use the service. All confirmed that they chose to live at Kathleen Chambers House and were provided with enough information before they decided to live here. One person commented that they stayed for a week on two occasions before moving in. A sample contract is included in the service user guide. Contractual arrangements were sampled; these appeared to be open and clearly written. Pre-admission assessments are made by the manager or the deputy manager to ensure care needs can be met at the home. The care plan is further completed on the first day of admission. Three care plans were sampled; these demonstrated that pre admission assessments are made where long-term placements are planned. Not all short term stays are assessed in person by staff, they rely on all the other evidence gathered pre-admission, such as the community single assessment process (SAP), hospitals are consulted, medication information is gathered and mobility assessments are reviewed. The key workers are being included with any care reviews attended by the person their family and the social worker. Kathleen Chambers DS0000031544.V372205.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): 7,8,9,10 Quality in this outcome area is good. Individual care plans detail how care needs can be met in a person centred way. People are treated with respect and dignity. Medication administration and management is safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People have their own rooms and these are treated as their private space. Staff were seen to knock before entering a bedroom. People can lock their rooms if they wish. No one was described as very ill and the inspectors managed to see all people living at the service during the day. A number were spoken with and the Expert by Experience, assisting at the inspection, sought their opinions. Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 12 People said they were happy and well cared for at Kathleen Chambers House. Three care plans were sampled. The health and social care needs of people had been assessed and care plans were written showing how needs would be met at the home. People are involved in their care planning and they had signed the reviews of their care plans. People are reassessed when their care needs change, in some cases this may indicate that the home can no longer meet a persons needs. An example would be where specialist dementia care is required. Where someone is taken ill and can be supported by supplementary care from the community nursing services, every effort is made to support such care. People living at the home commented that the increasing needs of some people meant that the staff were busy and not always as available to assist them with tasks such as letter reading or did not have time to sit and talk to them. It is important for the people living at the home that individual people’s changing care needs are recognised to ensure the level of care and the specialist care available is sufficient to meet the needs of all people living at the home. The dependency of people living at the home should be monitored to ensure there is sufficient staff on duty for people to receive the support they need with daily living activities. No complaints were made to the inspector about the care or the support given at the home. People found the staff to be friendly and helpful. All interactions heard during the inspection visit were kind and helpful. One concern was raised with CSCI concerning an incident and the standard of personal care for one person; the response from the manager and explanation of the circumstances was satisfactory. Appropriate regulation 37 notifications have been made to the CSCI. One included an error with a drug administration, this brought about a policy change, which was judged to be satisfactory by the regional pharmacist for CSCI. People were receiving input from the district nurse. The local medical and health care services are accessed for people living at the home. People can attend the local surgeries if they wish and from the Burnham on Sea surgery there is a regular weekly visit from a G.P when people can be seen at the home and their health care can be reviewed. Medication management was examined. People can self medicate where they are able, eight people were identified as self-medicating. There is a selfmedication risk assessment and monthly administration and stock check. The people have a lockable facility in their bedroom for the safe storage of their medication. Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 13 Medication administration was observed at lunchtime. The Medication Administration Records (MAR’s) were examined. Medication is receipted onto the MAR and is signed. Hand transcribed transactions were signed by two people to verify the entry. Instructions for anticoagulation therapy such as warfarin dosages and blood monitoring were very clearly recorded. Any changes to the prescriptions are faxed through and the record is retained. Controlled medication is carefully managed and was checked as correct. There is a regular checking system in place. The storage and fridge storage was safe and was locked. Prescribed skin creams are kept in bedrooms and are signed for on administration. One sample was checked to confirm this practice. All supervisors have first aid training and the home has a first aid trained member of staff on duty on each shift, both by day and at night. Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. The home offers a range of social care and people can choose how they spend their time. Visitors are welcome at any time. The catering is of a good standard and people have a choice of menu. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Personal choice in daily living is supported as much as possible, visiting friends and family are welcome at any time. The Expert by Experience noted: “The home was very spacious with wide corridors and rails all around the walls. Directional signs were in large print and Braille. I listened to the speaking notice board and it told me which staff were Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 15 working for the day and what activities were available. For Wednesday it was newspaper reading at 9.30 followed by a trip to the garden centre at 10.30 and finally a trip to the bank at 2 pm.” The home has a large hobbies room that is well used and is well equipped for hobbies and joint activities. The home currently has a volunteer on Mondays for a craft activity and new volunteers are currently being recruited. The homes activity coordinator works over twenty hours each week, which includes alternate Saturdays. There was newspaper reading held in the morning, this was a well supported and social occasion. People congregated afterwards over coffee and the trip into town to the bank was discussed. The Expert by Experience spent time with the activities coordinator. She heard that a survey went out to all the residents to ask what they would like to do and there is now a full timetable of activities. The newspaper reading is very popular, everyday 12-14 people join in. The quiz has 10-12 people, going out for a meal locally usually about 8 people attend, the maintenance man helps with this. Shopping can be difficult when only about four people can be taken and they sit in a café and take it in turns to shop one at a time with the activities coordinator. A volunteer comes in to read local newspaper magazine articles and this is also popular. The home has a minibus for trips out. The inspectors heard that because there is only one activity person trips out are local and for a small number of people only. The home had only one activities coordinator and one volunteer at the time of this visit. Comments heard by the Expert by Experience included that more staff are needed; one person blamed “ the lack of staff/volunteers” as the reason they were unable to go out for walks. Since the last inspection work has been undertaken to gather evidence on likes and dislikes to help design a programme of activities, this was fairly newly up and running at the time of the inspection visit. A volunteer meeting has been arranged to try to organise support for specific things, the example given was for a once a month shopping trip. People have their own private bedrooms and are encouraged to personalise them making them homely with their keepsakes and photographs. People have televisions and can have the use of a personal telephone. One person said they are “happy in the home and loved to sit in the conservatory and be with friends”. They also said they would like to have their hair done more often but could not always get an appointment. Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 16 Many people enjoy active and independent lives and can choose to access the local community or go for walks independently. People are encouraged to be responsible for their own money for as long as they wish. Staff give support where needed to help people maintain their independence for as long as they are able. Records were sampled and these demonstrated clear accountable management of the small amounts of monies held. There is safe storage with restricted access. Two signatures are obtained for any cash withdrawals. The home has policies and procedures to ensure that service users are protected from financial abuse. The Expert by Experience noted on arrival at the home that: “The Receptionist welcomed me and asked me to sign the register – a lovely smell of home baking greeted me!” The cook and the assistant cook managed the catering on the day of the inspection. The inspector heard that the cooks work extra shifts or have agency cooks in to help. One person asked about mealtimes said they have early morning tea in bed at 7am and breakfast at 8am; they said they chose to have cornflakes and prunes each morning. Lunch was served in the spacious, nicely presented dining room. People assembled for lunch and a number were assisted to their places by the care staff. The cook was seen going around taking the menu choices for the following day. The kitchen staff prepare home cooked food, which looked and smelled appetising. People were complimentary about the food they are served. One person commented to the Expert by Experience “the food is excellent ”. The Expert by Experience reported: I had lunch with three ladies, the dining room was bright and spacious, the tables were covered in bright yellow tablecloths and real glasses were used. Roast beef was served followed by gooseberries and custard it looked very appetising and the three ladies on my table really enjoyed it. All the residents managed remarkably well, and were offered help, my ladies declined. People’s comments varied on the food, some thought they had too much, some thought the vegetables could be fresh some could not fault the food at all. Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. The home has a complaints procedure and thorough investigations are undertaken if a concern is raised. People living at the home are protected from the risk of abuse by policies, procedures and good practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Regular meetings are held with people living at the home and regular care reviews are undertaken. People asked said they would be able to raise a concern at the home. Staff asked about safeguarding the people they care for, they were clear that they would report any abuse. Staff asked were clear about the ‘whistle blowing’ policy and a copy of the policy was supplied to CSCI at the inspection. Staff comment cards indicated that five of the six respondents knew what to do if a person, their relative or friend raised a concern about the home. Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 18 All service users are registered to vote and their legal rights are protected by the homes values, policies and procedures. The Complaint procedure is accessible and includes the Commission of Social Care Inspection and local Social Services contact details. This information is provided in the service users guide. CSCI contact details need to be updated, this is recommended. A complaints record is kept, the AQAA indicated that the home has received two complaints since the last inspection. The AQAA indicates that complaints are reviewed at the care home ‘Regulation 26’ visits by the RNIB management and by the corporate complaints officer. The Commission for Social Care Inspection (CSCI) has received one concern about care at the home, the manager investigated this and the explanation was satisfactory. Staff recruitment includes an enhanced Criminal Record Bureau (CRB) check is made to reduce the risk to people living at the home from the employment of unsuitable people. The CRB evidence was seen in three new staff recruitment files. The RNIB has a policy on safeguarding and an e-mail alert at a corporate level, which the AQAA indicated provides a forum for advice. The RNIB has also had a campaign called ‘In safe hands’ to raise awareness about safeguarding people in their care. The manager is reminded that the Somerset Safeguarding policy guidance (led by Somerset Social Services) must be adhered to if a safeguarding incident occurs at the home. Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is excellent. The home provides a well maintained, safe, comfortable environment. It has specialist equipment and is adapted to meet the needs of elderly people with a sight sensory impairment. The home is spacious and people have a choice of comfortable communal rooms for dining, activity, relaxation and entertaining visitors. The outdoor space and gardens are accessible and have level access and handrails. People are encouraged to personalise their rooms with their own belongings to make them homely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 20 A tour of the premises was made. The home was found to be clean, tidy and odour free on the day of the inspection. The home is well decorated and furnished to a very good and comfortable standard. People are able to bring in items of their own furniture by agreement with the home and to personalise their rooms in line with their choices and preferences. There is a range of communal areas, a large dining room, lounge space, and conservatory with access to the garden. The home has seating available in the gardens. The gardens are well maintained, there is level access with handrails, and the garden access is suitable for wheelchair users. The bathrooms and en-suite facilities seen were clean and tidy. All bedrooms have en–suite facilities and a small kitchenette. There are a number of toilets strategically placed around the home. The home provides a hairdressing salon, spa bath, library, training room (for staff) and a well-equipped activity room that opens onto the garden. The home has a call bell system throughout the home. All people asked confirmed that the call bell is answered promptly. There is a good laundry facility; no concerns were raised about the care of clothing or the laundry process. The large well-equipped kitchen was seen, the cooks reported that all their equipment was in working order and their records were kept up to date. There is textured flooring throughout the home to indicate different areas and a ‘talking notice board’ that tells people the activities for the day and the senior staff on duty. This was working at the inspection. Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. The home has a skill mixed workforce to manage the care and service delivery very well. Staff did not all reflect that there are sufficient staff in number to give enough time to people who use the service. Staff are carefully recruited and receive induction and training to have competency in their roles. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a sufficient staff team on duty in all departments at the time of this visit. There were four care staff and the deputy manager on duty. Other staff included the receptionist, an administrator, the activities organiser, laundry and domestic staff, the cook and assistant cook. Both maintenance staff were on duty. Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 22 The inspector heard that there are three carers and a supervisor on duty in the afternoon. At night there are two waking staff and one sleeping staff. Where there are staff vacancies, the regular staff have felt the strain; this was reflected in comment cards, which complained about the length of the recruitment process. The homes induction, which is now five days, was also blamed for the delay in staff commencing work at the home. Staff in comment cards felt the process was very long and prolonged the staff shortages. Staff also mentioned low morale and lack of having enough time with the people they care for. More able people in residence had noticed how busy staff are, people said they are reluctant to make further demands upon their time. All staff had positive things to say about the care and the support they give to people living at the home and reflected on it being a good level of service provided by them at the home. Staff recruitment files were examined and the three files checked demonstrated thorough recruitment practice, with CRB checks and references being taken up before someone new can commence working at the home. Staff were spoken with in private, the inspector heard that the home offers training and is a good employer. There have been staff vacancies over the past twelve months and agency staff have been and are being used to cover vacant shifts, the inspector heard that the agency supplies the same staff for continuity of care. The inspector was informed that there was a care support vacancy and two night shifts to cover at the time of the visit. New staff undertake the five-day induction programme and have a whole week shadowing a member of staff before they work on their own. From reading staff comments and visiting the home, where care needs have increased, the demand on staff time means there is detraction from the one to one time previously available to staff to fulfil their key worker role. Dependency and changing care needs should be reviewed to examine how the staffing can maintain the level of support people had previously felt they received at the home. Staff supervision records were inspected and there was evidence of regular staff supervision. Staff commented on training they receive regularly. Two staff responded that they did not feel the video training was as effective as their experience of previous ‘hands on’ style training. Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. The service is well managed. There is opportunity for people to feedback on the day-to-day running of the home and on what it offers people living here. Service users are protected by robust policies and procedures at the home. The home is well and safely maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 24 The registered manager is Mrs Margaret Main-Reade who had experience as an assistant manager. Mrs Main-Reade has completed a Postgraduate Certificate in Management and is working towards an NVQ level 4. The assistant manager was on duty and was helpful in assisting with the inspection process in the manager’s absence. Staff and people at the home had a good rapport with the assistant manager. The assistant manager demonstrated that she is knowledgeable about care and has a good understanding of the people living at the home. Regulation 26 visit reports were sampled and were seen to be carried out on a monthly basis by a representative for the RNIB. There are also RNIB financial management meetings with the homes manager. The AQAA indicated that the manager has a regular weekly meeting to update all departments. One staff feedback form reflected that all department meetings are now no longer held. Regular meetings are held for the people in residence at four to six weekly intervals. This was confirmed by asking the people who are living at the home. Stakeholder surveys and meetings are undertaken annually. The results of the surveys for quality assurance 2007 were included in the service user guide. The AQAA indicated that maintenance of equipment had been addressed in 2008 and was up to date. This included the servicing of the passenger lift, people hoists, fire safety equipment, gas appliances and the heating system. Since the last inspection, all fire alarm points and danger signs are now available in Braille. The AQAA indicated that the RNIB ‘Visibly Better Team’ are due to visit the home to assess where further improvements can be made. Infection control training has been introduced as mandatory training on day one for all new staff. The AQAA data set indicated that ten staff have undertaken infection control training. All staff (100 ) have undertaken food hygiene training. Kathleen Chambers DS0000031544.V372205.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 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 3 17 X 18 3 4 4 3 3 4 4 4 4 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Kathleen Chambers DS0000031544.V372205.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 Refer to Standard OP27 Good Practice Recommendations The dependency of people living at the home should be monitored to ensure there are sufficient staff on duty for people to receive the support they need with daily living activities. CSCI contact details need to be updated in the complaints contact information and service user guide. 2 OP16 Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Kathleen Chambers DS0000031544.V372205.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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