Inspection on 26/06/07 for Linkfield Court

This inspection was carried out on 26th June 2007.

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

The inspector 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

Linkfield Court 23/06/09

Linkfield Court 21/12/05

Linkfield Court 02/06/05

Linkfield Court 16/11/04

Linkfield Court 16/04/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Linkfield Court 19 Knyveton Road East Cliff Bournemouth Dorset BH1 3QG Lead Inspector Jo Pasker Key Unannounced Inspection 11:00 26 & 27th June 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 DS0000003957.V337076.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. DS0000003957.V337076.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Linkfield Court Address 19 Knyveton Road East Cliff Bournemouth Dorset BH1 3QG 01202 558301 01202 553642 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) www.linkfieldcourt.co.uk Linkfield Court (Bournemouth) Limited Mrs Yolanda Farrell Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places DS0000003957.V337076.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Within the total of 29 places one service user over the age of 40 may be accommodated in the Independent Living Unit for short term care and/or rehabilitation to enable them to return to live in the community. Within the total of 29 places, one service user may be accommodated between the ages of 50 and 65 within the care home. (See entry in Brief Description of Services below relating to this Condition). Date of last inspection 21st December 2005 2. Brief Description of the Service: Linkfield Court is a former hotel situated in a tree lined street, within a short level walk of local and national bus and train services. The centre of Bournemouth is not far away, with amenities including shops, cafes, restaurants, entertainment, library, places of worship, beaches and cliff-top walks etc. Retaining many of the features of a hotel, such as large communal rooms and reception area, Linkfield Court was converted to a nursing home before it changed its status and now provides personal care only, for up to 29 older people. Residents accommodation is located on the ground and first floors of the home with access between floors via a wide staircase, passenger lift or a new platform stair lift for rooms in the upper annexe. Aids and equipment are available for residents who may have disabilities, including ramped access to and from the home and assisted bathing facilities. The home is centrally heated throughout and eleven bedrooms have en-suite facilities. There is a large, attractive garden to the rear of the premises that is level and readily accessible with garden furniture and a patio area. Car parking is provided for visitors to the home and further parking is available on nearby roads. Service users are encouraged to participate in a range of activities organised in the home, including monthly entertainment and fundraising events for charity. Linkfield Court is registered with the Commission to provide residential care for 29 residents, the majority of whom are aged 65 years and over. However, the home has also been approved by the Commission to provide residential care for persons younger than 65 years of age and therefore the Conditions of DS0000003957.V337076.R01.S.doc Version 5.2 Page 5 Registration listed on this report are not strictly accurate. Linkfield Court will be issued with a new Certificate of Registration to reflect this change in due course. The home is owned by Linkfield Court (Bournemouth) Ltd, a family business, with one of the Responsible Individuals being Mrs Coombs and the other, her daughter Mrs Farrell, who is also the Registered Manager. Weekly fees for residential care range from £350 to £750. Additional charges are made for hairdressing, chiropody, hand massage, manicures and newspapers. See the following website for further guidance on fees and contracts: http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_people_ choos.aspx DS0000003957.V337076.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over the two days of the 26 and 27 June 2007 and took approximately 6 hours. The purpose of the inspection was to assess all of the key standards and review the 1 requirement made in the last report. The Registered Manager and also a Responsible Individual, Mrs Farrell and Mrs Coombs, the other Responsible Individual, were on hand to aid the inspection process, along with other key members of staff and were very helpful throughout. Information for this report was obtained from discussion with the Registered Manager, Responsible Individual, care manager, discussions with 5 residents and 5 members of staff on duty, a review of a variety of documentation including records provided to the Commission, care records, staff records, maintenance records, policies and procedures and a guided tour of the home. The home also submitted a completed Annual Quality Assurance Assessment (AQAA) and a total of 22 comment cards from residents, relatives and professionals were received and comments included: • • • • “My mother seems very happy with the service/support” “Can only say that the care and service provided are of the best” “I find the staff are friendly…” “Cannot from my visit see any matters that require improvement”. What the service does well: The pre admission process is good and treats prospective residents in a personal and caring manner. Care planning is good and ensures that residents’ needs are well assessed and appropriate care given. The general health needs of residents are well met with several different external healthcare professionals involved in delivering care. Residents are encouraged to maintain contact with the local community and visits by their friends and relatives are welcomed by the home. A varied, appealing and balanced diet is enjoyed by people living at the home, which caters for the varied needs of the residents. The home has an effective complaints policy and procedure in place, which ensures that residents’ and relatives’ concerns are well managed. DS0000003957.V337076.R01.S.doc Version 5.2 Page 7 The home provides a safe and well-maintained environment for the residents, with an excellent standard of décor and comfort. Sufficient numbers of staff are on duty throughout the day and night to be able to meet the needs of the residents and staff training is comprehensive. Management and quality assurance systems are excellent and ensure that residents are receiving a high standard of care. Financial procedures within the home also ensure that residents’ interests are protected. The health and safety of the residents and staff are protected by the policies and procedures that the staff follow at Linkfield Court. What has improved since the last inspection? What they could do better: 4 recommendations have been made as a result of this key inspection: When a medicine is prescribed ‘as required’ (PRN) the MAR chart should state the potential reason for administration. All hand written entries on MAR charts should be checked for accuracy and signed and dated by 2 competent persons and the medicines policy updated to reflect this. It is recommended that records accurately reflect activities provided to residents, showing how individuals’ recreational needs are being met and these are kept up to date. DS0000003957.V337076.R01.S.doc Version 5.2 Page 8 It is recommended that the home keep copies of their letters requesting references for new staff to help record who provides them. 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. DS0000003957.V337076.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 DS0000003957.V337076.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 3 (The home does not provide intermediate care so Standard 6 does not apply). Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides a clear Statement of Purpose and Service User Guide and all new residents can be assured of receiving a contract which gives clear information about fees and their accommodation. New residents move into the home having had their individual needs comprehensively assessed ensuring that the admission process is well managed and person centred. EVIDENCE: The home has a clear and comprehensive Statement of Purpose and Service User Guide, which sets out the aims and objectives of the home and what services and facilities are available. Copies of letters sent to prospective residents seen, confirmed that Linkfield Court was able to meet their needs. DS0000003957.V337076.R01.S.doc Version 5.2 Page 11 The files of 4 residents were viewed which all contained pre-admission assessments. Records covered areas such as behaviour, sleep, communication, continence and bathing and evidenced that a thorough and informative assessment had taken place. This ensures that sufficient information was gained so that a comprehensive care plan could be written; to ensure that the resident’s care needs could be met appropriately. Residents spoken with confirmed that their needs had been assessed by the manager and often in conjunction with their family, prior to moving into the home. The home ensures that the admission process and settling in period is tailored to the personal needs and requirements of the individual, making them and their relatives feel as comfortable as possible. Of the 10 respondents to the service user survey, 8 indicated that they had received enough pre admission information about the home prior to moving in and had received a contract. DS0000003957.V337076.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear, consistent care planning system in place, which provides staff with the information they need to meet residents’ needs. The home has a comprehensive medicines policy in place to protect residents yet some improvements could be made regarding aspects of recording by staff. The health needs of the residents are well met with evidence of good support from community health professionals. Residents are treated with dignity ensuring that that their rights and privacy are upheld. EVIDENCE: The care records of 4 residents were viewed over the course of inspection. These were found to be comprehensive, up to date and relevant and were based on the findings of appropriate assessments. Files contained a variety of assessments including: DS0000003957.V337076.R01.S.doc Version 5.2 Page 13 • • • • • • Moving and handling Falls risk Skin assessments Nutrition Pressure area risk Activities of daily living. The care plans clearly identified the individual residents’ needs, aims and actions/interventions giving staff clear goals to follow and there was evidence of individual choice, such as: • “X goes to bed when he chooses”. There was also evidence that care plans are now discussed with the resident or their representative after admission and signed to reflect this. Risk assessments seen covered a variety of areas, including seizures and disorientation and were thorough and again gave staff specific interventions to follow in meeting residents’ care needs or managing risks. There was clear evidence of regular external healthcare professionals’ involvement, such as GP’s and chiropodists, on the daily entry sheets. Comment cards received from both professionals and relatives, reflected their feelings regarding care given at the home: • • • “Provide a diversity of care; enable people to have choice” “They treat all the residents as if they were the only one they had to look after” “The home is very caring and the staff helpful”. Medicines were properly stored, being locked away and with a refrigerator for cold storage. Staff record fridge temperatures regularly and the records were seen to support this. Records were kept of the receipt, administration and disposal of medication and examination of these showed that all was well recorded and there was a clear audit trail available. The home employs a dedicated drugs administrator and trainer whose sole responsibility is the safe management of medication. All the medicine administration record (MAR) charts for each resident clearly stated whether there were any known allergies to medicines and there were no gaps seen in signing and all reasons for omission were appropriately documented. It is recommended however that a second competent person, also checks, signs and dates all handwritten medicine entries or changes on drug charts to DS0000003957.V337076.R01.S.doc Version 5.2 Page 14 ensure accuracy. Also, when a medicine is prescribed ‘as required’, the MAR chart should state the potential reason for administration (e.g. as required for joint pain). Self medication assessments were seen in individuals’ care files and locked facilities provided in residents’ rooms for medicine storage. The residents spoken with generally said they were well cared for. Eight respondents to the service user survey indicated that they ‘always’ received the care and support they needed and one resident made the comment: • “I feel sometimes I am forgotten but somebody eventually comes. I would like my cup of tea earlier and also to be dressed”. However, observation of staff working in the home showed they were polite, caring and attentive. DS0000003957.V337076.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an adequate range of social opportunities available in the home, which reflect some peoples’ interests and preferences, however the provision of activities could be improved to provide better stimulation for residents. Residents are encouraged to maintain contact with the local community and visits by their friends and relatives are welcomed by the home. Both relatives and staff members assist residents to make choices, enabling them to achieve control over their lives. The meals in this home offer choice and variety ensuring that residents receive a wholesome diet. EVIDENCE: The home does not provide a dedicated activities organiser but allocates activities responsibility to carers on a daily basis. Any resident’s participation is then documented on the daily activities record. Individual residents’ interests and hobbies are documented on the admission sheets under the areas of social DS0000003957.V337076.R01.S.doc Version 5.2 Page 16 needs, relationships, activities and links with the community. Activities available include: • • • • • • • • • • old time music hall nail care creative craft wordsearch chess movement to music scrabble newspapers puzzles classical music However, activities that took place were limited by how busy the care staff were on each day and on the records viewed, there were several days where there were no entries made and it appeared no activities had taken place. From the service user surveys received, 1 resident said there were ‘always’ activities arranged by the home that they could take part in, 4 said ‘usually’, 4 said ‘sometimes’ and 1 said ‘never’. Comments from all surveys received included: • • “I notice live entertainment is a regular feature” “Provide more activities”. Links with the community are good and residents’ spiritual needs are well met with regular visits from different denominational representatives. A visitors’ book in the reception area of the home evidenced that residents receive visitors at all times and residents were seen being visited by relatives during the course of the inspection. The home has also made exceptional arrangements for family members when a resident has been terminally ill and ensured that they were treated with care, sensitivity and respect during a particularly difficult time. 4 relative/carer comment cards received, stated that the home ‘always’ supported people to live the life they chose, with 3 saying ‘usually’ this was the case. The menu provides a wide choice and variety of meals, with the chef aware of residents’ likes and dislikes which are well documented upon admission to Linkfield Court. Entries seen included: • • “Y dislikes fresh cream” “Z enjoys small amounts of fruit cut up for her”. DS0000003957.V337076.R01.S.doc Version 5.2 Page 17 Lunch was seen on the day of inspection and looked well presented and appetising. Generally comments received about the food were good; however residents spoken with did not know what was for lunch that day and the menus were not readily displayed. DS0000003957.V337076.R01.S.doc Version 5.2 Page 18 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. This judgement has been made using available evidence including a visit to this service. The home has an effective complaints procedure that enables residents to raise concerns knowing they will be acted upon and dealt with. Staff’s knowledge and understanding of Adult Protection issues provides a safe environment to protect service users from abuse. EVIDENCE: The Commission has received no complaints since the last inspection and the complaints log was seen which evidenced that no complaints have been received by the home in the last year. There is a clear complaints policy available and residents spoken with during the inspection said that if they had any concerns they would feel confident about talking to the manager, knowing that she would listen to them. Relative and carer surveys returned indicated that 5 out of the 8 respondents felt the home had ‘always’ responded appropriately to concerns raised, with 3 saying ‘usually’. The home has updated its adult protection policy and procedure since the last inspection to fully reflect current Department of Health guidelines. The policy now clearly states that any issues of abuse will be dealt with following the local protection of vulnerable adult (POVA) procedures. Staff spoken with DS0000003957.V337076.R01.S.doc Version 5.2 Page 19 demonstrated a sound knowledge of elder abuse issues and how to correctly report them. There has been 1 adult protection referral made since the last inspection, which has been fully investigated by the local authority yet no final outcome has been received by the home or the Commission. Following the investigation, a referral regarding a member of staff was made to the POVA list. DS0000003957.V337076.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): 19, 22 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within Linkfield Court is good providing residents with an attractive, homely and safe place to live. The home is generally clean and free from any offensive odours, providing a pleasant and hygienic environment. EVIDENCE: A tour of the premises found the home clean, in good order and it provides a comfortable environment in which to live. It was noted that the home appeared safe and well maintained during the duration of the inspection. The home has an on going programme of routine maintenance and refurbishment and work completed since the last inspection includes: • • Refurbished bath/shower room New curtains DS0000003957.V337076.R01.S.doc Version 5.2 Page 21 • • • • • • Refurbished staff toilet Pond has been removed and replaced with a safer water feature New call system installed with additional remote controls New doors in quiet lounge New fire doors Bedrooms redecorated. The Responsible Individual, Mrs Coombs confirmed that more work is planned for the coming year, including replacing all carpets in the hallways and quiet room, providing new beds and dining furniture and replacing commodes. Since the last inspection a new stair ramp for the annexe building has been fitted, after appropriate consultation with the local fire service. This now enables physically frail residents to be accommodated in these rooms and be able to freely mobilise to the main building. The home was clean and generally free from any unpleasant odours, with evidence of good infection control procedures in place and the laundry appeared well managed with ample supplies of clean linen seen throughout the home. Comments received from residents and relatives included: • • • “Everything is so beautifully kept and always so very clean” “More care and attention to washing. Articles of clothing go missing although everything is labelled” “Generally the home is clean and doesn’t smell”. DS0000003957.V337076.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): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staff are employed and deployed to meet the care needs of residents. The home’s recruitment system ensures that residents are properly protected from the risks of potentially unsuitable staff being employed. Staff receive comprehensive training and are competent in their skills with the majority of staff having the NVQ level 2 in Care award, ensuring that residents are well cared for. EVIDENCE: The duty rota was seen during the inspection and it showed that there were adequate numbers of care staff employed to meet the needs of the residents, including a care manager and 2 assistant care managers, chef and domestic staff. The home has an ongoing training programme, which includes NVQ level 2 in care. The AQAA submitted by the home showed that 14 care staff have completed NVQ award at level 2 and 2 staff are working towards it. 2 other staff are working towards achieving their NVQ level 3, 1 staff member their NVQ level 4 and 2 others towards their Registered Managers Award (RMA). DS0000003957.V337076.R01.S.doc Version 5.2 Page 23 3 staff recruitment files were seen and these contained: • Proof of identity • 2 written references • Employment histories • Job description • Offer letters • Documentary evidence of any relevant qualifications Linkfield Court employ a company to ensure all staff receive a POVA First check and enhanced Criminal Records Bureau (CRB) check prior to starting work. It was unclear who had written some of the references seen as the referees had not printed their names, the home had not kept copies of letters requesting references and the signatures seen were illegible. Training files demonstrated that healthcare assistants were receiving Skills for Care induction training and this was confirmed with staff spoken with during the inspection. The home have also involved the local adult learning college for providing in house learning and provided a training room for staff. Recent training seen included: • First aid • Fire training • Infection control. Further information on available training can be accessed through the following websites: www.picbdp.co.uk www.skillsforcare.org.uk DS0000003957.V337076.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): 31, 33, 35 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is run by a committed and competent manager, who creates an open and positive atmosphere, which supports good care practices for residents. Excellent quality assurance systems are in place ensuring that practice within the home reflects the home’s policies and procedures and listens to the views of others. Residents are assured of sound management of their financial interests. Staff are appropriately supervised ensuring that training needs are identified and met. The welfare of residents and staff are well promoted and protected, ensuring that risks to health and safety are minimised. DS0000003957.V337076.R01.S.doc Version 5.2 Page 25 EVIDENCE: Mrs Yolanda Farrell is the Registered Manager of Linkfield Court and has been for the last 14 years. She is also one of the Responsible Individuals, along with Mrs Coombs, who both have a ‘hands on’ approach to the running and management of the home. Mrs Farrell’s duties include the overall running of the home, responsibility for the financial accounts and overseeing the staff team alongside the care manager. The Registered Manager has recently completed Mental Capacity Act training and First Aid training. It was evident from speaking with residents and staff that Mrs Farrell and the whole management team are well liked and approachable and demonstrate a strong commitment to maintaining a high standard of care throughout the home. Comments received included: • • • “I think the home is run very well…” “Friendly and accommodating” “Good service in all ways”. The home submitted a completed AQAA prior to inspection and has excellent quality assurance systems in place. They have completed the ISO 9001/2, which covers areas such as: • • • • • • Service user care Recruitment and training Continual improvement Purchasing Enquiries and admissions Company overview. This standard requires an external auditor to come into the home 3 times a year and audit different areas with a yearly audit to ensure standards are maintained and the award is kept, with this paid for by the home. The home also uses resident satisfaction questionnaires and action plans were seen to introduce surveys for relatives and professional visitors. A copy of the annual development plan was also seen. Residents confirmed that they either deal with their own finances and lockable facilities were available in each room. Some residents have appointed a responsible representative to manage their money and this is frequently another family member. The home does not hold ‘pocket money’ for residents and all bills (for chiropody or newspapers etc) are paid first by the home and then families invoiced. DS0000003957.V337076.R01.S.doc Version 5.2 Page 26 The care manager confirmed that formal staff supervision takes place the recommended six times a year with staff also receiving an annual personal development plan session. Supervision records reviewed demonstrated this and showed it was of a good standard. Records showed that all staff had received recent training in fire safety, evidence was seen of a recent drill taking place and all fire safety maintenance checks were up to date. Substances hazardous to health were seen to be stored securely. Records showed that equipment had been serviced regularly and all servicing certificates seen were in date. Accidents were well recorded and audited weekly with appropriate action taken as necessary, such as risk assessments. DS0000003957.V337076.R01.S.doc Version 5.2 Page 27 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 4 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 3 X 3 DS0000003957.V337076.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP9 OP12 Good Practice Recommendations When a medicine is prescribed ‘as required’ (PRN) the MAR chart should state the potential reason for administration. All hand written entries on MAR charts should be checked for accuracy and signed and dated by 2 registered nurses and the medicines policy updated to reflect this. It is recommended that records accurately reflect activities provided to residents, showing how individuals’ recreational needs are being met and these are kept up to date. It is recommended that the home keep copies of their letters requesting references for new staff to help record who provides them. 4. OP29 DS0000003957.V337076.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000003957.V337076.R01.S.doc Version 5.2 Page 30 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!