Inspection on 01/07/08 for Malmesbury Lawn

This inspection was carried out on 1st July 2008.

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

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

Malmesbury Lawn 27/07/07

Malmesbury Lawn 05/02/07

Malmesbury Lawn 25/10/05

Malmesbury Lawn 01/06/05

Malmesbury Lawn 23/02/05

Malmesbury Lawn 05/08/04

Malmesbury Lawn 02/03/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Malmesbury Lawn Woolston Road Leigh Park Havant Hampshire PO9 4JY Lead Inspector Laurie Stride Unannounced Inspection 1st July 2008 09:45 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 Malmesbury Lawn DS0000038646.V367344.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. Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Malmesbury Lawn Address Woolston Road Leigh Park Havant Hampshire PO9 4JY 023 92 244900 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) Bill.Dyet@hants.gov.uk Hampshire County Council William Tollins Dyet Care Home 37 Category(ies) of Dementia - over 65 years of age (35), Old age, registration, with number not falling within any other category (35) of places Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th July 2007 Brief Description of the Service: Malmesbury Lawn is managed by Hampshire County Council Social Services. It is a purpose built residential care home for 35 older persons including those who have dementia. The home is situated within a residential area of Leigh Park, a short distance from the town of Havant. Residents are accommodated on two floors in single bedrooms. A passenger lift provides easy access to both floors. The home has recently been refurbished and the residents have the benefit of two enclosed landscaped gardens. The fees for the home are £446 per week. This information was obtained at the time of the inspection visit. Members of the public may wish to obtain more up-to-date information from the care home. Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This unannounced visit took place as part of a key inspection of this service. The visit lasted approximately seven hours during which, we (the commission), spoke with the relatives of one of the people who use the service, a visiting healthcare professional, two members of staff, the registered manager and three other members of the management team. We received survey questionnaires from three people who use the service, who had been supported to complete the survey by relatives or carers. We also received survey questionnaires from five members of staff and two from healthcare professionals who visit the service. We also looked at samples of the records kept in the home and undertook a brief tour of the communal areas of the premises. Further evidence used in this report was obtained from the home’s annual quality assurance assessment (AQAA) and the previous inspection report. What the service does well: The home provides a suitably adapted, well-maintained and homely environment and staff respect people’s privacy and dignity. There is an excellent approach to providing people who live in the home with a range of activities and mental stimulation to meet their needs. All staff members are checked before they start work so that people who use the service are protected. The registered manager ensures that the home is run in a way that promotes the health and welfare of the people using the service. People who use the service indicated that they know who to speak to if they are not happy and that they know how to make a complaint. One person using the service who completed a questionnaire told us “My wife and daughter visited the home a couple of times before I became a resident to make sure it was the right place for my needs. We have no complaints at all. The home is very well run.” Another person who lives in the home said “lucky to have nice staff to look after me.” Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 6 Comments from two healthcare professionals who visit the home were positive, for example one told us “staff are caring and approachable, the general atmosphere is caring and positive.” Asked what does the service do well, one staff member commented that people who use the service “are encouraged to have their say and they are listened to and their wishes acted on. If for some reason this is not the case, then it is explained to them and their families why.” 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. Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 7 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 Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 8 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): Standard 3 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People wishing to use the service benefit from a comprehensive assessment of their needs to ensure these can be met before moving into the home. The home does not provide intermediate care and therefore standard 6 is not applicable. EVIDENCE: The previous inspection report identified that the home makes sure that it can meet the needs of the people who wish to use the service, by carrying out a full assessment of their needs prior to them moving in. During this inspection visit we looked at the admission records for three people who use the service. These contained copies of the assessments undertaken by the service in relation to each individual, which identify the person’s abilities and support requirements in respect of their health and welfare, social, emotional and Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 9 cultural needs. We saw that the home also obtains copies of the individual’s care manager assessment and encourages people’s relatives to be involved, where appropriate, in the gathering of information in order to obtain as full a picture of the person as possible. We spoke with the relatives of one person who uses the service. They told us they had already known about and visited the home prior to using the service and had been confident that it would meet their relatives’ needs. On the day of our visit the relatives had attended a review of the placement with the individuals’ care manager, where they were able to discuss and confirm they were happy with the placement. Three members of staff who completed survey questionnaires indicated that they are always given up-to-date information about the needs of the people they support or care for. One added “if there are any changes we are always informed of it.” Two health professionals who returned survey questionnaires confirmed that the service seeks advice and acts upon it to manage and improve individuals’ health care needs. One also commented “I’ve always thought staff act in the individuals’ best interests and embrace the care input from other disciplines.” Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Care plans now provide more information to ensure that the people in the home have all their needs met. Staff medication administration practices have improved to better protect people who use the service. EVIDENCE: The home’s annual quality assurance assessment (AQAA) told us that staff have continued to work very hard to improve the quality of the care plans which they feel now give a true reflection of individuals’ needs and the provision of care. The care plans also include individual life histories where possible. During this visit we looked at the care plans for three people who use the service and also spoke with the relatives of one of the individuals. The care plans contained pen pictures and personal histories, details of individual Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 11 routines and preferences, interests and activities. The information about daytime and evening routines was well documented with guidance for staff about what support is required and what the person can do their self. In this way care plans support peoples’ independence. Each individual has a named key worker within the staff team who provides a point of contact and makes it possible for continuity of care to be maintained. Five members of staff who completed survey questionnaires said that they always or usually feel they have the right support, experience and knowledge to meet the different needs of people who use the service. All five indicated that more staff would be beneficial at busy times. Records were on file showing when the care plans had been reviewed by the service and also when reviews by the person’s care manager took place. A care management review took place in the home at the time of our visit and the person’s relatives were in attendance. We spoke with the relatives, who told us that they had been involved in providing the background information for the care plan. The relatives were very satisfied with the care provided and were pleased to be able to continue providing some assistance with their relative’s personal care. They confirmed that staff members provide personal support in a way that respects’ people’s privacy and dignity. Care records also contained medical notes including appointments with doctors and other health care professionals. Risk assessments were in place, for example in relation to falls and the use of bed rails. Incident reports are completed when someone has a fall and the records showed that these are monitored, advice is sought and action taken. We spoke with a visiting health care professional who had also taken part in our questionnaire survey about the service. They told us that they thought the staff in the home are very good and try hard to give the best care. We were also informed that staff members were very welcoming and not defensive and that they ask for advice. The health care professional has visited the home without prior notice and said they have never seen an incident where an individual’s privacy and dignity has not been respected. This was further confirmed by comments from another health care professional. Three of the people who use the service and returned survey questionnaires indicated that they receive the care and support, including medical support, they need. They also indicated that the staff are usually available when they need them. They confirmed that staff listen and act on what they say, one adding ‘’the staff are always very friendly and helpful and do a very good job.’ Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 12 The previous inspection report identified requirements in relation to the management and administration of people’s medication. We observed medication being given at midday and one of the assistant unit managers demonstrated the medication procedures. We saw tablets from blister packs were put into medicine pots without being handled and then passed straight to the recipient. We observed that people were given glasses of water before staff gave them their medication; then staff signed the record after the person took the medication. The medication administration records contained photographs of each individual and also guidance about how each person prefers to take their medication. We saw staff adhering to this guidance when giving the medication. Records and guidance about giving ‘as required’ (PRN) medication were evident, including risks and indicators of when the individual may need the medication and the reason why it is given. The medication trolley contained gloves and hand wash spray, for use when administering eye drops for example, and is stored securely when not in use. We saw that the home is not overstocked with medication and a record of returned medication, signed by the pharmacist, was kept. The home uses a sterilizer for the medication pots and there is suitable storage for controlled drugs, although the home does not currently hold any of these. This is sufficient evidence that the requirements have been met. Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 People who use the service experience excellent outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home provides an excellent and innovative programme of activities, designed so that people who use the service are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. The dietary needs of the people who use the service are well catered for. EVIDENCE: We spoke with the home’s activities co-ordinator, who told us that the homes’ approach is to involve all of the staff in being responsible for providing mental stimulation and activities. We saw that the home uses a tool for identifying individual levels of activity, which includes activities of daily living, individual abilities and guidance for staff on engaging with the person. This information is being used in conjunction with the information from pen portraits and life histories, to provide people with individualised and flexible leisure and social activities. Key workers record outcome evaluations about what went well during a given activity and also what the individual did not like about it. For example, one person went to a supermarket with their key worker for shopping Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 14 and lunch. The evaluation showed that being involved in carrying the shopping and feeling they were doing something useful decreased the individual’s initial anxiety and made the experience enjoyable for them. We spoke with two staff members who explained the key working role and how they support people to exercise choice and control, for example taking the individual shopping for things they want rather than buying things for them; and supporting people who prefer showers to baths, as recorded in the care plan. The staff members confirmed that each is assigned tasks in relation to providing activities and mental stimulation for people, such as arts and crafts and sing-a-longs. There is a four-day training module for staff on what dementia is, it’s effects on behaviour and providing activities for people with dementia. There is an attendance register kept in relation to planned activities, such as quizzes, bingo, jigsaws, reminiscence, games, singing, laundry, cooking biscuits, entertainments and going out for a meal. This also helps the service identify peoples’ activity preferences. Times for activities are not specified although the days are, to ensure that activities take place on a flexible basis. Entertainments are also brought into the home, such as music therapy and comedians. The home arranges garden parties and trips out to local areas. There are also celebration days, for example Ascot day, complete with hats and betting, champagne, strawberries and cream. A staff member showed us a photo album of activities that had taken place in the home, which is also used as a talking and remembering activity. A sporting calendar as on the home’s notice board, along with details of a residents and family meeting. We spoke with the relatives of one person who uses the service, who told us that staff members get people out when they can and try their best at providing activities and stimulation, although people who live in the home do not always want to know. Care staff and managers told us that some staff members take people out on their days off, as this means there is less restriction on time. Four staff members who completed survey questionnaires indicated that additional staff would help at busy times and to provide and maintain quality time with individuals. A health professional told us they have observed activities taking place during their visits and that staff members keep people supplied with drinks. Three of the people who use the service and returned survey questionnaires indicated that activities are arranged by the home, one saying they ‘like to join in.’ All Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 15 indicated that they like the meals. The relatives we spoke with also praised the food provided. At lunchtime we saw that people who use the service were able to choose whether to eat with others in the main dining area or to eat alone. Staff members were available to give support and did this at a pace that suited the individual. We spoke with the kitchen staff, who showed us that choice is provided on the menu and confirmed that they are made aware of individual’s dietary needs and preferences. Nutritional assessments are undertaken and recorded in care plans. The home’s annual quality assurance assessment (AQAA) told us that people who use the service had requested that they would like to get out for walks as often as possible - this has led onto developing a project called ‘a walk in the park’, where the inner garden will incorporate a ‘tea room’ and seating area where residents and families can enjoy a walk in the gardens and stop off for a cup of tea. This project was successful in winning a £1000 reward from the ‘Adult Services Rewarding Innovation Scheme’. During our visit we saw that work is underway in building the project. The AQAA also stated that people who use the service like to watch a good film and some, through the distraction caused by others, could not get the opportunity or peace to do so. The home have therefore planned to incorporate a ‘cinema’ into the activity / craft room. The home has already sourced a large screen television, which has been wall mounted and several movie posters - the seating and lighting are the next items on the agenda. Malmesbury Lawn DS0000038646.V367344.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): Standards 16 & 18 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who use the service can be confident that any concerns they have will be taken seriously and acted upon. The home’s policies and procedures, backed up by regular staff training, protect people who live in the home from abuse. EVIDENCE: The previous inspection report confirmed that the home’s Statement of Purpose and complaints procedure provide people who use the service and their representatives with clear information on how they can make a complaint and how this will be managed. The home has a complaints logbook where the nature of the complaint is recorded, what action has been taken and the outcome. The home’s annual quality assurance assessment (AQAA) told us that there had been no complaints received by the home since the last inspection and the manager confirmed this during our visit. We have also not received any concerns or complaints about the service. Three people who use the service who returned survey questionnaires indicated that they know who to speak to if they are not happy and that they Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 17 know how to make a complaint. Five staff members said that they know what to do if someone has concerns about the home. Two health professionals indicated that the home has always responded appropriately if they or the person using the service have raised concerns about their care. One commented “I feel staff respond to individual client care in a positive way. Staff are open to constructive criticism. I have always been impressed by the care provided to clients at Malmesbury Lawn.” The other said that staff “are very aware of these issues and act promptly.” The AQAA also told us that the home has updated the safeguarding policy and there have been no safeguarding issues in the past twelve months. During our visit we saw that the home provides staff training in safeguarding awareness and also in conflict management and disengagement. An incident reporting system is in place. We spoke with two members of staff who demonstrated knowledge of the reporting procedures if they suspected any form of abuse was taking place. Malmesbury Lawn DS0000038646.V367344.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): Standards 19 & 26 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who use the service benefit from having a clean, pleasant and comfortable environment to live in, which meets their individual needs. EVIDENCE: The previous inspection report showed that the manager demonstrated that he has a good awareness of the needs of people with dementia and the importance of having an environment that is planned and decorated to assist people to maintain their independence. This was supported by the use of specific colours, textures and notices around the home. During our visit we saw that this remains the case and that the home is well lit, bright and airy and equipped with quality furniture and fittings. We spoke with the relatives of one individual, who told us they were very pleased with the accommodation provided and that a choice of bedroom had been offered. Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 19 The previous report also identified that the home was lacking in communal space and the manager had plans in place to address this. For this inspection, the home’s annual quality assurance assessment (AQAA) told us that two bedrooms are currently closed due to the restrictive communal space and this is being actively addressing with the building of an additional lounge area. During our visit we saw this work in progress. There are also further plans for continuing work on the garden and cinema projects, which have already been mentioned in the section on Daily Life and Social Activity. The home has a dedicated team of domestic staff and we observed a good standard of cleanliness throughout the building. Three people using the service who returned survey questionnaires told us that the home is always fresh and clean. Malmesbury Lawn DS0000038646.V367344.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): Standards 27, 28, 29 & 30 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Staff in the home are well trained to enable them to meet the needs of people who live there and the homes’ staff recruitment procedures ensure people are protected. EVIDENCE: Five members of staff who completed survey questionnaires said there are sometimes enough staff members to meet the individual needs of all the people who use the service. All commented that they felt more staff members are needed, particularly at busy times. During our visit the registered manager showed us the staff rota, saying that this was being re-worked to provide more flexibility where there has previously been ‘upstairs’ and ‘downstairs’ staff teams. We saw that there are generally four care staff members on duty during each of the morning and late shifts. The manager said that this can also be flexible and confirmed that staffing numbers are based on the needs of people receiving a service. The majority of the staff work part-time, which the manager said is helpful for covering shifts at short notice, as staff members can choose to work additional hours. The home does not use agency staff. Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 21 The home’s annual quality assurance assessment (AQAA) told us that all staff members had undergone relevant recruitment checks. Also that there is induction, training and development programmes in line with the national minimum standards for the service. The AQAA stated that improvements have been made through the introduction of palliative care training, falls risk assessment training, improved Dementia care training and increased National Vocational Qualifications (NVQ) training for staff. The previous inspection report identified that the home had robust recruitment procedures in place to safeguard the people who use the service. For this inspection, all five members of staff who completed survey questionnaires confirmed that their employer carried out checks, such as their criminal records bureau (CRB) and references, before they started work. We looked at a sample of recruitment records in relation to two staff members who had commenced work within the last three months. These contained all the required information, such as dates of employment and completed job application forms, two written references and evidence of satisfactory Protection of Vulnerable Adults (POVA) and Criminal Records Bureau (CRB) checks. This demonstrates that people who use the service are being protected. We looked at the staff training and development matrix, which showed a comprehensive programme of induction and training to equip staff to meet the needs of people who use the service. The manager told us that new staff members are being registered to undertake national vocational qualifications (NVQ) in care, which approximately 90 of staff were reported to have obtained. Two assistant unit managers were completing NVQ level 4 training, so that all the management team will then have the qualification. We spoke with two members of staff who confirmed they had received induction, training and updates. Both thought that the training is good and relevant to their work, particularly the four day training in relation to dementia. They both had completed NVQ level 2 training and one said that the home is also good in terms of health and safety training and procedures. The five members of staff who completed survey questionnaires said that their induction covered everything they needed to know to do the job when they started. All said that they are being given training which is relevant to their role, helps them to understand and meet people’s individual needs, and keeps them up to date with new ways of working. Two health professionals who returned survey questionnaires indicated that they think the care staff have the right skills and experience to support individuals’ social and health care needs, Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 22 one adding “I get the impression most staff see this as an important aspect of client care and general well being.” The other said “as far as I am aware the carers seem capable and act with empathy.” Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 & 38 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home is well run and management practices promote the wellbeing and best interests of the people who use the service. EVIDENCE: We were assisted throughout our visit by the registered manager, who was responsive to people who use the service, visitors and staff and demonstrated an enthusiastic and dedicated approach to managing the home. The home’s annual quality assurance assessment (AQAA) states that the registered manager meets with his peers and service managers on a monthly basis for service updates, peer group support and specific training. Managers receive regular supervision, have individual performance plans and personal Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 24 development reviews as for all staff. A quality assurance tool is used to ensure that the quality of the service is monitored. Resident surveys are conducted and feedback given to the people who use the service. We saw records of residents and relatives meetings and the manager confirmed that survey questionnaires are also used to gather stakeholders’ views about the service provided. A new staff survey is being developed. We saw that the manager has a quality assurance file that he is working through in order to develop the service. The relatives of someone who lives in the home said that the management and staff listen to them. They had also been involved in reviewing the care provided to their relative. We also spoke with a visiting health care professional who told us they thought that the manager is open and responsive to new ideas. The responsible person for the organisation designates a senior manager to undertake monthly visits as required by care homes regulations and write reports. Copies of these reports are held in the home and were seen in relation to February through to and including June 2008. The AQAA confirmed that the home encourages people to maintain their independence in managing their money, but provides a safe place where monies can be kept and managed on their behalf if they wish. The manager, administrator and/or deputy manager hold the keys to this safe place. Each person who lives in the home has lockable storage in their room where they can keep valuables and money. The manager regularly audits monies held on behalf of individuals and the home is also subject to external audits. Four staff members who completed survey questionnaires said that their manager meets with them regularly or often to give them support and discuss how they are working. One said sometimes. We spoke with two members of staff who confirmed they receive one-to-one supervision at approximately monthly intervals. Asked if the ways that information about people is passed between staff work well, three staff members replied ‘sometimes’ in the survey. The other two said usually. The AQAA states there are plans to improve the line management support to give clearer guidance to staff and so improve reporting and communication links. Evidence was seen that safe working practices are maintained in the home. Staff members receive training in food hygiene, emergency aid, infection control, management of health and safety, fire safety, moving and handling. We also saw records of safety and maintenance checks and servicing of the Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 25 home’s equipment and appliances, such as gas, electric, lifts, hoists and fire safety systems. The manager had just updated the fire risk assessment for the building and staff members receive regular fire training and drills. Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 26 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 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 3 X 3 X X 3 Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Malmesbury Lawn DS0000038646.V367344.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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