Inspection on 21/11/06 for Littlebourne House

This inspection was carried out on 21st November 2006.

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

Littlebourne House 19/08/08

Littlebourne House 01/10/05

Littlebourne House 13/06/05

Littlebourne House 18/01/05

Littlebourne House 19/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Littlebourne House 2 High Street Littlebourne Canterbury Kent CT3 1UN Lead Inspector Mark Hemmings Key Unannounced Inspection 21st November 2006 09:15 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 Littlebourne House DS0000023469.V299956.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. Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Littlebourne House Address 2 High Street Littlebourne Canterbury Kent CT3 1UN 01227 721527 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) Mrs Maralyn Hussein Mr Michael Moreland Mrs Luciana Jarmaine Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the service may accommodate up to 3 service users in the DE (E) category. 1st October 2005 Date of last inspection Brief Description of the Service: Littlebourne House (the Service) is registered to provide care for up to 41 older people. Of this number, three older people may be accommodated who experience a significant reduction in their ability to organise some of their thoughts. The premises are an older property which has been modernised and extended. The accommodation is arranged on the ground floor and the first floor. A stair-lift connects these two levels. In the main building, there are 39 bedrooms. Two of these can be shared by two people each. All of them have a private toilet and wash hand basin. Most of them also have a private bath or shower. Also in the main property, there is a self contained flat which can be used by visitors who have travelled a long distance. Recently, the Registered Providers have developed a suite of self contained flats. These are in a building which is separate from but which is near to, the main house. These flats have a bedroom, lounge, bathroom and kitchenette. They are designed to be used by service users who want the security of being able to call upon assistance, while at the same time wanting to maintain a good deal of their independence. The Home is situated by the main road in the rural village of Littlebourne. This village which is about five miles from Canterbury, has a small selection of shops. The Service has a large and an attractive garden to the rear. This is more or less on the one level. A large all-weather conservatory looks out onto the garden. To the side of the main house, there is room for relatives to park their cars. The Registered Providers supply information to prospective service users through a variety of routes. These include the provision of a Service Users’ Guide. This is a brochure which outlines the principal features of the facilities and services available in the Service. There is a document called a Statement of Purpose available for review in the Service. This gives a more detailed account than does the Guide. Also, the Registered Providers ensure that a copy of the most recent Inspection Report from the Commission, is available for reference in the Service if requested. The Registered Providers have informed the Commission that the range of fees they charge currently for each of the service users’ residence in Littlebourne House, runs from £300.00 to 550.00 per week. Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 5 Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This Report has been based upon a number of sources of evidence. These included a review of the correspondence in relation to the Home received by the Commission since the last inspection. Another source of evidence involved any written information received from service users and from their relatives. Also, the Inspector completed an unannounced site visit to the Service. This took about seven hours to complete. During this time, the Inspector spoke in some detail and/or spent time with eight of the service users. Some of these discussions/periods of time were in private. The Inspector consulted with both of the Registered Providers, with the Registered Manager and with the Administrator. Also, he spoke with four of the care workers, with the Activity Coordinator and with the cook. The Inspector examined various parts of the accommodation and he reviewed a selection of the key records and documents. The Inspector concludes that the Registered Providers operate the Service in a suitable manner to enable the service users in residence to receive the support and assistance they need. There are no Required Developments at the end of this Report. With respect to the limited number of suggested improvements identified in the main sections of this Report, the Registered Providers should consider how best to progress their introduction. What the service does well: Service users said or indicated by their manner, that the Service provides them with a relaxed and generally comfortable setting within which to make their home. They observed or indicated, that they receive all the assistance they need. Also, that the care workers are attentive and kind in their manner. The Inspector considers that the provision of personal care services takes place within a prudent assessment of potential risks to personal health and safety. Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 7 There is a suitably varied calendar of social activities in which service users can choose to participate. The Service’s catering service provides the service users with meals which they consider to be enjoyable and sufficient. Care workers have the competencies they need in order to provide reliable and appropriate support for the service users. Service users are invited to comment upon the adequacy of the facilities and services provided in the Service. Sensible provision has been made to ensure that potential environmental hazards to do with the building have been identified and managed. What has improved since the last inspection? What they could do better: The Registered Providers should ensure that they have suitable provision in place to ensure that used water from appliances such as the washing machine Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 8 does not run back into the main water supply. Naturally, it is important to ensure the separation of used water from drinking water. The Registered Providers should ensure that their plan for the avoidance and if necessary for the management of a fire safety emergency, has been reviewed and approved by the Kent Fire and Rescue Service. This is necessary so that this Agency can be sure that an appropriate level of fire safety protection remains available in the Service. Some of the radiators in the bedrooms are not fitted with guards. Some of the hot water taps fitted to wash hand basins are not fitted with temperature regulation valves. In relation to these facilities, the Registered Providers should ensure that suitable provision has been made to help prevent the risk that a service user might be burnt or scalded. This will entail them assessing these possible risks and if necessary introducing sensible measures to respond to any significant hazards identified by the exercise. The Registered Providers should correct an oversight in one aspect of the security checks which have been completed in relation to one of the care workers. This is important because the checks are one of the means by which attempts can be made to ensure that only trustworthy people have unsupervised access to service users who may be vulnerable. The Registered Providers should ensure in future that the completion of all unannounced fire drills is recorded correctly. This record will be an important management tool for them, because it will enable them to double check when the events in question have occurred and who has taken part in them. The Registered Providers should ensure that a new system is introduced to ensure that everyone who works in the Service knows how best to avoid the occurrence of a fire safety emergency. Also, that they know what they are expected to do if one were to occur. This is important because the level of fire safety protection provided in the Service depends not only upon the presence of fire detection and fire fighting equipment, but also upon the actions taken by members of staff. 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 Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 9 be made available in other formats on request. Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 10 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 Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 11 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): Standards 1, 3, 4 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this Service. Prospective service users and their representatives should have the information they need in order to choose a service which will meet their needs. Prospective service users have their needs assessed. EVIDENCE: The Registered Providers said that they and the Registered Manager complete an assessment of each prospective service user’s needs for assistance, before a decision is made about whether or not the Service is a suitable place for the person’s residence. They said that they are aware of the need to ensure that Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 12 information is collected about someone’s established lifestyle and preferences. This is very important because it enables care workers to promote the continuation of the person’s chosen way of living, if this is their preference. The Inspector spoke with several of the service users about their experience of having moved into the Service. They said that their needs for assistance had been determined before they moved into the Service in the manner described. Also, they indicated that the care workers had been prepared in advance to respond to their requirements at the point of their admission. Care workers told the Inspector that they are briefed fully about the needs of new service users. Also, that this constitutes a useful introduction upon which they can build as they get to know someone better with time. The Registered Providers and the Registered Manager said that they are aware of the range of specialist resources which is available in the community and which can be accessed should a service user need additional help. The Inspector reviewed evidence which showed that some of these resources had been used in a timely manner since the completion of the last inspection visit. For example, use had been made of the local consultant for older people who have special comprehension needs. The Registered Providers said that most service users are admitted to the Service for longer periods of residence. In some residential care homes, service users are admitted for shorter periods of time. This might be done in order to allow some free time for relatives who provide care at home for the person. Or, it might be to enable someone to leave hospital before they are quite ready to return to their own home. The Inspector did not examine this matter further, other than to note that the Registered Providers are aware of the need to promote a service user’s return home if this has been the purpose of the admission. Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 13 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): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this Service. The health and personal care which service users receive, is based upon their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Service users said or indicated, that the care workers offer them all the assistance they need and that this is provided in a reliable and consistent manner. The Registered Manager said that there is a plan of care for each of the service users. These are important documents because they form one of the means by which each service user can be informed about and can agree to Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 14 the assistance they will receive. Also, the plans constitute a source of reference information for care workers, which then helps them to deliver appropriate personal care in a consistent manner. The Inspector examined a selection of these documents and he noted them to be detailed suitably. This assessment was based partly upon the Inspector’s understanding of the related systems in use, which inform care workers orally about the provision to be delivered. In so doing, the Inspector recognises that not everything can or needs to be written down when providing effective residential care services. The Inspector observed care workers when providing elements of assistance to some of the service users. He noted this provision to be appropriate and to be consistent with that described in the respective plans of care. The Registered Providers and the Registered Manager were noted to be aware of the need to ensure that service users are assisted to maintain their health. They said that care workers are alert to the need to identify occasions when someone is becoming unwell. This is so that medical assistance can be sought promptly. The care workers confirmed this account. The service users did not comment about this matter. However, the Inspector reviewed evidence which showed that since the last inspection visit, the Registered Manager indeed had requested assistance from a range of medical personnel as and when the need had arisen. The Inspector notes that the Commission has not received any expressions of concern from local health care providers about any aspect of their working relationships with the Service. The Registered Manager said that most of the service users currently in residence, have chosen to receive assistance in managing their medication. The Inspector examined a selection of the administrative arrangements used by the Registered Providers to organise the completion of this task. He noted that the systems in use were organised well. This means that they should function so as to ensure that each service user receives medication in the manner intended by their family practitioner. The Inspector was informed that a small minority of the service users have elected to handle their own medication. The Inspector is satisfied that suitable consideration has been given to the advisability of this arrangement. Service users said or indicated, that care workers are cordial in their manner towards them, while at the same time being respectful of their individual preferences. The Inspector saw plenty of examples of this, with care workers being observed to be kind in their manner and to be attentive in their approach. Also noted, was the way in which care workers varied their response depending upon the known preferences of the people concerned. For example, some people wanted to spend quiet time in their bedrooms, while others wanted to be in the company of others in the lounges. Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 15 Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 16 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): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this Service. There are some social activities taking place. Service users are able to choose their life style and to keep in touch with family and friends. Service users receive a healthy and varied diet according to their requirements and choice EVIDENCE: Service users said or indicated, that they consider themselves to be occupied suitably. The Inspector noted that the Registered Providers and the Activity Coordinator have developed a suitably varied calendar of social activities. The Registered Providers said that they are aware of the need to keep under review Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 17 the adequacy of this calendar. This is so that the particular interests and abilities of each service user can be engaged. The Inspector noted that the Activity Coordinator had a detailed knowledge about what social events were popular with which service users. Service users said or indicated, that the pace of daily life in the Service is relaxed and unhurried. They used various examples such as the fact that they can retire to their bedrooms whenever they wish. Also, they observed or indicated, that it is up to them to decide when to get up, when to go to bed and how to spend their day. The Registered Providers said that the service users are assisted to keep in touch with members of their families, if this is necessary and if it is their wish. They observed that family members are welcome to call to the Service at any reasonable time. The service users confirmed this and they said that their relatives are made welcome by members of staff whenever they call. Also, they commented that they are free to spend time in private with their relatives, should they choose to do so. Service users said that they receive good quality meals and they always have enough to eat. They observed further that meal times are relaxed affair and that they enjoy their dining experience. The Inspector examined the record of food served in the Service. He concluded that it indicated that the service users are offered the opportunity to have a normally varied diet. The cook said that there are sufficient provisions in the Service to enable all the meals listed on the planned menu to be prepared. Littlebourne House DS0000023469.V299956.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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this Service. Service users and other stakeholders have access to an organised system should they wish to make a complaint. Service users’ wellbeing is promoted and they are protected from abuse. EVIDENCE: There is a complaints procedure which explains how service users and other stakeholders can make a complaint about any aspect of the facilities and services provided in the Service. The service users who commented about this matter, indicated that they are confident that any matter they raise will receive serious attention and if possible will be addressed. The Registered Providers were noted to be aware of the need to investigate promptly and thoroughly any complaint they might receive in the future in relation to the facilities and services provided in the Service. However, in the absence of a complaint having been received since the time of the last Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 19 inspection visit, the Inspector was not able to establish how well these of the Registered Providers’ systems will work in practice. The care workers were noted to have a sound understanding of what constitutes good care practice. As part of this, they were aware of the need to be alert to instances which might jeopardise the well-being of a service user. Service users said or indicated, that they feel safe living in Littlebourne House. Littlebourne House DS0000023469.V299956.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): Standards 19, 22, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this Service. Service users are provided with a generally satisfactory and homely environment. EVIDENCE: Service users said or indicated, that they are comfortable living in Littlebourne House. They consider the accommodation to be homely and welcoming. The Inspector did not identify any significant defects in the general presentation of the accommodation. Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 21 Service users said, that they are assisted by care workers to move around the accommodation safely. The Inspector noted that the Registered Provider has supplied a number of necessary aids such as the stair-lift, hoists in bathrooms and sensible things such as bannister rails in hallways. The care workers said that they have all the facilities they need in order to undertake effectively this aspect of their work. The Inspector understands that the local Department of Environmental Health has not recommended any improvements in the kitchen which remain outstanding. The Inspector examined parts of the kitchen. They were noted to be clean and orderly. The cook was noted to be conversant with good food handling practices. The Inspector understands that the Kent Fire and Rescue Service has said that the Service is safeguarded by a suitable range of fire safety equipment. The Registered Providers have completed an organised assessment of the possible risks to fire safety in the Service. The Inspector noted that the results of the assessment had not yet been submitted for approval to the Kent Fire and Rescue Service. This now should be done. This is because it will contribute to this Agency’s evaluation of the continued adequacy of the fire safety regime operated in the Service. The Registered Providers said that the necessary submission will be made by 1 January 2007. Service users said that their accommodation is kept comfortably warm. The Inspector noted that some of the radiators in the bedrooms have not been fitted with guards. These are an effective means of helping to reduce the chance that a service user might accidentally burn himself or herself, if they were to have a fall. Given the absence of guards in some locations, the Registered Providers are going to complete an assessment of the possible risks remaining. Once this has been completed, suitable steps can be taken should they be needed for a radiator in a particular location. The Registered Providers have said that this exercise will be completed by 1 January 2007. The care workers said that there is a reliable and adequate supply of hot water in the Service. The Inspector noted that some of the hot water taps fitted to wash hand basins used by the service users, have not been fitted with valves which are designed to limit the temperature of hot water to a level which is not likely to scald someone. Again, the Registered Providers now are going to review this matter so that the need for any further protection for service users can be identified and completed. They have informed the Inspector that this development will be undertaken by 1 January 2007. Service users said that their clothes are laundered suitably and that they are returned promptly to them in a presentable condition. The Inspector observed that the service users were wearing neat and clean clothes. The Laundry Manager said that the laundry is equipped adequately to enable her to complete efficiently the laundering of service users’ clothes and other Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 22 household linen. The Inspector examined the laundry. He noted it to be orderly and clean. New regulations have been introduced which are designed to help prevent used water syphoning back into the main pipe-work, from appliances such as washing machines and dishwashers. The Registered Providers were not sure about whether or not the Service complies currently with these regulations. They said that they would make the necessary enquiries and that any additional work which might be necessary, will be completed by 1 January 2007. Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 23 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): Standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this Service. The members of staff have the competencies they need and they are available in suitable numbers to meet the changing needs of the service users. EVIDENCE: There are between four and six care workers on duty to respond to service users’ needs for assistance from early in the morning until the waking night care workers come on duty. During the day, the care workers are supported in their work by other people who undertake most of the catering and housekeeping tasks. The Inspector considers that there are enough members of staff duty to enable service users’ needs for support to be met in a timely and reliable manner. The Inspector understands that the majority of the care workers have acquired a National Vocational Qualification (NVQ) in health and social care. This Award is useful because it provides care workers with a range of opportunities to confirm elements of good care practice and to extend their range of skills. The Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 24 Inspector was told that the Registered Providers intend to continue to encourage additional care workers to study for the Award. The Registered Providers complete a number of security-related checks. These are designed to ensure that all members of staff employed in the Home are suitable to be entrusted with access to service users, who may be vulnerable. The Inspector sample checked one set of these records in relation to Support Worker A. He noted them to contain an omission. The Registered Providers said that this oversight would be addressed by 1 December 2006. The Registered Providers are responsible for ensuring that all care workers are confirmed as having the skills they need to enable them to support effectively the service users currently in residence. The Registered Manager said that all new care workers receive introductory training. This is designed to ensure that they have the basic competencies they need in order to be able to work without direct supervision. This is important because the quality of care service users can expect to receive, depends largely upon the adequacy of the knowledge and skills which care workers can invest in the completion of their duties. In addition to the introductory training, existing care workers undertake a number of training courses. These are designed to enhance their capacity to deliver care. The Registered Providers said that they intend to strengthen aspects of these arrangements further. This will be done by the development of a new system which is designed to review specifically the continued adequacy of the competencies possessed by each care worker. The Inspector was pleased to note that this exercise will be based upon a version of a national model which the Commission recognises to constitute good practice. The Inspector understands that the preparatory work necessary to begin the review will be completed by 1 February 2007. As noted earlier in this Report, service users consider that care workers are supportive in their manner and that they are able to deliver the assistance they need. The Inspector observed care workers when they were assisting the service users. He noted this help to be delivered in an appropriate manner. During these observed episodes, the care workers demonstrated that they were able to respond effectively and reliably to the individual requirements of the service users in question. Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 25 Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 26 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): Standards 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this Service. The management of the Service is effective. There is a quality assurance system. Measures are in place to promote the health and safety of the people who live and work in the Service. EVIDENCE: Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 27 The Registered Providers were noted to have established suitable systems to oversee the running of the Service. They have established a clear lines of communication within the management team. Also, there are various arrangements in place to help to ensure that all of the care workers are up to date with what is going on in the Service. This is very important because they need to know what to do and when, if the service users are to experience a consistent and reliable response to their needs for assistance. Service users said that the Service is run without there being any intrusive rules or routines. This means that they can continue to experience a normal home life of their choosing. The Registered Providers operate a system by means of which service users are invited to comment about their home. The Inspector noted that this entails an annual meeting with each person to see how well they consider their expectations of the Service have been met. The service users said that in addition to this, there is a more or less continuous process of less formal consultation. The Inspector noticed this is operation as one of the Registered Providers was around the place generally chatting with service users about this and that. Having said this, the Inspector has identified several ways in which this quality assurance process now can be strengthened further. One of these will include the preparation of a Quality Report. This document will summarise the responses received from the service users and from their representatives. Also, it will detail what steps the Registered Providers intend to take in order to act upon the suggestions they have received. The Report should form the basis of feedback given to the service users, who have the right to know what is going to be done. The Inspector understands that the first such Report will be prepared and that it will be shared with service users and with their representatives by 1 January 2008. The Registered Providers assist some of the service users to administer aspects of their weekly personal spending allowance. The Inspector examined a selection of the records relating to the various transactions involved and he noted them to be adequate. The Registered Providers use various systems to support and to supervise the quality of the work completed by each member of staff. This includes an annual review in which the member of staff and the Registered Providers discuss how things are going and what if any guidance is needed. The Inspector has identified that these meetings would benefit from being rather more frequent given the changing needs of the service users and the likely challenges these may constitute for some members of staff. The Registered Providers have said that they will consider increasing the frequency of the reviews in the manner recommended. Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 28 The Registered Providers said that all items of equipment in use in the Service remain in good working order and that they are serviced regularly. The Inspector sample reviewed some service certificates which were consistent with this account. The Inspector noted that the Registered Providers since the last inspection visit, had completed most of the various checks which are designed to ensure that the Service’s fire safety equipment remains in a suitable operational condition. However, the Inspector did notice that the programme of unannounced fire drills had not been recorded in the correct manner. The Registered Providers said that this matter would be addressed without delay. The Registered Providers arrange for all members of staff to attend a course in fire safety as soon possible after they commence their employment. This arrangement now needs to be complemented or replaced with a system which is designed specifically to ensure that everyone knows how to implement the Service’s fire safety regime, including how to prevent the occurrence of a fire safety emergency in the first place. The Registered Providers said that this development would be completed by 1 January 2007. In the interim, the Inspector can observe that the care workers who he asked about this matter had a reasonable understanding of what they should do in the event of a fire safety emergency. The Registered Manager said that she monitors regularly key areas of the premises so that potential hazards to health and safety can be identified and resolved. She said that this exercise had not identified any significant hazards which remained to be addressed. The Inspector examined various parts of the premises. He did not notice any obvious hazards which led him to question further the Registered Manager’s reported assessment. Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X 3 X X X X STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 30 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. Refer to Standard Good Practice Recommendations Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Littlebourne House DS0000023469.V299956.R01.S.doc Version 5.2 Page 32 - 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!