CARE HOMES FOR OLDER PEOPLE
Ludbourne Hall South Street Sherborne Dorset DT9 3LT Lead Inspector
Rosie Brown Key Unannounced Inspection 11:00 13th October 2006 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 DS0000026838.V316539.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. DS0000026838.V316539.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Ludbourne Hall Address South Street Sherborne Dorset DT9 3LT 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) 01935 816382 01935 815901 Scosa Ltd Mrs Denise Lesley Read Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places DS0000026838.V316539.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. One of the following bedrooms may be used at any one time for shared occupancy, not exceeding a total of sixteen (16) residents: Bedrooms 7 & 11. 31st January 2006 Date of last inspection Brief Description of the Service: Ludbourne Hall is a registered care home offering both long and short-term places to a maximum of 16 people over the age of 65. On the day of the inspection there were 16 residents living in the home. The home is owned by Debra and Phillip Scott, under the title of SCOSA Ltd; the registered individual (RI) is Debra Scott and the registered manager is Mrs Denise Read. Ludbourne Hall is situated a short level walk from the centre of Sherborne and is within easy access of the towns facilities including the railway station, gardens and Abbey. Parts of the building date back to the 18th century. Extensions have been added to create the present accommodation comprising 16 bedrooms, a ground floor lounge and separate dining room. Residents’ accommodation is on the ground and first floor. There are assisted bathing and toilet facilities on both floors. The home has a stair lift fitted on the main staircase. Care staff are on duty at all times and include wakeful night staff. In addition to personal care and support the service provided includes all meals, laundering of clothes, and all housekeeping. A range of social and leisure activities are provided and the manager and staff ensure residents’ attend healthcare appointments when necessary. A variety of professionals visit the home including chiropodist, optician, hairdresser, GPs and community nurses. The home has an enclosed sheltered patio at the rear of the building and a small parking area is situated at the side of the house. The pre-inspection questionnaire received in June 2006 notes that the fees for accommodation and care range between £380-£500. For interested consumers the web link to the Office of Fair Trading which is concerned with value for money and fair terms of contracts is: www.oft.gov.uk and Web link to the report entitled Care Homes in the UK - A Market Study http:/www.oft.gov.uk/NR/rdonlyres/5362CA9D-764D-4636-A4B1A65A7AFD347B/0/oft780.pdf The home’s service user guide notes that a copy of the home’s latest inspection report is available in the home’s entrance hallway. Alternatively inspection reports can be downloaded for free from our website: www.csci.org.uk
DS0000026838.V316539.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on 13th October 2006 and was undertaken by inspector Rosie Brown. The inspection commenced at 11am and was concluded by approximately 3pm. The inspector assessed the key National Minimum Standards highlighted in this report and the requirements and recommendations set out in the previous inspection report. The communal areas and a selection of bedrooms were viewed: residents’ care and medication records, staff records and certain policies and procedures were examined. The inspector used observation skills to assess the interactions between staff and residents, spoke with the manager Mrs Denise Read, two staff that were on duty and three residents. Prior to this inspection, comment cards supplied by the Commission were returned. These included six survey forms from residents; two cards from relatives, two from care professionals that are in regular contact with the home and three from GP’s. The comments were entirely complimentary about the care provided and the information within them has been used as evidenced in this report. The manager’s pre-inspection questionnaire completed and returned to the Commission in June 2006 has also been used to provide information. What the service does well:
The home’s statement of purpose/service user guide and latest inspection report are readily available in the home’s entrance hall. The manager undertakes a pre-admission assessment of care needs before each residents moves into the home to ensure that the home can meet the person’s needs prior to admission. Care plans and care related risk assessments are in place for each resident and contain detailed guidance so that staff can meet identified needs: these are regularly reviewed. Two comment cards from relatives noted that visitors are always welcome in the home. Monthly resident’s meeting are held in the home to encourage residents’ to express their views about life in the home. Residents’ social care provision forms a very positive part of life in the home and links with the local community are maintained. Residents are supplied with a variety of wholesome home baked food that is served in the home’s comfortable dining room or in residents’ rooms: the
DS0000026838.V316539.R01.S.doc Version 5.2 Page 6 majority of residents choose to eat their main meal in the dining room. The menu is displayed and alternatives including special diets, eg vegetarian options are supplied. The home has a complaints procedure is displayed for information on the residents’ notice board in the home’s hallway. The home is pleasantly decorated and furnished in a homely manner and residents reported that the home is always clean. The manager has set up an annual quality assurance review that includes residents’ views and it was evident that action had been taken to address findings and necessary improvements. Care records comment cards and conversation with residents’ revealed that staff actively promote each resident’s independence, privacy and dignity. As stated in the previous report, residents’ views are respected and acted upon appropriately and this is demonstrated in the minutes of residents’ forum meetings. The residents’ care records, staff records, and the home’s maintenance records are kept by the manager in an organised manner, they were up to date and evidenced that arrangements are in place to ensure that the health, safety and welfare of residents and staff are promoted and protected. What has improved since the last inspection?
The requirements and recommendations set out by the Pharmacy CSCI inspector following an inspection in January 2006 have been addressed. This includes more accurate recording of administered medicines, the updating of the home’s medicines practice policy, proper refrigerator storage of medicines, dating the boxes and bottles of medicines when opened that are not supplied in the monitored dosage. All staff that administer and handle medicines have now undertaken appropriate medicines training and the manager has set up an audit trail to evidence regular monitoring of the prescribed medicines received and their proper administration. The manager is now using up to date ‘Skills for Care’ induction training packages with new staff. The home’s first floor bathroom now has new non-slip floor covering. In July 2006 Mrs Scott sent a letter to the Commission with plans to develop and refurbish the home and create one new first floor and two ground floor bedrooms with en-suites. Other improvements will include a new utility/laundry room and a conservatory extension to the main lounge. The manager and deputy have applied to attend a Protection of Vulnerable Adults training course provided by the local authority to ensure they are familiar with local procedures. DS0000026838.V316539.R01.S.doc Version 5.2 Page 7 The staff recruitment and Whistle blowing policies have been updated to make reference to the POVA guidance. 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. DS0000026838.V316539.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 DS0000026838.V316539.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): 3, Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager undertakes a comprehensive pre admission assessment of each service user’s needs prior to admission to ensure their needs can be met by the home. The home does not provide intermediate care. EVIDENCE: The home’s manager has recently married and is currently updating the home’s statement of purpose and guide to reflect this change in circumstances. The care file for one recently accommodated resident demonstrated that the manager carried out a pre-admission assessment of care needs before the resident moved into the home. An assessment questionnaire was also completed by the staff nurse in the hospital where the resident had stayed prior to moving in. The assessment was detailed and a care plan was drawn up
DS0000026838.V316539.R01.S.doc Version 5.2 Page 10 to ensure that identified needs could be met by the home. A copy of a letter sent to the prospective resident prior to admission confirming that the home could met their needs was seen on file and was signed by a relative. Terms and conditions of residence agreements are provided and also signed by service users/representative and the manager. Six residents’ comment cards noted that they had received enough information about the home to enable them to decide it was the right place before moving in: most residents visit the home before moving in. DS0000026838.V316539.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident has an individual care plan with care related risk-assessments in place so that staff have up to date guidance on how to meet their care needs. Six residents’ comment cards confirmed that they receive the health care support they need. The home’s medication storage and administration arrangements are satisfactory with all residents’ medicines cared for by the home. Two residents’ confirmed their privacy is protected and that their known wishes are respected. EVIDENCE: Two resident’s care records evidenced that care plans are in place and reviewed each month. Daily care reports demonstrate how the personal and health care needs of each resident are attended to by staff and other care
DS0000026838.V316539.R01.S.doc Version 5.2 Page 12 professionals, GP, hospital consultant, chiropodist and optician. The home also operates a key worker system to ensure that personal individual needs are discussed and addressed. The manager has drawn up care related risk-assessments for each resident and these include the prevention of falls, personal hygiene and dignity, mental health issues, vulnerability to burns from night storage heaters and the hot water supply. These are reviewed each month and updated at times of change, eg following a fall. The prevention of falls risk-assessment for one resident did not take into consideration that there are two small steps to be negotiated when leaving or entering their bedroom. One resident said that staff are very helpful and always attend if they call for assistance: they also confirmed they are regularly consulted about their care needs. One relatives comment card noted: ‘ Ludborne Hall is a superb example of residential care, the staff are kind and caring and make great efforts to see that residents are happy’. The home has an accident records book that is routinely used and the manager audits all accidents that occur on a monthly basis. The manager reports notifications concerned with untoward incidents and accidents. The home’s notification form notes the actions taken in such situations but should make clear the actions taken to prevent recurrence: further information about Regulation 37 notifications is available on the CSCI website: www.csci.org.uk The home has a documented medication policy that provides guidance to staff that handle and administered residents’ medicines. This has recently been improved to include guidance on the use of homely remedies and the use of an audit trail to determine where medicines are at all times Staff check and record the quantity of all medicines received in the home and the manager then rechecks this at a later date so that an audit trail for medicines is evidenced by regular monitoring to ensure that medicines are given to residents as prescribed. Staff training records show that all staff that handle and administer medicines have were supplied with training in the safe handling of medicines in February 2006: a list of all staff trained to give medicines to residents is displayed on the drugs cupboard. As stated in previous reports residents’ medicines are stored in a locked facility, but it is not ideally situated in the home’s kitchen. In the longer term the medicine storage cabinet should be relocated to a more suitable place other than the kitchen. In the meantime, staff record the temperature of stored medicines on a daily basis to ensure that medication are stored appropriately. The manager reported that the medicines storage arrangements
DS0000026838.V316539.R01.S.doc Version 5.2 Page 13 would be relocated as part of the refurbishment of the home: a discussion also took place about using a medicines refrigerator. The controlled medication is stored in the Controlled drugs (CD) cupboard within the cabinet and since the previous inspection a CD register has been obtained for use. Each resident has a monthly Medication Administration Record (MAR) chart. Staff are now ensuring that MAR charts contain all the details of prescribed medicines when written onto the chart by hand. While checking medication storage it was noted that one controlled drug had been recorded as received on the MAR chart but the amount had not been added to the running total kept in the CD register. Three comment cards from GP’s who regularly call into the home noted that are able to see residents in private and that staff demonstrate a clear understanding of the care needs of residents. DS0000026838.V316539.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Visitors are welcomed by the home and social activities are organised to provide additional interest for the residents living in the home. Individual care records indicate social care needs are promoted for each resident to ensure their individual expectations and preferences are fulfilled. The meals and food supplied by the home are very good offering both choice and variety and catering for special dietary need. EVIDENCE: The home’s visitors record book and residents’ daily care records evidenced that relatives, friends and care professionals regularly visit residents in the home. One resident confirmed that staff at the home encourage and enable resident to keep in contact with their relatives and friends. For example, daily care records evidenced that one male resident has a mobile buggy that he uses to go to town, thereby maintaining local community contacts while one female said she regularly goes out to a supermarket for her favourite biscuits and a coffee and also regular spends time in the local gardens.
DS0000026838.V316539.R01.S.doc Version 5.2 Page 15 Comment cards noted that visitors are ‘always’ welcome in the home. The social activities programme is decided with residents at their monthly forum meetings. Information is then posted onto the residents’ notice board for residents to decide if they wish to participate. Social care provision includes theatre visits and outings, church concerts and communion, various in-house entertainers including visits from the local boys school. Group activities involve music for health, memory box, mobile library, nature movers and an art group. The home uses a weekly menu that is changed seasonally and also includes residents’ choices. However the record of meals and food supplied to residents does not contain sufficient detail: the record did not note the vegetables supplied with lunch or the vegetarian option provided. One vegetarian resident confirmed that their preferences are honoured. It was evident on the day that lunchtime is a leisurely social occasion. Two residents said that the food supplied is ‘always very good and homebaked’. Plans to completely refurbish and upgrade the home’s kitchen are in place and due to commence shortly. DS0000026838.V316539.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s complaints procedure is supplied to residents as part of the admission process and is displayed on a notice board in the home. Comment cards confirmed that resident and relatives feel confident their concerns would be taken seriously and acted upon. The home has a policy concerned with adult protection to ensure that residents are protected and allegations of abuse properly responded to. EVIDENCE: The home has a complaints procedure and the complaints procedure is readily available on the home’s notice board. Six residents comment cards noted that they know how to make a complaint and also know who to speak to if they are unhappy about something. One resident said that she is confident that any concerns raised with the manager are listened to and appropriately managed, eg she moved rooms in the home because she wanted a room with an en-suite when one became available. DS0000026838.V316539.R01.S.doc Version 5.2 Page 17 Since the previous inspection there have been no adult protection issues raised with the home. Appropriate policies and procedures regarding adult protection and the identification of abuse are in place for staff guidance. The manager and deputy have applied for a two-day training course with the local social services concerned with the protection of vulnerable adults. DS0000026838.V316539.R01.S.doc Version 5.2 Page 18 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, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is very clean and maintained to a good standard; it provides an attractive, comfortable and homely environment for the residents who choose to live there. Until all night storage heaters are protected and the hot water supply to all washbasins in the home is governed and supplied at a safe temperature vulnerable residents remain at risk. Residents confirmed that the home is always kept clean and hygienic. EVIDENCE: As described in previous reports residents’ bedrooms are available on the ground and first floor of the home; there is a stair lift for people unable to independently use the stairs. All bedrooms are single and many have en-suite facilities: those without have bathrooms and toilets nearby.
DS0000026838.V316539.R01.S.doc Version 5.2 Page 19 Bedrooms viewed on the day were highly personalised with residents’ furniture, pictures and other personal items appeared comfortably furnished and clean. One resident said their son had brought a favourite armchair, telephone and a TV for their bedroom. The manager explained hat bedrooms are routinely redecorated when they become vacant. The home’s entrance hall is attractively furnished and decorated and this is where the home’s ‘parakeet’ lives. There is a communal lounge where ‘Lily’ the home’s dog has her basket. The separate dining room is situated close to the kitchen, comfortable armchairs are available offering an alternative room to sit and relax in: this homely area appeared to be very popular with the residents on the day of the inspection. Assisted bathing and toilet facilities are available on both floors and non-slip floor covering has recently been laid in the home’s the first floor bathroom. Both sinks in the first floor bathroom and toilet did not have a plug and some hazardous cleaning products were also seen: these matters were both remedied during the inspection. The home is heated by night storage heaters and the manager has drawn up risk-assessments regarding residents’ vulnerability to hot surface temperatures. Some heaters are protected but others are not and this is generally due to residents’ specific requests for the heaters in their rooms not to be covered. However, the home should continue to implement a programme of protecting heaters where identified as necessary and fitting fail-safe hot water temperature control valves to ensure that hot water is supplied close to 43 degrees using a risk-assessment process. A discussion took place with the manager concerning the need to ensure that when the new bedrooms are built they should be fitted with central heating radiators that have low temperature surface finishes. The home is generally in good order but some areas would benefit from redecoration, eg chipped paintwork and shirting boards. However, it is well maintained and homely and many of the original features in parts of the ‘old house’ have been carefully restored. Generally a homely environment is created. The home’s laundry is functional and currently situated in an outhouse and future plans include moving this facility inside the house for easier staff access. DS0000026838.V316539.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A team of care staff, including a deputy manager and a cook are employed to assist the manager to ensure residents’ needs are routinely met in the home each day. The manager uses a company staff recruitment and employment procedure that incorporates proper checks to ensure residents are safe. The home provides care staff with NVQ training and staff induction training has recently been upgraded to meet with ‘Skills for Care’ specifications. EVIDENCE: When the inspection commenced the manager, two care assistants; the cook and a domestic/care assistant were on duty. A staff rota was supplied with the pre-inspection questionnaire and demonstrated that there are always two care staff on duty each day with a cook and domestic assistant on duty each morning. One wakeful and one sleep-in night care assistant are on duty each night between the hours of 9pm –7am. The manager tends to work five days each week with the deputy manager on duty at other times. It is recommended that the staff rota be improved by including the full name and job title of each staff member.
DS0000026838.V316539.R01.S.doc Version 5.2 Page 21 One resident said that staff are always available to help and provide assistant with the things that residents find difficult to do, eg dressing and bathing or going out. One relatives comment card stated, ‘ The staff are kind and caring and make great effort s to see that residents are happy’, while three comment cards from GP’s noted that staff demonstrate a clear understanding of the care needs of service users’. Two staff files were examined and detailed that all necessary checks and information were obtained before they commenced working in the home. Records showed that the new staff member was subject to a CRB/POVA check and that induction training now meets ‘Skills for Care ‘ specifications. Further information can be accessed from the website: www.skillsforcare.org.uk other useful websites that assist with funding for training are; Partners in Care www.Picdp.co.uk and a new project that started on August 1st specifically focusing on training needs and related issues in Dorset, supported by the Learning and Skills Council and Business Link, who provide a brokerage role, at: www.traintogain.gov.uk The manager confirmed that 15 care assistants are employed to work in the home: several work in a part-time capacity. Five staff hold an NVQ level 2 in care qualifications or above. Therefore the home needs to progress with staff NVQ training programme to ensure that at least 50 of the care team are qualified to NVQ2. Training supplied to staff since the previous inspection includes, induction, health & safety topics, fire safety, eye care, NVQ 2 in care and safe handling and administration of medicines. Eight staff currently have up to date first aid certificates and further training is planned. Additionally training concerned with managing dementia positively has also been arranged. DS0000026838.V316539.R01.S.doc Version 5.2 Page 22 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed by the registered manager, Mrs Denise Read who is experienced in residential care of the elderly and the appropriate qualifications. A quality assurance system has been implemented and includes the views of service users. Residents’ finances are protected by the home’s policies and practice: small amounts of personal allowances are held for the minority of residents. Arrangements are in place to ensure that the health, safety and welfare of residents and staff are promoted and protected. DS0000026838.V316539.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has successfully run the home for several years and is supported by regular Regulation 26 visits from the Registered Individual Mrs Debra Scott: monthly reports of these visits are documented with copies supplied to the manager and the Commission. A Deputy manager/ Head of Care is employed to cover in the managers’ absence. The staff team are routinely supplied with mandatory Health & Safety training and update training for food hygiene and moving & handling is booked for 17th October 2006. The manager explained that individual staff supervision takes place and a diary record of meetings was shown to the inspector. Annual staff appraisals are undertaken with a record kept on individual staff personal files. However, a record of these meeting is not documented as recommended. Monthly staff meeting are held and two staff confirmed that they feel supported by the manager. Some time was spent discussing new infection control guidance for homes issued by the Department of Health in June 2006, and the need to update the homes policies to include this information. Additionally a ‘Heat wave’ plan must be drawn up for the home taking into account residents collective and individual needs using the NHS guidance also issued by the Department of Health. This information is available at: www.dh.gov.uk/publications The manager reviews the home’s policies and procedures on an annual basis and since the previous inspection the recruitment and Whistle blowing policies should be updated to make reference to the POVA guidance. The manager keeps personal allowances for a small number of residents: many remain independent or have assistance from family or solicitors. Each person’s money is kept separately in a locked drawer and a record of all expenses with receipts is kept and signed: one resident’s money was sampled and funds held tallied with the record held. The home’s equipment and house maintenance records are kept in a file and this contained certificates, which indicated regular servicing of the stair lift, central heating, gas and electrical systems take place. Other certification detailed up to date house insurance, controlled waste transfer and ‘PAT’ testing. DS0000026838.V316539.R01.S.doc Version 5.2 Page 24 The home’s fire records demonstrated that in house checks of the fire safety system and fire fighting equipment are undertaken and a regular servicing contract is in place with an external contractor. Records evidenced that fire drills take place: fire safety training was supplied to staff during a staff meeting in July 2006. The fire records should also note that ‘door guard’ devices fitted to some fire doors in the home are routinely checked when the fire alarm system is tested on a weekly basis. The Fire Safety Officer’s most recent visit (May 2006) highlighted the need for the home’s fire risk-assessment to be updated and the manager is currently undertaking this. DS0000026838.V316539.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 X X 3 X X N/A 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 3 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 DS0000026838.V316539.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. Refer to Standard OP7 Good Practice Recommendations The prevention of falls risk-assessment for one resident should take into account the two small steps that are situated just outside of their bedroom and note any necessary actions to be undertaken. When controlled drugs are checked into the home and entry should be made in the CD register as well as the resident’s MAR chart to demonstrate a clear audit trail. The record of meals and food supplied to residents should contain sufficient detail, eg the vegetables supplied with lunch, the vegetarian option and any other alternatives provided. Some of the older areas of the home now need to be redecorated and these should be attended to when the extension and building works commence in November. A programme of protecting the homes’ night storage radiators and the governing of the hot water supply to washbasins and baths in residents’ en-suites should be progressed using a risk-assessment process.
DS0000026838.V316539.R01.S.doc Version 5.2 Page 27 1. 2. OP9 3. OP15 4. OP19 5. OP19 6. 7. 8. OP27 OP28 OP36 9. OP38 10. OP38 The staff rota should detail the full name and job title of each staff member and who is in charge if each working shift. The registered persons should ensure that 50 of care staff are trained to NQV level 2 standard. Records of the individual supervision supplied to staff should be kept and include the information recommended in National Minimum Standards 36. The home’s infection control guidance should be updated to include the guidance issued by the Department of Health in June 2006. Additionally a ‘Heat wave’ policy and plan should drawn up for the home taking into account residents collective and individual needs using the NHS guidance also issued by the Department of Health. The home’s fire risk-assessment should be updated as planned and include the recommendations by the Fire Safety Officer. DS0000026838.V316539.R01.S.doc Version 5.2 Page 28 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
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