Inspection on 15/01/08 for Madelayne Court

This inspection was carried out on 15th January 2008.

CSCI found this care home to be providing an Good service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Madelayne Court 26/01/09

Madelayne Court 20/02/07

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Madelayne Court School Lane Broomfield Chelmsford Essex CM1 7DR Lead Inspector Diana Green Unannounced Inspection 15th January 2008 09:30 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 Madelayne Court DS0000068095.V358114.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. Madelayne Court DS0000068095.V358114.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Madelayne Court Address School Lane Broomfield Chelmsford Essex CM1 7DR 01245 443986 01245 443835 manager.madelayne@runwoodhomes.co.uk www.runwoodhomecare.com Runwood Homes Plc 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) Manager post vacant Care Home 112 Category(ies) of Dementia - over 65 years of age (112), Old age, registration, with number not falling within any other category (112) of places Madelayne Court DS0000068095.V358114.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 112 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 112 persons) The total number of service users accommodated in the home must not exceed 112 persons The registered person must not admit persons subject to the Mental Health Act 1983 or the Patients in the Community (Amendment) Act 1995 Staffing levels to be reviewed within six months of date of registration Date of last inspection 20th February 2007 Brief Description of the Service: Madelayne Court provides personal care with accommodation for up to 112 older people. The home is also registered to care for service users with dementia. Madelayne Court is owned by Runwood Homes PLC. The home is located in Broomfield, a village type locality on the perimeter of Chelmsford, Essex. The home is a three-storey building that was purpose built and first opened in 2006. There are 112 single en-suite bedrooms on three floors that are accessible by stairs and three lifts. There are 41 single en-suite rooms on the ground floor, divided into three units, 50 single en-suite rooms on the first floor divided into 3 units and 21 single en-suite rooms within one unit on the second floor. Each unit has a lounge and dining room. There are six bedrooms with adjoining doors to accommodate shared accommodation for three couples if required. The gardens surrounding the property are laid mainly to lawn with established trees and are fenced. Gardens to the rear of the property have paved areas and raised beds that are accessible to wheelchair users. Madelayne Court DS0000068095.V358114.R01.S.doc Version 5.2 Page 5 The home is on the main bus route. The home is accessible by car and the nearest railway station is nearby. Parking is available for staff and visitors in the large car park located to the rear of the home. The fees range from: £434.63 -£670. per week Additional costs apply for chiropody, toiletries, hairdressing and newspapers. This information was provided to the CSCI on 15/01/08 Madelayne Court DS0000068095.V358114.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was a key unannounced inspection that was undertaken on the 15/01/08 and 17/01/08 and lasted 14 hours. The inspection process included: discussions with the manager, deputy manager, care team managers, the laundry assistant, the cook, six residents, six relatives, two care staff and feedback from relatives and health and social work professionals; a tour of the premises including a sample of residents’ rooms, bathrooms, communal areas, the kitchen, the laundry and the sluice-rooms; an inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Evidence was also taken from completed surveys and the Annual Quality Assurance Assessment completed by the management of the home and submitted to the CSCI. Twenty-six standards were inspected, two were commended and three requirements and two recommendations made. The manager and staff were welcoming and helpful throughout the inspection. What the service does well: The standard of assessment and care planning is good. Comprehensive information is provided to potential residents to enable them to make an informed choice. There is good focus on person centred care planning and on meeting individual needs with emphasis on dementia care needs. Health care needs are well monitored and met through positive multi-disciplinary working. There is good communication with residents and their representatives. The quality and variety of meals provided is very good and residents are regularly consulted regarding their preferred choices and changes made to menus to accommodate them. The premises are cleaned to a high standard, well decorated and provide residents with a homely type environment. The standard of laundry is good. Staff recruitment is robust and residents are safeguarded through comprehensive complaints policies and procedures and staff training. Staff are well trained and well supervised. Madelayne Court DS0000068095.V358114.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? 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. Madelayne Court DS0000068095.V358114.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 Madelayne Court DS0000068095.V358114.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): Quality in this outcome area is excellent based upon sampled inspected standards 1, 3 & 4. People planning to live at Madelayne Court can expect to receive comprehensive information and have a detailed assessment of their care needs prior to moving in to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a statement of purpose and service user guide that had been updated since the previous key inspection and met regulatory requirements. Residents and their relatives spoken with confirmed that a copy had been made available to them prior to admission. Some were observed in residents’ rooms and copies were displayed in the entrance of the home for visitors’ information. Information was also available in the reception of the home. This included Alzheimer’s information with guidance on understanding vascular dementia. Age Concern and Advocacy leaflets and NAPPA (National Association Madelayne Court DS0000068095.V358114.R01.S.doc Version 5.2 Page 10 of Activities for Older People) development booklets/newsletters were also on display. Pre-admission assessments were carried out by the manager or deputy manager. Care team managers who had NVQ level 3 or had received in-house training also undertook some pre-admission assessments. A sample preadmission assessment form was seen, and included a basic dementia assessment (mental status questionnaire). Since the previous key inspection a dementia dependency assessment tool (provided by the local authority) has been introduced that enabled more robust assessment of need to be undertaken. Dementia care standards had been developed since the previous key inspection and had been personalised to the home (copy provided). The standards had been adapted from the Alzheimer’s Society’s publication ‘Quality Dementia Care in Care Homes’ and are based on the philosophy of person-centred care approach. All staff had received training to provide them with a basic understanding of care of people with dementia. A programme of ongoing training and development was also in place to enable staff to further develop their skills. Guidance was available on dementia care. For example on people exhibiting aggressive behaviour; what it means, the causes and advice on how to manager their care and on prevention. A policy statement was also available for staff guidance on ‘respecting service users’ relationships, religious beliefs and customs’. The home does not provide intermediate care. Madelayne Court DS0000068095.V358114.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): Quality in this outcome area is good based upon sampled standards 7, 8, 9 & 10. The health and personal care needs of residents are well met through care planning that is closely monitored and regularly reviewed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of eight files were viewed that included dementia and non-dementia service users. All files contained an assessment form completed on admission and used to trigger care plans. This form contained standard categories of need, each with a range of descriptors selected by tick boxes. This was supported by an assessment for the elderly that used a behaviour scale to assess need and a dementia dependency assessment tool (provided by the local authority. Additional individual assessments had also been completed in regard to specific needs (e.g. risk of falls, moving and handling, dependency, continence, nutrition, pressure areas, etc.), and all had been regularly reviewed. Madelayne Court DS0000068095.V358114.R01.S.doc Version 5.2 Page 12 The records confirmed evidence of good monitoring of health care needs with prompt referral to GPs and health care professionals and appropriate follow up action being taken. Residents nutritional needs were closely monitored with regular weights undertaken and supplements provided as needed. The home had positive relationships with local GPs and district nurses who regularly attended the home. A specialist nurse who was in close communication with the home also provided additional training and support. The records confirmed that residents were enabled access to outpatient services, dental, chiropody and annual eye tests. Positive comments were received from relatives about the care: ‘they are very good at explaining about care of my relative’; ‘the communication is very good’; one relative said they thought their loved one would not survive but they had improved substantially since admission. The home had a medication/clinical room on the ground floor; this housed a drug fridge. It was not used for medication storage but had been allocated for use by district nurses and for GPs to see residents. A much smaller room was used to store the medication. A second storage room was provided on the first floor of the home that housed three trolleys. This was also too small to enable medication supplies to be checked in and a separate clinical room located some distance away was used for this purpose. Air conditioning units had been installed in both rooms and monitoring of temperatures showed that temperatures were within recommended levels (25°Centigrade). A review of the storage of medication is needed as both rooms are too small to enable staff to check medicines on receipt from the pharmacy, and there is not room for practical training of junior staff. The storage poses a health and safety risk as there are no handwashing facilities, staff have to take trolleys into the narrow corridor when they are checking the supplies and space is inadequate to safely store oxygen cylinders. The home had medication policy and procedures that were available for staff guidance. The deputy manager/care team managers administered all medication at the home and the records confirmed that all had received appropriate training. Regular audits were undertaken and any issues addressed through supervision/training. Medication was supplied through a local pharmacy in pre-dispensed packs and individual containers and appropriate ordering and disposal procedures were followed. Medication supplies and administration records (MAR) for ten residents were checked. All supplies were available as prescribed. MAR sheets were in the main well recorded. However one medicine stopped by the GP had the date recorded but no signature and another had no date recorded and no signature. One supply of eye drops had no date of opening recorded on either the contained or carton. Madelayne Court DS0000068095.V358114.R01.S.doc Version 5.2 Page 13 Care files contained clear information and indicated each person’s preferred name. Staff were noted to treat residents with courtesy and dignity. Residents and their representatives said that care staff were caring and respectful. Comments received from complete surveys and in discussion with residents: ‘the staff are always kind and caring’; ‘I can go to sleep at night knowing …is being looked after’; ‘they look after me well’. Madelayne Court DS0000068095.V358114.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): Quality in this outcome area is good based upon sampled standards 12, 13, 14 & 15. People living at Madelayne Court can expect to have their social and cultural needs met and have choice and control over their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ten residents’ care files were viewed. All contained a social history or family tree, providing a good profile on the person, and information on their past interests. Social activities care plans were also seen in the records. The home employs three activities coordinators who had all attended an eight-week dementia day course ‘Yesterday, Today and Tomorrow’ and had also received training on the snoozelum that had very recently been introduced. Three residents had benefited from the snoozelum on the day, which uses lights and music to calm their mood. One activities coordinator spoke positively about the training opportunities made available to her that had provided her with the skill and confidence to undertake her role. Evidence of an activities programme was seen displayed in the home, and individual records were maintained of residents’ involvement in the activities. A craft session was observed where five residents were involved in painting eggcups, picture frames and a Madelayne Court DS0000068095.V358114.R01.S.doc Version 5.2 Page 15 jewellery box. In another unit later in the day six residents were seen taking part in musical bingo session and other residents were taking part in the singing along to the music. However controversial feedback was received from relatives with some stating there were a lot of activities and entertainment provided and others that ‘there are not enough activities arranged’. Comments were also received that there was a need for ‘staff who have the time and skill to provide more stimulating activities’; ‘more activities including talking to residents’ were needed. One resident said they would appreciate being taken for a walk occasionally. Residents said that their friends and relatives could visit at any time, and they could meet with them in private in their rooms. One resident’s spouse said they enjoyed staying for lunch most days. One resident attended a Darby and Joan club locally. A church service is held in the home each month, and staff reported that some local community groups had visited the home at Christmas (e.g. bell ringers, local school children carol singing). Residents spoken with were clear that they had choices about their daily life in the home, especially in regard to where they spent their day, meals, etc. A relative said their loved one was a private person and they appreciated the fact that they did not have to take part in social activities or leave their room if they did not wish to. Many of the rooms seen were well personalised, showing that people could bring their own possessions into the home with them, and residents were seen to be able to have keys to their room, in order to give them control over their personal space. One married couples’ needs for autonomy over their lives were promoted through the accommodation provided (e.g. two adjoining rooms, used as bedroom and lounge). A menu was observed displayed in dining areas, and the manager reported that copies of the menus are provided in residents’ rooms. The home operates a four weekly menu that had been developed corporately for Runwood Homes. The chef reported that following discussion with residents some meals had been adapted to meet their preferred choices. Residents spoken with were generally positive about the meals served at Madelayne Court and that they had improved since the appointment of the new chef who was seen to be talking with residents during the inspection. Residents were provided with a roast dinner twice a week and could have a cooked breakfast on alternate days. Only homemade soups were provided (apart from emergencies) and cakes and deserts were baked on site. The supper menu had been developed recently to provide more substantial meal and comprised a choice of pizza, sausage rolls, sausages, ham and eggs all served with chips. The main meal served on the day of the inspection looked and smelt appetising and comprised steak pie with boiled potatoes, broccoli and carrots followed by apple crumble and custard. Pureed food was served attractively to residents with separate meat and vegetable portions. Hot drinks were seen being served during the day, and water jugs were seen in residents’ rooms. Food stocks were plentiful with an appropriate range of fresh, frozen and dried food available. Madelayne Court DS0000068095.V358114.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): Quality in this outcome area is excellent based upon sampled standards 16 & 18. People living at Madelayne Court can expect to have their complaints listened to and acted upon and to be protected from abuse by robust safeguarding policies, procedures, staff training and practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure that was displayed in the reception area of the home. Feedback received from relatives indicated they knew there was a complaints procedure and who to refer to if they had a complaint. One relative spoken with said they had ‘no complaints whatsoever. The care is first class; when there are any issues they deal with it straight away’. Residents spoken with said they felt able to tell someone if they had any concerns. The homes’ record of complaints viewed detailed the investigation and action taken as a result. From discussion with the manager it was clear that all issues of concern were used to improve practice. The home had safeguarding policy and procedures and a whistle blowing policy. All staff had attended awareness of protection of vulnerable adults and this was also confirmed from the records. A regular in-house training programme was in place for all staff. A staff questionnaire was used to assess staff competencies in understanding abuse (confirmed from the records) and Madelayne Court DS0000068095.V358114.R01.S.doc Version 5.2 Page 17 this was also followed up through individual staff supervision. There had been no allegations of abuse since the previous key inspection. Madelayne Court DS0000068095.V358114.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): Quality in this outcome area is good based upon sampled standards 19, 22, 24 & 26. Madelayne Court was safe, well maintained and had a homely environment; residents’ rooms were individually furnished and equipped for their safety, comfort and privacy. The home was clean and hygienic with safe infection control practices that were generally well adhered to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial inspection of the premises was made that included communal areas, a number of residents’ rooms, the kitchen, the sluices, clinical room and the laundry. The home was well maintained and well decorated and was furnished in accordance with the client group. Positive comments were received from relatives spoken with and in completed surveys from both residents and their representatives: ‘the home is kept clean and fresh and always appears welcoming’; ‘the home has an excellent atmosphere and staff do their best to Madelayne Court DS0000068095.V358114.R01.S.doc Version 5.2 Page 19 get to know their residents’; ‘the accommodation is very well looked after; ‘the home is always comfortable and warm I feel my loved one is very safe’. The home had passenger lifts to enable access throughout the premises and to the gardens. There were grab rails, and aids in bathrooms, toilets and communal rooms to meet the needs of residents. Assisted baths and toilets were provided and the home was fully accessible to wheelchairs. Designated storage areas for equipment were provided. Call systems were provided throughout all individual and communal rooms. Pressure relieving mattresses and cushions available and the district nursing service also provided specialist equipment as needed. All equipment was serviced as per manufacturers recommendations and confirmed from the records inspected. The home had policies and procedures for infection control in place for staff guidance. The home was clean and hygienic throughout apart from two residents’ rooms that smelled of urine. However it was evident from discussion with care staff that this was as a result of residents’ behaviour specific to dementia and that efforts were being made to address this. The laundry room was large and had separate rooms for clean and dirty laundry. There were three washing machines and five driers (four in use). The room was clean and well organised and linen and residents’ personal clothing seen were well laundered. Positive comments was received from residents spoken with: ‘the laundry service is excellent’; not a word to fault it’; ‘nothing gets messed up’. Sluice facilities were located on each floor of the home. Systems were in place to minimise risk of infection via the use of red bags for any laundry soiled by body fluids, placed directly in the washing machines, which had the capacity to carry out sluice wash cycles. Personal protective clothing (gloves and aprons) and appropriate hand washing facilities were provided for staff safety but there was no clinical waste bin in the laundry and a black bag rather than a clinical waste bag was being used for their disposal. Clinical waste bins stored externally in a secure area (reference also standard 38) were also found to be unlocked and used gloves left on the ground. Madelayne Court DS0000068095.V358114.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): Quality in this outcome area is adequate based upon sampled standards 27, 28, 29 & 30. People living at Madelayne Court can expect to be cared for by staff that are robustly recruited and well trained but staff deployment sometimes results in residents having to wait to receive care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were one hundred and ten residents at the home. Staffing numbers and skill mix were: Ground floor: 1 Care team manager 6 care assistants for 39 residents First floor: 1 Care team manager 6 care assistants for 50 residents Second floor: 1 Care team manager 2 care assistants for 21 residents There was evidence from the staff rota that staffing levels were well maintained and from observation these appeared to meet residents needs. However feedback received from relatives indicated they were not always sufficient to meet the needs of residents. Six of the thirteen completed surveys from relatives stated that staffing levels were not sufficient at times and residents spoken with said that staff were usually available to help them but this depended on how busy they were. The deployment of staff clearly needs to be reviewed at peak times. Positive comments were also received from relatives: ’ friendly staff have made my ‘loved one feel very much at home’; ‘staff are extremely supportive and most caring’; ‘I have always found help and Madelayne Court DS0000068095.V358114.R01.S.doc Version 5.2 Page 21 experienced staff to deal with any problems arising’; ‘they are all so helpful’. A visiting health professional stated that they always found the staff to be courteous and welcoming. The home had 16 care staff with NVQ level 2 qualifications or above and a further 28 staff were working towards NVQ level 2 qualification or above. The percentage of staff with NVQ level 2 training was therefore less than the 50 needed to meet the standard. Information received from the manager indicated that retention of care staff had been a problem that had impacted on staff in employment who were qualified to NVQ level 2/3. The recruitment files of four recently employed staff were inspected. All had evidence that the required checks had been obtained (two satisfactory references, CRB/POVA checks) and evidence of identification and photographs obtained before the individuals commenced employment at the home. All had received a statement of terms and conditions of employment. The manager reported that all staff received induction to Skills for Care Standards. The home had an established training programme. The training records seen confirmed that staff had completed training on abuse, fire safety, and moving and handling and health and safety. Training had also been provided on first aid, food hygiene, infection control, care planning, dementia care, medication system handling and care of skin and pressures. One completed survey from a relative stated ‘the training given to staff is excellent’. Madelayne Court DS0000068095.V358114.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): Quality in this outcome area is good based upon standards 31, 33, 35, 36, 37 & 38. The home is well managed and staff and residents are protected by good health and safety standards that are in the main well adhered to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been in post since before registration of the home. An application to register the manager was being processed by CSCI. The manager is a registered nurse with RMA (Registered Manager’s Award) /NVQ level 4 qualifications. From information received and discussion with her it was evident that she is appropriately trained and experienced to carry out her role competently. The manager was undertaking the ‘For Dementia’ training course that was due for completion in March 2008 and had also undertaken a Madelayne Court DS0000068095.V358114.R01.S.doc Version 5.2 Page 23 ‘Leadership Matters’ course in person-centred dementia care since the previous key inspection. Surveys completed by residents and their relatives stated: ‘the manager is very approachable and has an open door policy’; ‘the manager and deputy are effective’. One relative stated that recently they had become more confident in the care team managers. There is a corporate quality assurance programme whereby an annual audit is undertaken of Runwood care homes. A quality audit of the home had recently been undertaken and the manager was awaiting feedback on the outcome. The home monitored all complaints and compliments and also had a suggestion box for residents and visitors. Relatives meetings had been held monthly since the home was registered. Visits required under regulation 26 had been undertaken and reports sent to the CSCI. The home has secure facilities for the storage of any money looked after on behalf of residents. There were clear individual records of this, with receipts kept and cash held in individual zipped ‘pouches’. Four residents’ records were inspected, and records, receipts and cash all balanced. Regular staff meetings were held and handover sessions between shifts were used to discuss care of residents and ensure staff were well informed. The manager described the system of supervision in place for staff support. This included direct supervision and counselling sessions to provide an opportunity for individual circumstances to be discussed and used for positive reinforcement of care practice. Supervision meetings were held at six weekly intervals (confirmed from a sample of records viewed) or more frequently as needed. Records held on behalf of residents were kept up to date and were stored safely in secure facilities. Records viewed at this inspection included: the statement of purpose, service user guide, care plans, medication records, staff recruitment and training records, maintenance records, accidents/incident records and fire safety records. The home had a health and safety policy manual and a designated health and safety manager. The records confirmed that staff had attended relevant health and safety training. Evidence of a sample of records viewed showed that there were systems in place to ensure the servicing of equipment and utilities and there was evidence of appropriate weekly and monthly internal checks being carried out (e.g. checks on fire equipment and door closures, fire alarms and emergency lighting, hot tap water temperatures, etc.). All accidents, injuries and incidents were well-recorded and appropriate action taken. However external clinical waste bins were unlocked and two COSHH items (washing up liquid and air freshener spray) were found in unlocked storage facilities posing a risk to residents and staff. Madelayne Court DS0000068095.V358114.R01.S.doc Version 5.2 Page 24 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 3 X X 3 X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 2 Madelayne Court DS0000068095.V358114.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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. 1. Standard OP9 Regulation 13(2) Requirement To ensure residents receive medication as prescribed with risks minimised: 1. Changes in medication must be confirmed by the date and signature of the person making the change. 2. Medication with a limited shelf life must have the date of opening recorded on the container and carton. 3. Medication storage must be reviewed to provide sufficient accommodation that meets health and safety and infection control standards. To minimise the risk of infection: 1. Malodorous smells must be removed from the two rooms identified. 2. A clinical waste bin must be provided in the laundry. To ensure staff and the public are protected from health and safety risks: 1. Items assessed under COSHH must be kept locked when not in use. DS0000068095.V358114.R01.S.doc Timescale for action 31/03/08 2. OP26 13(3) & 18(1) 31/03/08 3. OP38 13(3) & 13(4) 31/03/08 Madelayne Court Version 5.2 Page 26 2. External clinical waste bins must be locked at all times. This is a repeat requirement. Timescale of 30/04/07 not met. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The list of homely remedies should be reviewed and agreed with general practitioners on an annual basis. Madelayne Court DS0000068095.V358114.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge CB21 5XE 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 Madelayne Court DS0000068095.V358114.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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