Inspection on 30/07/07 for Mallard Court

This inspection was carried out on 30th July 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mallard Court 25/07/08

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Mallard Court Avocet Way Kingsmeade Bridlington East Yorkshire YO15 3NT Lead Inspector Eileen Engelmann Key Unannounced Inspection 30th July 2007 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 Mallard Court DS0000069344.V347121.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. Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mallard Court Address Avocet Way Kingsmeade Bridlington East Yorkshire YO15 3NT 01262 401543 01262 403344 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) Barchester Healthcare Homes Ltd Mrs Sylvia Mary Burnett Care Home 64 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (64), of places Physical disability (3), Physical disability over 65 years of age (64), Terminally ill over 65 years of age (10) Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users in category PD are 40 years plus There are a maximum of 3 service users in the PD category. Date of last inspection New Service Brief Description of the Service: Mallard Court is a Care Home with nursing that provides a service for people who meet the following criteria of need: - Dementia, Old age and Physical disability. The home is situated in the town of Bridlington and enables easy access to the local shops and public transport routes. Accommodation consists of sixty-four placements within single and double rooms on two floors with lift and stair access. People have a good choice of lounges and dining rooms in which they can relax and enjoy the company of others, although the staff do recognise that some individuals need time on their own. An activities organiser is employed, who will see each individual to discuss their interests and hobbies and arrange in-house entertainment and outings on the home’s minibus. People also have access to the grounds of the home, which are designed to be accessible to those in wheelchairs and with mobility problems. Information about the home and its service can be found in the Statement Of Purpose and Service User Guide, both these documents are available from the manager of the home, and copies are on display in the entrance foyer of the home. The latest inspection report for the home is available from the manager on request. Information given by the manager within the Annual Quality Assurance Assessment indicates the home charges fees from £369.80 to £675.00 per week depending on the source of funding, type of care required and the nursing input needed. People will pay additional costs for optional extras such as hairdressing, private chiropody treatment, toiletries and newspapers/magazines. Information on the specific charges for these is available from the manager. Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 5 Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit was carried out with the manager, staff and people using the service of Mallard Court. The visit took place over 1 day and included a tour of the premises, examination of staff and people’s files, and records relating to the service. Informal chats with a number of people and staff took place during this visit; their comments have been included in this report. Information was gathered from a number of different sources before the inspector visited the home. Questionnaires were sent out to a selection of relatives, people living in the home and staff and their written response to these was good. We received 10 back from relatives (67 ), 13 from staff (65 ) and 14 from people using the service (93 ). The manager completed an Annual Quality Assurance Assessment and returned this to the Commission for Social Care Inspection within the given timescale. The views of outside professionals and other visitors to the service have been listened to and analysed as part of the inspection process. Since the last visit to the home the service has been re-registered and on this basis is classified by the Commission for Social Care Inspection as a NEW service. What the service does well: The home has an enthusiastic team of people working within the service, who like doing their jobs and learning more about how to do it well. The people working in the home want to make sure that the people who live in the home receive good care. People living in the home said they are offered a good choice of meals and they enjoyed the quality of food. Specific wishes are catered for and they have plenty to eat and drink throughout the day. People in the home are provided with a warm, safe and comfortable environment that welcomes visitors and makes them feel at home. The home is clean and staff work hard to make sure the building is odour free. People said they are happy with their bedrooms and can bring in their own possessions, making it feel more like home. Relatives of the people living in the home said that they are made to feel welcome by the people working in the home and that they can visit when they please. Mallard Court DS0000069344.V347121.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. Mallard Court DS0000069344.V347121.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 Mallard Court DS0000069344.V347121.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): 1, 2, 3, 4 and 6. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People undergo a full needs assessment and are given sufficient information about the home and its facilities prior to admission, to enable them to be confident that their needs can be met by the service. EVIDENCE: The Statement Of Purpose and Service User Guide is on display in the entrance hall and copies are available from the manager. Each of the documents is produced in a clear print version, and these are very in-depth and informative. Given the wealth of information in the documents and the different abilities of the people using the service, we queried how many of the people living in the home are able to take in and use the information provided. It is recommended that the home consider producing more appropriate formats that use innovative methods to make the information they give meaningful and interesting, for example using photographs, leaflets, visual or audio versions. Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 10 Information from the surveys shows that the majority of people received sufficient information to make an informed choice about the service before accepting the placement offer. These individuals have also received a contract/statement of terms and conditions from the home. One person said, “My daughter came in and had a good look around the home, and was given plenty of literature to take away.” A number of people within the home are self-funding and their files show that information about fees and fee increases is sent out to the person responsible for each individuals finances and sufficient notice of changes to the prices is given in writing. Each person has their own individual file and four of those looked at had a needs assessment completed by the funding authority and the home also completes its own needs assessment before a placement is offered to the individual. The home develops a care plan from the assessments, identifying the person’s problems, needs and abilities using the information gathered from the person and their family. Those people at the home who receive nursing care have undergone an assessment by a NHS registered nurse from the local Primary Care Trust, to determine the level of nursing input required by each individual. It is recommended that the manager should make sure that the admission process is looked at as part of the quality assurance audits to determine the level of people’s satisfaction with their experiences of these processes within the home. This will help the manager to assess if the home and staff are achieving the aims and objectives for the service. People and their relatives are very pleased with the care and support given by the staff. The majority of those who responded to the surveys said the home met the needs of people living there and commented that “the staff are friendly and do a professional job of care”, “we as a family feel at ease with our relative’s care, staff are friendly, polite and always listen to any concerns we may have”. The home employs four staff from overseas countries including Africa and Poland. People are able to make a limited choice of staff gender when deciding whom they would like to deliver their care, as the home has five male care staff as well as the 43 female members. Discussion with three people indicated that they have a good relationship with the staff and are comfortable in asking for specific individuals to deliver their personal care. One person said, “I did not get on with the key worker assigned to me on admission so I asked the manager if I could have a certain staff member to look after me and this was arranged straight away and I am 100 happy now.” Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 11 The staff training files and the training matrix show that new staff go through an induction before starting work and that the home has a training programme in place. Information from the files and matrix indicates that the majority of staff are up to date with their basic mandatory safe working practice training, and have access to a range of more specialised subjects that link to the needs of the people using the service, including dementia care, diabetes and the Mental Capacity Act. Information from the Annual Quality Assurance Assessment and discussion with the people using the service indicates that all of the people are of white/British nationality. The home does accept people with specific cultural or diverse needs and everyone is assessed on an individual basis. Discussion with the manager indicated that the home looks after a number of people from the local community, although placements are open to individuals from all areas. The home does not accept intermediate care placements so standard six is not applicable to the service provided. Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health, personal and social care needs of the people who live in the home are clearly documented and are being met by the service and staff. EVIDENCE: Staff said that individuals are able to input to their care plans as they are being written and people using the service sign these to say they agree with the contents. Relatives of those with dementia are asked to assist with information for the plans. People using the service said that staff listen to them and act on what they say, one person commented that “most of the time they are very busy, but they do this as soon as possible.” Another individual said, “Most of the staff have developed a friendly relationship with my relative, which is fundamental to their wellbeing as he/she have all their mental faculties, but needs full time physical care.” Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 13 The care of four people was looked at in depth during this visit and each person has their own care plan detailing what care is needed to meet their needs. The plans are kept up to date by the staff and individuals are able to input to these on a daily basis by talking to their key worker or during the review process with the funding authorities and the home. Risk assessments are in place for safe working practices, daily activities of living and restraint factors such as bed rails, wheelchair straps and alarm systems in the bedrooms for those who wander. Two people said that they have good access to their GP’s, chiropody, dentist and optician services, with records of their visits being written into their care plans. They all have access to outpatient appointments at the hospital and records show that they have an escort from the home if wished. Responses to the surveys indicated that people and their relatives are satisfied with the level of medical support given to the individuals living at the home. When asked in the surveys, what do you think the home does well? The responses were ‘the staff spot any changes in health care, communicate them to others and take action’ and ‘keep bedridden people clean and comfortable – no pressure sores’. Entries in the care plans specify where individuals have dietary needs, including PEG feeds, supplement drinks and puréed diets. The staff weighs everyone on a regular basis and evidence in the plans show that dieticians are called out if the home has particular concerns about an individual. Pressure areas are monitored carefully and proactive measures include risk assessments and special mattresses and seat cushions. One person whose care was looked at during this visit came into the home with a large pressure sore. Details in their care plan show that this is healing well and they told us that they are very happy with the care they are receiving. Relatives commented that they are kept informed of their relative’s wellbeing by the staff; they are regularly consulted (where appropriate) on their care and feel involved in their lives. Overall there is a good level of satisfaction with the care being given to people using the service. The medication policy for the home says that individuals can self-medicate if they want to and after a risk assessment has been completed and agreed. All of the residents spoken to prefer to have staff administer their medication. Checks of the medication records showed that overall these are well maintained and kept up to date, however there were two areas of practice which they could improve • It was noted that medication already held in the home when a new medication sheet is started is not added to the supplies on the DS0000069344.V347121.R01.S.doc Version 5.2 Page 14 Mallard Court medication record sheets. This should be done so as to ensure a running total is available at all times and an audit of stock is easy to carry out. • Where staff are hand writing medication onto the sheets (transcribing), they are not following best practice. Staff must write the instructions from the box or bottle onto the sheet in full, include the amounts of medication received or brought forward, and have two staff sign the entry to indicate they have both witnessed that the information on the sheet is correct. Checks of the controlled drugs and register showed that staff on one unit had been late in giving one person their pain relief patch. This was discussed with the manager and staff and clearly was an isolated incident that was rectified as soon as it was noticed. People and relative comments show they are very satisfied with the care and support offered by the staff. Chats with people using the service revealed that they are happy with the way in which personal care is given at the home, and they feel that the staff respect their wishes and choices regarding privacy and dignity. Individual comments were that ‘I feel cared for and safe’ and ‘my relative has only been here a short time, but we are very pleased with their care’. Observation of the service showed there is good interaction between the staff and people, with friendly and supportive care practices being used to assist people in their daily lives. Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with choice and diversity in the meals and activities provided by the home. Individual wishes and needs are catered for and people have the option of where, when and how they participate in both eating and leisure activities. EVIDENCE: There are two activity co-ordinators within the home, who together provide a programme of events from Monday to Friday. A letter informing people about the forthcoming activities and events is given out to people every week. During this visit it was observed that the people with dementia were enjoying a music and movement session in the upstairs lounge. The home has a library area in the entrance foyer, with a selection of books including those with large print. One person who spoke to us is partially sighted and was waiting for the regular visit from the mobile library. This person said they enjoyed listening to their talking books, the radio and music CD’s. Discussion with people living in the home indicated that they have access to a minibus two to three times each week and can go out on regular trips; they also take part in Quizzes and other group activities. One individual told us that they had particularly liked the Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 16 music provided by an organist who had played in the home the week before this visit. Individuals spoken to are satisfied with the activities and social events that take place and comments were made that ‘the interaction between people and carers is good. There is a plentiful provision of activities and we cannot praise the staff highly enough. They do their jobs well and are extremely kind and loving towards the people living in the home’. Regular meetings are held with people and their relatives; these are used as an opportunity for individuals to express their ideas of what activities and trips out they want and to give their feedback on events that have taken place. Good records are kept of all the social interactions going on in the home and evidence seen at this visit indicates that people are encouraged to celebrate Christian events such as Birthdays, Easter and Christmas. There are monthly in-house church services from the Church of England, and the Catholic priest will visit anyone wishing to take communion on request. Discussion with the people living in the home indicates that they have good contact with their families and friends. Everyone said they were able to see visitors in the lounge or in their own room and they could go out of the home with family or staff would take them into the town. Visitors were seen coming and going during the day, staff were observed making them welcome and there clearly was a good relationship between all parties. Relatives and visitors to the home are very positive about the service and the staff. Written and verbal comments given to us showed a high level of satisfaction. Individuals said ‘the staff are wonderful, they give good care and people are well looked after’, ‘staff are extremely professional and this is one of the best run nursing homes in this area’. Advocacy information is on display within the home and people who use the service are encouraged to be as independent as possible. Some individuals attend the local PAGER group, taking part in coffee mornings and awareness sessions that explain their rights as individuals and this is held every month in Bridlington Library. People on the dementia unit are less able to make their own decisions due to their mental frailty, but staff were seen to offer them choices around meals and drinks and take time to ask their preference around mobility and where they wished to sit in the dining room and communal spaces. People spoken to are well aware of their rights and said that they had family members who acted on their behalf and took care of their finances. People spoken to are satisfied that they can access their personal allowances when needed. Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 17 Comments from the people living in the home and their relatives were on the whole very positive about the meals and kitchen service provided. Individuals said ‘the food is excellent with a good choice and they are approachable to ask for something else where possible’, ‘Perfect as I am a fussy eater, and they make the meals to accommodate my appetite’. A few people were less satisfied and said ‘Sometimes a bit repetitive, but has improved lately’, and ‘Food portions sometimes seem small, particularly at teatime. People in bed do not always get an evening drink’. The lunchtime meal was well presented and offered a good choice of food, menus were on the dining tables and the dining room was welcoming and spacious. Staff were organised when serving the meal and a number of individuals were seen to offer assistance to people who needed help with eating and drinking. Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a robust complaints system with some evidence that peoples’ views are listened to and acted upon. Visitors and people using the service are confident about reporting any concerns and the manager acts quickly on any issues raised. EVIDENCE: The home has a complaints policy and procedure that is included in the statement of purpose and service user guide. It is also on display within the home and all fourteen of the survey responses from people using the service showed individuals have a clear understanding about how to make their views and opinions heard. Those people spoken to said ‘the manager comes round every day to see us and will discuss any problems at this time’. Seven relatives who completed a survey said that they felt the home responded appropriately if they raised a concern and minor issues were dealt with quickly. One relative said ‘the staff are very approachable, and try to deal with issues before they become a problem’. The home has received one complaint in the past six months; this was around cigarette smoke in the dining room. The issue was investigated and resolved and with the new smoking policies that came into force on 1st July 2007, should not happen again. The home reviews the number and nature of complaints made as part of the quality assurance process. Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 19 The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of resident’s money and financial affairs. The staff on duty displayed a good understanding of the safeguarding of adults procedure. They are confident about reporting any concerns and certain that any allegations would be followed up promptly and the correct action taken. Information in the staff training files showed that they all have received Safeguarding of Adults training. Staff understand what restraint is and try to ensure that this is not used within their practice, wherever possible. Bedrails, keypads, recliner chairs and wheelchair belts are all risk assessed and involve the agreement of the family or individual plus other professionals such as the person’s GP. Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides an extremely high standard of environment, which offers people a safe, comfortable and attractive place to live. EVIDENCE: Mallard Court is a purpose built nursing home that was opened in 1993. There is an ongoing programme of refurbishment and decoration and one person said, “Will you tell Barchester that this home is a wonderful place to live, and I appreciate the time and effort that has gone into making this place welcoming and a pleasure to be in.” The décor is hotel standard, with lots of pictures and soft lighting, and a number of different seating areas. The home is building a six-bedded extension, which is due to open in October 2007. The day room will be ready by 23rd August 2007 and the dining room is being refurbished. Building work is not affecting the people living in the home and health and safety procedures are in place to protect people using the Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 21 service. The building site is not accessible from inside the home and the area being built is fenced off during the day and locked up at night. People were seen to be using the lounges upstairs and down during this visit and observation of the communal areas found these to be warm, bright and odour free. The gardens to the home are very well kept and people enjoy sitting out in the sunshine. There are a number of seating areas provided for them around the home and access is easy for those in wheelchairs or with mobility problems. Inspection of the home showed that it has been designed and built to meet the needs of disabled individuals. Doorways to bedrooms, communal space and toilet/bathing facilities are wide enough for wheelchairs, and corridors are spacious enough for people in wheelchairs or with walking frames to move along comfortably. The home is built on two floors and the upper floor is accessible by a passenger lift and/or stairs. There are flat walkways inside and out, providing safe and secure footing for people with limited mobility. Discussion with the staff and manager indicates that there is a wide range of equipment provided to help with the moving and handling of people and to encourage their independence within the home. This includes mobile hoists, stand aids, slide sheets, moving and handling belts and handrails. Bathrooms are fitted with rise and fall baths or fixed hoists and shower rooms are designed for disabled access. Thirty-two specialist nursing beds are provided where people have an assessed need, and these aid staff in caring for these people and make life more comfortable for individuals who spend a lot of time in bed. The home and the community teams provide pressure relieving mattresses and cushions, where people are deemed at risk of developing pressure sores. The environment is clean, warm and comfortable and no malodours were present. Comments from the day of this visit indicate that the people using the service find the home to be spotlessly clean and they are satisfied with the laundry service provided by the home. The laundry on site is spacious and has a new cleaning system fitted, which is designed to kill any germs especially those causing MRSA and Clostridium Difficile. A separate room is available for storage of clean clothes and linen until it goes back out to the bedrooms. Staff have a good understanding of infection control and demonstrated its use during their care practices, such as hand washing, use of anti-bacterial gel and wearing of protective clothing. Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standards of recruitment, induction and training of staff are very good with appropriate checks being carried out and staff demonstrating a clear understanding of their roles, ensuring that people are protected from risk and looked after by motivated and knowledgeable people. EVIDENCE: Comments from the people using the service and relatives are on the whole very positive about the staffing levels within the home, and individuals feel that there is a high standard of care being given to the people living in the home. People said ‘the staff create a good atmosphere; it is caring, comfortable and safe. Staff are supportive, friendly and professional’. Some individuals commented that ‘ there are not enough staff on duty, and higher levels of staff are needed on the dementia unit’. At the time of this visit there were 63 people living in the home and staffing is provided as follows Morning – there are two nurses and ten care assistants Afternoon – there is one nurse and nine/ten care assistants Night – there is one nurse and four care assistants Observation of the staff showed that the home is busy, but well organised. Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 23 Information from the annual quality assurance assessment and the staff rotas about the number of staffing hours provided, and information gathered during the inspection about the dependency levels of the people using the service, was used with the Residential Staffing Forum Guidance and showed that the home is meeting the recommended guidelines. The company has achieved City and Guild training status and staff members are undertaking their NVQ 2/3 with the homes training officers. At the moment 23/41 care staff employed at the home (56 ) have achieved an NVQ 2 or 3 and two more staff are working towards this qualification. The home has an equal opportunities policy and procedure. Information from the staff personnel and training records and discussion with the manager, shows that that this is promoted when employing new staff and throughout the working practices of the home. The home has a recruitment policy and procedure that the manager understands and uses when taking on new members of staff. Checks of four staff files showed that police (CRB) checks, written references, health checks and past work history are all obtained and satisfactory before the person starts work. Nurses at the home undergo regular registration audits with the Nursing and Midwifery Council to ensure they are able to practice. The home has two in-house training officers and has access to further training resources from a sister home in Hull. The home offers staff a wide range of training aimed at meeting the needs of the people using the service, in addition to a comprehensive induction and foundation programme, which meets the Skills for Care training targets. Staff receive in excess of three days paid training per year and the home has individual staff training plans that are discussed through supervision and appraisal. Four staff files were looked at and they contained evidence of a variety of training events attended over the past year, including safe guarding of adults, visiting mum, customer care, medication, diabetes, dementia care, wound care, palliative care as well as those pertaining to safe working practices. Staff said that ‘the home offers staff good training opportunities and career structure’. Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home is satisfactory overall and the home regularly reviews aspects of its performance through a good programme of audits and consultations, which includes seeking the views of people using the service, staff and relatives. EVIDENCE: Sylvia Burnett is the registered manager of Mallard Court and has been in this post for some years. She has access to training and support from the Barchester managers training programme and has regular contact with her operations manager. The manager is a trained nurse with an active registration with the Nursing and Midwifery Council and she is just finishing her NVQ 4 in Management. Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 25 Comments from the staff, people and relative surveys are very positive about the manager and the way that she runs the home. Individuals have said that “You are able to voice opinions and these are listened to in a non-critical way. Issues dealt with promptly and appropriately” and “the home is well run and I am very happy here”. The home has an up to date quality award from Investors in People and the local councils quality award (QDS) parts one and two. Continuous monitoring and assessment of the home and its practice/service by the various authorised bodies is an essential part of the process leading to the awards being reaffirmed year after year. Meetings for people using the service are held on a regular basis and minutes are circulated to people living in the home. Staff have meetings with the manager and everyone is encouraged to join in with discussions and voice their opinions. People and staff agreed that they are able to express ideas; criticisms and concerns without prejudice and the management team will take action where necessary to bring about positive change. Policies and procedures within the home have been reviewed and updated to meet current legislation and good practice advice from the Department of Health, local/health authorities and specialist/professional organisations. The manager completes in-house audits of the home and its service on a monthly basis, and the registered individual does spot checks and completes the regulation 26 visits. A copy of the monthly visit is sent to the commission. The importance of the Commission’s document called Key Lines Of Regulatory Assessment (KLORA) was discussed with the manager, and how it is used in the inspection and report writing process. Evidence was seen that the Barchester Company has produced its own crisis plan for the Flu Pandemic that may affect the country in or around 2009, this is detailed and sets out what each home must do to ensure the people and staff receive the care and support needed in the event of a flu outbreak. Checks of the financial systems found that these are computerised, up to date and maintained on a daily basis by the administrator of the home. Sixteen people have their own personal allowance account, and these are independently audited each year. The home is moving towards a system of billing individuals, or the person looking after their finances, on a monthly basis where extra services have been accessed, such as hairdressing, chiropody and papers/magazines. Where individuals have their families looking after their finances, relatives who are unable to visit very often are asked to send spending money for the person as and when their personal allowance accounts show their monies are low. Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 26 These requests from the home are accompanied by a print out of the person’s account. The home only keeps a limited amount of money within the safe, surplus monies are kept in a communal account, which does not pay individuals any interest. It was recommended that this information is put into the Service User Guide so all those coming into the home are aware of the homes arrangement, and can decide if they wish to make their own. Maintenance certificates are in place and up to date for all the utilities and equipment within the building. Accident books are filled in appropriately and regulation 37 reports completed and sent on to the Commission where appropriate. Staff have received training in safe working practices and the manager has completed generic risk assessments for a safe environment within the home. Risk assessments were seen regarding fire, moving and handling, cot sides and daily activities of living. Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 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 4 4 X X 4 X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The home should consider producing the statement of purpose and service user guide in more appropriate formats, which make the information within them meaningful and interesting for the people using the service. The manager should make sure that the admission process is looked at as part of the quality assurance audits to determine the level of people’s satisfaction with their experiences of these processes within the home. The manager should make sure that where staff are hand writing medication onto the sheets (transcribing). Staff must write the instructions from the box or bottle onto the sheet in full, include the amounts of medication received or brought forward, and have two staff sign the entry to indicate they have both witnessed that the information on the sheet is correct. Staff should ensure that medication already held in the DS0000069344.V347121.R01.S.doc Version 5.2 Page 29 2. OP3 3. OP9 4. OP9 Mallard Court 5. OP35 home when a new medication sheet is started is added to the supplies on the medication record sheets. This should be done so as to ensure a running total is available at all times and an audit of stock is easy to carry out. Information about the non-interest bearing account for people’s monies should be put into the Service User Guide so all those coming into the home are aware of the homes arrangement, and can decide if they wish to make their own. Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Mallard Court DS0000069344.V347121.R01.S.doc Version 5.2 Page 31 - 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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