Inspection on 02/08/07 for Melrose Court

This inspection was carried out on 2nd August 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

Melrose Court 20/06/06

Melrose Court 26/10/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Melrose Court 74 Cambridge Road Southport Merseyside PR9 9RH Lead Inspector Elaine Stoddart Key Unannounced Inspection 2nd August 2007 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Melrose Court DS0000065047.V341452.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. Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Melrose Court Address 74 Cambridge Road Southport Merseyside PR9 9RH 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) 01704 226177 01704 226177 Melrose Court Rest Home Limited Mr Ian Burns Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service must employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Service users to include a maximum of 21 in the category of Old Persons, not falling within any other category. 20th June 2006 Date of last inspection Brief Description of the Service: Melrose Court is a residential care home, which is registered to provide personal care and support for up to 21 elderly residents. There were 17 residents accommodated at the time of the site visit. 18 single and 1 double room provided. En suite facilities are provided in 4 single rooms and the double room. Communal areas consist of 2 lounges, conservatory/dining room and a designated smoking room for the residents. All are located on the lower ground floor. The residents have the use a large enclosed garden during the summer. The home has equipment and aids to assist residents who require help with their mobility and ramps and a lift allow access to all parts of the house and gardens. There is parking at the front of the home. A call bell system is available throughout. Nursing care is provided when required by the district nursing service. The home is situated close to the seaside resort of Southport and its amenities can be accessed via the local transport. The new manager is Mr John Burns, who is yet to be registered by the Commission. The home is owned by Melrose Court Rest Home LTD. The fee rate for accommodation is £365.00 a week. Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A site visit took place as part of the unannounced inspection over one day for a duration of approximately eight hours. Seventeen residents were accommodated at this time. A partial tour of the premises took place and a number of the home’s care, staff and health and safety records were viewed. Discussion took place with four residents; three care staff, one of the owners, the cook and the new manager. During the inspection three residents were case tracked (their care files were examined and their views of the home were obtained). This process was not carried out to the detriment of other residents who also took part in the inspection process. All the key standards were inspected and also previous requirements and recommendations from the last inspection in June 2006 were discussed. Satisfaction survey forms “Have Your Say About …” were distributed to a number of residents and relatives prior to the inspection. A number of comments included in the report are taken from the site visit and also the survey forms. Surveys were received from one relative and six residents. An annual quality assurance assessment (AQAA) was completed by the manager prior to the site visit and some of the information from the assessment is contained within the report. The AQAA provides details of the service and the current staff and resident group. What the service does well: Melrose Court had a pleasant welcoming atmosphere and residents appeared happy and settled. Visitors are encouraged to call and residents can meet with them in the lounges/conservatory or in the privacy of their own rooms. Residents spoken with were pleased with the standard of care and support given to them. Residents are positively encouraged to exercise their own choice whenever possible in many aspects of their daily lives. This was observed and discussed with residents in relation to meals, social arrangement and time of getting up in the morning and retiring at night. Comments regarding the care included: “I feel this is definitely the right place to live”. “I can’t get better care than what I receive”. Staff were observed to be respectful in their approach when talking with residents and also assisting with various aspects of personal care. The menu for the day is displayed and residents stated that they received a good choice of different meals; the food is tasty and well presented. Residents spoken with said: Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 6 “The meals are very good”. “We always get a choice”. There is a varied activity programme in place and the resident have the choice to join in if they wish. Comments include: “I “I “I “I like the bingo and card games”. love playing bingo” would rather go out, but I play bingo for good prizes”. like my own company and don’t like to join in the activities”. What has improved since the last inspection? What they could do better: The manager should continue the ongoing maintenance programme. Future plans include: the replacement of windows, redecoration of rooms, new boiler, fitting of new bathroom and a new hairdressing/treatment room. The manager should continue National Vocational Qualifications training for all care staff to reach the 50 of care staff qualified in this area. Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 7 Financial records should be reviewed and audited regularly. This was agreed with the manager at the time of the visit. Written entries on medication administration records (MAR) should be countersigned. The manager should make an application to the commission to become registered. 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. Melrose Court DS0000065047.V341452.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 Melrose Court DS0000065047.V341452.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): Standards 1,2,3, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Contracts are in place and information is available to residents and prospective residents. Residents’ needs are assessed to ensure the staff can provide the care and support they require. Standard 6 is not provided. EVIDENCE: Since the last visit a new manager John Burns has taken over the position and is to make an application to the commission to become the registered manager. The new manager has updated the ‘Welcome pack/ service user guide/ statement of purpose’ for prospective residents and residents. This contains up to date information on the service, staff employed and their qualifications. All residents have a copy of this and these were seen in resident’s rooms. Contracts of terms and conditions of residency are provided to all residents accommodated and include fees and charges for the service. Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 10 Visits by prospective residents are encouraged and this was confirmed with the residents interviewed who said that they or their families came to view the home prior to their admission. All residents receive a full assessment of their needs prior to admission to ensure the staff can meet their needs. Assessments were viewed for three residents and contained personal profiles on the residents interests, hobbies, past experiences, spiritual, cultural and religious needs, death wishes, sleep patterns, food likes and dislikes, medication, dependency level and personal, health and physical needs. A risk assessment is completed for all residents for manual handling needs. The assessment details are then used to form the plan of care, which enable the staff to provide the care to meet the resident’s needs. Residents spoken with and surveys received were complimentary regarding the care received at the home. Comments include: “I am very happy with the way my Mum is looked after”. Relative. “I would recommend this home to anyone”. Resident. Standard 6 was not assessed, as this is not provided at the home. Melrose Court DS0000065047.V341452.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): Standards 7,8,9,10,11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are treated with dignity and respect and their health and personal care needs are met. EVIDENCE: Three residents care plans were viewed and contained personal profiles as stated in the above section. The assessment details are then used to form the plan of care. Records are maintained of all health care visits to chiropodist, district nurses and hospital appointments. Care plans are drawn up with the residents/and or their representatives, outline the needs of each resident, show the aims and goals to be maintained and the support required by the staff. Care plans are signed by the residents/or their representative and these were viewed on files seen. The deputy manager reviews all care plans monthly to monitor changing needs. Shift handovers take place with staff to ensure that any changes in residents’ circumstances are fully communicated and documented. Records of shift handovers and staff spoken with confirmed this. Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 12 Observation and discussion with residents confirmed that they are treated with dignity and respect at all times. Personal care is given in the privacy of resident’s rooms. Residents are able to remain in their own rooms if they wish or use the communal areas in the home. The laundry system is organised to avoid losses and ensure the residents wear their own clothes at all times. Access is available to a telephone, however some residents have their own telephone for use in their own rooms. The residents’ wishes at the time of their death are recorded. Residents are encouraged to maintain contact with relatives and friends. Surveys received and residents spoken with confirmed this. Staff were observed to knock prior to entering residents rooms and always spoke with them in a courteous and polite manner. Staff were observed to spend time sitting and talking to the residents throughout the day and a relaxed, friendly and comfortable atmosphere was evident. Policies and procedures are in place, which cover dignity, respect and residents rights. These are contained within the service users guide and are available in all residents’ rooms. Staff spoken with showed they are aware of individual residents care needs, are kept up to date via shift handovers and are involved in their care planning process. All rooms have single occupancy at the time of the visit. Comments from residents spoken with and surveys received include: “I can’t get better care than what I receive”. Resident. “I am very pleased with the care my Mother receives”. She developed breathing problems and an ambulance was called immediately. Excellent”! Relative. “I like my own company. My son’s come and visit often”. Resident. Medication policies and procedures are in place and were viewed during the visit. Medication procedures ensure medication is administered safely. Only staff who are trained in the ‘safe administration of medication’ are responsible for administering. The Medication administration record (MAR) sheets showed that written entries were not countersigned. A recommendation is made for written entries on MAR to be countersigned by staff. This was discussed with the senior on duty and the manager at the time of the inspection. Melrose Court DS0000065047.V341452.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can choose how they wish to spend their day and are given wholesome nutritious meals according to what they would like to eat. EVIDENCE: Three pre-admission assessments viewed contained information on the resident’s family contacts, past history, likes and dislikes, hobbies and interests. This enables the staff to obtain a clear picture of the residents’ previous lifestyles and their individual wishes and expectations. The residents are encouraged to make decisions daily whom they wish to see, and what activities they wish to join in. They are also encouraged to choose what they wish to eat, whether to mix with other residents in the home or have the privacy of their own room. This is provided in the flexible routines at the home. Meals are served at set times, however residents can have the choice of having their meals in their own rooms or within the attractively decorated dining areas. Residents were observed having their main meal of the day in pleasant, relaxed, unhurried manner and staff were polite and attentive at all times to the residents needs. The main meal is served at lunch and relatives and visitors are invited to join them if they wish. The menu is varied and wholesome and alternatives are available at all times. The menu of the day is Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 14 displayed in the conservatory. The residents are consulted on their choice of the day by the care staff and a record is maintained of the food they have chosen within their care records. Diabetic, vegetarian and low fat diets are catered for. This is all set out within the home’s information pack available to all residents and prospective residents. Records confirmed that the staff are catering for their needs. The cook is qualified in food hygiene and nine other staff also hold this qualification. The kitchen is well organised and clean. Drinks and snacks are served throughout the day or upon request 24 hours a day. Discussion took place with the cook who has worked at the home for two years and made the following comments regarding the home and facilities available. “I chat with the residents regularly to get feedback from them about the food. The fridge and freezers are always well stocked and I cook my own puddings. If there is anything I need I only have to ask and John the manager will just get it. The kitchen is well equipped with all I need”. Residents spoken with and surveys received provided positive comments regarding the meals provided. “The meals are very good”. Resident. An activity programme ensures the residents have access to a range of entertainment. This includes bingo, quizzes, entertainers and summer BBQ’s. The staff arrange individual shopping trips and meals out for residents. The home has a large enclosed rear garden, which has recently been improved and has an accessible large patio area, lawn and gazebo. The residents were observed to use the garden area during the site visit to sit in the sunshine and chat with the staff on duty under the shade of the sun brollies. The activity programme for that afternoon was 1 –1 sessions with residents to enable the staff to have some time to chat individually with them. Both the staff and residents spoken with said they enjoy these sessions. All activities are recorded and who took part. There are several communal areas were residents can meet their visitors in private, conservatory, two lounges, large garden and their own rooms. The home has a designated smoking room for the residents only. Relatives and visitors are encouraged to call and join in with any activities and stay for lunch if they wish. Communion is held at the home monthly and the local clergy will visit on request. Religious needs are assessed on admission and the home aims to meet residents’ hobbies, interests and religious beliefs. The home is equipped with adaptations and assisted aids to promote independence and equality. Rooms viewed showed that residents are encouraged to bring in personal possessions. Access is available to advocates should they wish. Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Polices and procedures are in place to listen and respond to complaints and to safeguard and protect vulnerable people from abuse. EVIDENCE: The statement of purpose and service user guide clearly outlines the complaints procedures and contains the Commission for Social Care Inspection and the ombudsman contact details, should complaints be unresolved. All residents have a copy of this information in their own rooms. Residents spoken with confirmed their understanding of how to make a complaint should they need to. Comments include: “I would speak to Pam (Deputy) if I wasn’t happy”. “I will speak to John (The Boss) if I wasn’t happy”. A whistle blowing policy is in place and staff spoken with are aware of this procedure. Nine staff have completed training in abuse and this training is ongoing. A copy of Sefton and Liverpool’s ‘Safeguarding adults’ policy is available to staff and staff spoken with are fully aware of the procedures. Residents are encouraged to manage their own finances were possible. The manager is appointee for one resident who receives a monthly statement from Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 16 him. All personal allowances handled on behalf of residents are recorded and receipts obtained. Discussion with the manager confirmed that the recording of this system should be reviewed. All records should be noted in a numbered book for each resident, signed by the resident and audited regularly by another senior staff member. The manager agreed to action this immediately to safeguard the staff and the residents. Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 17 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 19,20,21,22,23,24,25,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live is a safe, clean, well-maintained and comfortable home. EVIDENCE: A full tour of the premises confirmed that the maintenance programme is continuing and progress has been made to improve the home since the last site visit. These include some new carpets fitted, blinds and new dining and day room furniture. The garden has been flagged, new garden furniture purchased and new plants laid. The garden now provides an atractive, spacious and accessible area for the residents to sit in the summer. This was observed throughout the site visit as residents sat in the sunshine and chatted with staff and other residents. The concrete fencing has been replaced with a brick wall along the side of the home. Redecoration has taken place in a number of rooms and window restrictors in place for the protection of the residents. Plans are in place to refurbish the roof, purchase a new boiler, fit new windows at the side of the home, installation of a new bathroom, provide en suite to room Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 18 10 and re decorate stairs and landings. An ex bathroom on the top floor is to be converted to a hairdressing/treatment room. Residents rooms viewed contained personal possessions and were clean and comfortable. Radiator covers are in place throughout. Positive comments were received regarding the environment from both residents and relatives. Comments include: “10 out of 10 for everything”. Relative. “I feel this is definitely the right place to live”. Resident. The home has a number of communal rooms where residents can sit and chat with others, meet their visitors. These are also used to watch TV, listen to music or take part in the activities. The communal rooms are comfortably furnished, spacious and clean. A designated smoking area is provided for the residents use. The laundry is well organised and a new tumble dryer and washing machine has been purchased to improve the performance in the laundry. Dining takes place in a small dining room and the conservatory, which provides a pleasant place for the residents to eat their meals and the tables are attractively set with napkins. Two residents rooms require redecoration and discussion with the manager confirmed that this will be done on completion of new windows being fitted in the next six months. The home was found to be clean and hygienic. Plenty of protective clothing is available and hand-washing facilities are in place. Specialist equipment is available in the form of a bath hoist, raised toilet seats, wheelchairs, Zimmer frames and ramps for those residents with mobility needs. Certificates for services, such as gas, are all up to date. A fire risk assessment was completed in October 2006. Water temps are completed weekly and records kept. An emergency call system is available throughout and was inspected in February 2007. The home had an assessment by an occupational therapist in 2004, to assess the suitability of the layout for older people. Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 19 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are recruited through robust recruitment procedures and there are sufficient numbers of trained staff to provide care and support to the residents. EVIDENCE: At the time of the visit there were three carers, the manager a cook and a domestic on duty. Two staff – one waking and one sleep in provide night cover. Duty rotas seen confirmed sufficient staff are in place and the manager is in the process of recruiting more staff. The cook covers two sleep in night duties and cooks six days a week. This was discussed with the manager to confirm that should the cook be awakened to care for residents’, cover would be provided to cover her day duties as a cook. The correct recruitment and selection procedures are followed. Two staff records were viewed and these evidenced completed job application forms, induction and referees had been contacted for two references prior to commencing work at the home. CRBs (Criminal record bureau checks) are in place. Certificates were on file to confirm the training received. A full induction process is in place to enable the staff to ‘shadow’ care staff and receive all there is to know about the service and care practice. Residents interviewed and surveys received were complimentary regarding the standard of care they receive and the new manager of the home. Comments included: Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 20 “Girls are good to me”. Resident. “The staff do their best”. Resident. “I am very happy with the way my Mum is looked after”. Relative. Staff spoken were very positive about their roles at the home and confirmed that there is always sufficient staff on duty, support available from their colleagues and they are made fully aware of the residents needs. Comments included: “I love it here. The training is very good. There is always support to help you out”. “I love the work”. Through direct observation it was evident that staff provide a good standard of care. Staff were seen to interact positively with residents, were polite and plaeasant at all times and had time to sit and chat with them individually. A pleasant , relaxed atmosphere was evident. A full training programme is now in place for staff and this has been introduced since the new manager took over in June 2007. The training completed in the last two months include: health and safety, medication, abuse, manual handling, food hygiene and fire awareness. Staff interviewed confirmed that they are undertaking National Vocational Qualifications and a number have have enrolled on NVQ courses. Sixteen care staff are employed, three have NVQ Level 3, six are working towards NVQ Level 2. 47 of staff are qualified in NVQ. The manager should continue the NVQ programme to reach 50 set out by the National Minimum Standards. Records viewed showed supervision and personal development plans have been provided for all the care staff by the new manager in the last two months. Certificates are on file for all training completed by staff. Staff spoken with and records viewed confirmed the training plan in place. Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 21 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 31,32,33,35,36,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interest of the residents. EVIDENCE: The new manager has only been in post since June 2007. The manager is qualified in NVQ Level 4 management and advanced food hygiene. He is a qualified trainer and is able to provide staff training in house. The manager although has little experience in the caring field is hoping to take his registered managers award and any additional training required to expand his knowledge. Since taking over from the previous manager he has concentrated on meeting the requirements set at the last visit, getting the staff training programme up to date, supervising all the staff and involving them in their personal development plans. The recording systems were found to be organised and up to date. New systems have been introduced for monitoring residents’ food and Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 22 activity programmes. The manager demonstrated an open, inclusive and positive approach to the needs of the residents and staff. Residents and staff spoken with confirmed their satisfaction with the care and support provided. In the short time the manager has been in post, both staff and residents spoken with feel he has made changes to improve the service and is approachable and caring. The manager is to make an application to the commission to become the registered manager. His application was seen and almost completed to be forwarded to CSCI. Comments include: “If there is anything I need John will get it”. Cook. “John has worked so hard over the last few months he wants to improve the home”. Carer. Through observation it was evident that the management team and staff support the residents and have a good understanding of their individual needs. Since the appointment of the new manager, he has undertaken quality assurance surveys of the residents and their relatives to obtain their feedback of how the service is performing. Completed survey forms were viewed and confirmed the residents and their relatives are satified with the service provided. Residents meetings now take place to involve them in the day-to-day running of the home. Residents manage their own finances were possible. (see section in complaints and abuse). Policies and procedures are in place and accessible to the staff and are in the process of being reviewed by the new manager. Some have been completed ie food safety, care planning, reviews, induction and this is ongoing. Staff take part in handovers at each shift change to discuss the care of the residents to ensure they are up to date with their care needs. A selection of safety contracts for equipment and services in the home were viewed and found to be up to date. Fire alarms are tested weekly and the fire log book evidenced the most recent tests. All accidents and injuries are recorded. Portable appliance testing was completed on 12/10/07. Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 23 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 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 2 3 3 X 3 3 X 3 Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 24 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. 2. 3. 4. 5. Refer to Standard OP28 OP19 OP35 OP9 OP31 Good Practice Recommendations The manager should continue to provide an ongoing training programme for NVQ to achieve the 50 of qualified care staff. The manager should continue the ongoing maintenance programme to improve the standard of the environment. Financial records should be reviewed and audited regularly. This was agreed with the manager at the time of the visit. Written entries on medication administration records (MAR) should be countersigned. The manager should make an application to the commission to become registered. Written entries on medication administration records (MAR) should be countersigned. Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Merseyside Area Office 2nd Floor, South Wing Burlington House Crosby Road North Waterloo L22 0LG 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 Melrose Court DS0000065047.V341452.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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