Inspection on 29/04/08 for Memory House Care Centre

This inspection was carried out on 29th April 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

Memory House Care Centre 24/06/09

Memory House Care Centre 30/04/07

Memory House Care Centre 08/08/06

Memory House Care Centre 16/12/05

Memory House Care Centre 11/07/05

Memory House Care Centre 09/03/05

Memory House Care Centre 05/08/04

Memory House Care Centre 22/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Memory House Care Centre 6-9 Marine Parade Leigh On Sea Essex SS9 2NA Lead Inspector Ann Davey Unannounced Inspection 29th April 2008 08:30 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 Memory House Care Centre DS0000015512.V362048.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. Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Memory House Care Centre Address 6-9 Marine Parade Leigh On Sea Essex SS9 2NA 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) 01702 478245 01702 711168 memory.house@ashbourne.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Mrs Jean Margaret Sanders Care Home 45 Category(ies) of Dementia - over 65 years of age (45), Old age, registration, with number not falling within any other category (45) of places Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Personal care to be provided for older people aged over 65 years. Personal care to be provided to no more than forty-five service users who have dementia and are over the age of 65 years. The number of persons for whom personal care is to be provided shall not exceed forty-five. 30th April 2007 Date of last inspection Brief Description of the Service: Memory House provides accommodation for up to forty-five older people. Some residents may have care needs associated with dementia. Accommodation is provided in a large older style building that over looks the Thames estuary. The home is within a short walk of Leigh Broadway and Old Leigh Town. Memory House has thirty-three single bedrooms and six shared bedrooms. There are three dining areas and two lounge areas. The range of fees for accommodation ranges from £388.01-£650.00. The actual fee depends on the source of funding (local authority or private), the type of bedroom required or available and the assessed care needs. There are additional fees for hairdressing, chiropody and personal items. The home’s Statement of Purpose and Service User’s Guide are displayed in the main entrance. Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of this service is 2 star. This means the people who use this service experience good quality outcomes. This was a key unannounced site visit that started at 8.30am and finished at 3.30pm. The last key inspection took place on 30th April 2007. The home had completed and returned their Annual Quality Assurance Assessment (AQAA) to us prior to the inspection. This document gives homes the opportunity of recording what they do well, what they could do better, what has improved in the previous twelve months as well as their future plans for improving the service. Aspects of the information and detail provided within the AQAA have been included in this report. The manager, the operations manager (area manager), residents, a visiting professional, a visitor and staff on duty were all spoken with during the inspection. We (CSCI) received five completed surveys from relatives, two completed surveys from staff and one completed survey from a visiting professional. We sent surveys for residents to complete, but none were returned. Reference to the information we received from the returned surveys has been made within this report. The day was pleasant and all staff were very co-operative and helpful. The whole inspection process was undertaken with ease. A tour of the home took place. Throughout the inspection, care practices were observed and a random selection of records viewed. A notice advising any visitors to the home that an inspection is taking place was displayed. A visitor we spoke with said that they had seen the notice. All matters relating to the outcome of the inspection were discussed with the manager and the operations manager. They took notes so that development work could be started immediately where necessary. Full opportunity was given for discussion and/or clarification where necessary. Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Residents pre-admission assessment documentation was in good order. Care plans are reviewed on a regular basis. This means that the care provided to residents is based on current information. Since the last inspection the home has resolved some supply issues with the local pharmacist. This means that residents can be assured that their medication will be delivered on time. The home has purchased some more small tables in the lounge areas so that residents can place their drinks on them. The garden area is now very pleasant area for residents to use. Staff recruitment records were in good order. This means that residents can be cared for by staff that are properly recruited. The ‘unpleasant odour’ within one specific area of the home that had been identified in the previous five inspection reports, has been addressed. After a full investigation, the manager established that it was in connection with the underground water pipe system. Staff training has improved and staff now have regular supervision sessions. Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 7 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. Memory House Care Centre DS0000015512.V362048.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 Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (standard 6 was not inspected as the home does not provide intermediate care). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New residents can expect to receive a comprehensive pre-admission assessment that would reassure them that their needs could be met. EVIDENCE: The pre-admission assessment documentation of three of the most recently admitted residents was viewed. Pre-admission assessments had been undertaken and care plans had been put in place. Documentation demonstrated that the residents and their respective families had been fully involved in the process. There were entries within the documentation that demonstrated residents had been asked about their personal preferences and wishes. One section asks about a name by which residents prefer to be addressed by staff. All files contained a family history that had been prepared by the respective family. Residents and/or their relatives had been given the opportunity to visit the home before any decision had been made about Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 10 moving in. Relatives within their surveys were positive about the information they had received about the home. Two surveys when asked if they had received sufficient information reported ‘usually’, two reported ‘always’ and one reported ‘sometimes’. Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are involved in the planning of their care and have a plan of care that reflects their needs. Residents can expect to be protected by generally good medication practices and receive the services of the community health team. EVIDENCE: Six care plans and associated documentation such as risk assessments and accident records were viewed. Entries demonstrated that residents and families are consulted and personal wishes recorded. Entries on one care plan demonstrated to us that residents are referred to by a name of their personal choice. Each resident had an indexed file and all documentation requested by us was in place. Records demonstrated that care plans and risk assessments are reviewed on a regular basis. We could see that where care needs had altered as a result of a review, the care plan had been updated. The manager reported that social workers carry out annual care reviews of residents funded by the local authority. Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 12 Care planning documentation was kept in a secure place but with easy access for all staff. Staff confirmed this. Information within care plan documentation reflected our observations of good practices on the day. For example, information within one care plan gave details about how the resident likes to be involved and occupied. We saw staff providing the resident with this opportunity. Staff were able to provide us with a good verbal overview of individual residents’ care requirements. Staff spoke in a respectful manner when referring to individual residents needs. We saw evidence that care plan documentation is read by staff because we noted the following exert in the daily records ‘I was reading x’s assessment sheet and it was written down that X is fond of dogs….a visitor was in with her little dog….I asked if I could take (the dog) to X’s room so X could see it and have a stroke. X was delighted to see (the dog) and it made X happy’. In some further records we noted, ‘X likes to choose what she is going to wear every morning’. Information with four of the relatives’ surveys was positive about the care the home provides. All reported that the home kept them up to date with important issues affecting their respective relative. One survey reported ‘caring helpful staff….giving great reassurance to the people they care for’. Another reported ‘looks after the complete care and welfare of people within the home….provides very tasty lunches’. Another survey reported ‘we are quite satisfied with the care our mother receives’. Information on the health care professional’s survey was positive. They reported ‘the care service are very communicative with the residents families and show a genuine attitude towards the residents’. There were some comments that the professional thought that staff would benefit from identified areas of training. We made specific details known to the manager. We asked residents about what it was like to live in the home. We received comments such as ‘it’s ok here’ and ‘I’m well looked after thank you’. During the afternoon a resident became unwell and required the services of an ambulance. We were with a senior member of staff when the situation arose and observed the sharing of information and how the situation was managed. The resident was looked after well by staff. There is a daily record/staff communication book. This book provides staff with a good communication tool. The manager acknowledged that residents’ personal information should not be recorded in a communal book as this infringes their rights of privacy. We discussed with the manager and the operations manager an alternative method of recording the information. The operations manager and the manager were able to demonstrate several management tools that are in place to ensure good practice in the home is Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 13 maintained and also to identify areas for improvement. For example, the operations manager carries out monthly audits on care plan documentation. We looked at how accidents that sometimes happen to residents are recorded. Information within the daily records about accidents had been appropriately recorded in the accident book. We spoke to a visiting health care professional who reported that staff had managed a resident’s recent accident well. The professional reported that staff had demonstrated a good understanding and knew what to do. We spoke to the visiting hairdresser who reported that the home ‘was a nice place to be’. The manager reported that the home has a good working relationship with all social and health care professionals. Senior staff confirmed this. Residents have separate medical/clinical/community nursing records within their file. Recent entries demonstrated that residents have access to health care professionals. Storage facilities for medication were clean and orderly. There were no gaps within the medication administration records viewed at random. Some residents receive PRN (as/when required) prescribed medication. On those records seen there were no personalised instruction about how this medication should be given, how much should be given and under what circumstances. There was the same broad general protocol on each file. The manager reported that each file should have had a personalised protocol and agreed to find out what had happened. The operations manager reported that they were due to carry out a medication audit and would have identified the issue. The manager reported that the shortfall would be addressed with minimal delay. There was a record of named staff that had received training to administer medication. It is also good practice to ensure that two members of staff sign any hand written medication administration instructions made by them. This will help to prevent mistakes being made and any wrong instructions being carried forward. A senior member of staff reported that it is normal practice for there to be two signatures, but confirmed our findings. We observed two aspects of good medication practices within the home. Senior staff giving out medication wore a tabard with the words ‘do not disturb – medication administration in progress’. This practice is observed by all staff in the home to allow the person administrating medication to do so without being distracted. The other aspect of good practice is that routinely three times a day at shift handovers, controlled drugs (medication which has to be stored and managed in a special way because they are strong) are checked to make sure that the number of tablets in the bottle/packet is the same as the information on records. Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to be provided a balanced diet but cannot be assured that adequate records made maintained to demonstrate this. Residents can expect to experience a lifestyle that reflects their choice. EVIDENCE: An activities co-ordinator is employed by the home. Records showed us that this member has received appropriate training for the role. Further training has also been arranged. An activities programme was displayed and the activity on the day was in line with the programme. We observed residents enjoying a game of cards. We also observed the co-ordinator spending time with individual residents who had indicated that they did not wish to participate in the communal activity. The home is registered to provide care for residents with dementia. The coordinator and the manager spoke to us about how this area of care is being developed. For example, more pictorial activities are being arranged. They understood the importance of providing appropriate occupation and stimulation for residents with dementia care needs. The co-ordinator demonstrated a Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 15 sound understanding of how the programme needs to be developed to meet the needs of these residents. The manager reported that they would support the co-ordinator in development plans. The manager is also aware that the environment should be made more ‘user friendly’ for residents with dementia care needs. For example there is a lack of visual orientation aids and signage in the home. The manager reported that the vast majority of residents have regular and active family involvement. This was reflected within care plan documentation and evidenced by the constant stream of visitors to the home during the day. For part of the day, we were sitting in an area that was adjacent to the main entrance. Each visitor arriving was greeted in a very friendly way by staff. We also noted that many wanted to speak to the manager and exchange information about their respective relative. The manner in which this was done indicated to us that this level of interaction was normal practice. Visitors to the home appeared relaxed and indicated that they were enjoying their visit. The menu for the day’s lunch and evening meal was displayed and demonstrated that residents have a choice at all meal times. Residents confirmed this. One resident reported ‘oh, the food is so good’. The chef explained that residents are asked for their choice of lunch and evening meal the day before. Detailed documents were available to show what food the residents had ordered. The manager confirmed that the home does not keep a record of the food actually eaten by individual residents or the quantity of food eaten at each meal. We discussed this with the operations manager and the manager and explained that a record needs to be kept to provide detail of what each resident actually ate and in what quantity. The manager agreed to implement this immediately. Tables at lunchtime looked attractive. Each one had a clean tablecloth, drink glasses and serviettes. The chef explained that they supervise the serving of lunch. Lunch looked very appetising. Some residents require their food liquidised. Their lunch was served attractively on patterned china plates with a specially built up rim around the top edge. This good practice means that many residents can remain independent at meal times. Those residents requiring the help of staff at lunch were being assisted in a sensitive manner. A member of staff was overhead to be going around to each resident asking if they would like gravy and in what quantity. It was positive to note that even those residents who were quite frail were being asked. Another member of staff was asking individual residents ‘would you like orange or lemon (to drink) please’. Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to have any concern or complaint dealt with appropriately and to be protected by the home’s ‘safeguarding adults from harm’ procedures. EVIDENCE: The home’s complaints procedure is within the Service User’s Guide and in the Statement of Purpose. Both documents were on display. Residents spoken with said that they knew they had the right to raise any issue of concern and would feel comfortable about approaching a member of staff. Two residents said that they would probably speak with their relatives first and ask them to deal with the matter. A visitor we spoke with reported that they knew about complaint process and reported ‘yes I know what to do if I was concerned, but to be honest, it never comes to that because I have a good relationship with the manager and we would talk things over….I think you’ll find most of us would say that’. The home has complaint record log. Since the last inspection the manager has received three concerns about various aspects of care. All had been recorded appropriately and information included the nature of the concern, how it was investigated, who investigated it and the outcome. Letters were on file to demonstrate that the home communicated well with those who feel they have reason to raise an issue. All concerns have been fully resolved. Four of five Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 17 relatives within their surveys said that they knew how to make a complaint and would be confident of the home acting appropriately in order to resolve it. The information on one survey indicated that a relative was not happy with some aspects of the home. We would recommend that if anybody does have a concern or that they felt things could be better, to contact the manager or arrange to see the operations manager. Since the last inspection the local authority had investigated a safeguarding issue. The allegation was not proved against the home. There had been some miss communication by hospital personal following an admission of a resident to hospital. It was positive to note the following which was taken from a communication from the local authority to the home about the matter….’(the safeguarding issue) was managed well by the home….it appears that the home took the appropriate steps when X became unwell’. We saw records to demonstrate that training had been provided for staff to ensure residents are protected and the measures they should take if poor practice is suspected. Care staff spoken with understood that if they suspected any abuse, they should report it immediately to a senior member of staff. Senior staff on duty knew that they had a duty to report any such matter to the relevant authorities in line with current guidance and policy. Senior staff told us that if their own manager were not on duty, they would immediately contact the ‘on call’ manager for the area for advise and further guidance. Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a home that may not be as clean as it should be to protect them. EVIDENCE: During the day, several small tours of the home were made. We felt that the home was warm, comfortable and homely. Bedrooms were clean and functional. We noted some trailing electrical leads in some bedrooms. Although they had been put against a wall there was still a risk of residents getting their feet caught up in them. There were no risk assessments in place. The manager advised that they would be in place by the end of the week. Communal areas were comfortable. There were no unpleasant odours in the home. Bathrooms were functional, two were in need of redecoration and new fitments. The rear garden/patio area has been upgraded since the last Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 19 inspection. This provides a very pleasant area for residents to sit in. The home has a shaft passenger lift so that residents can access all rooms. We noted that all the staircases had gates across them to prevent residents using the stairs unsupervised. We discussed this with the operations manager and the manager as some staircases are on a fire escape route and we thought the gates might obstruct an evacuation in the event of a fire. There were no risk assessments in place. The operations manager told us that appropriate advice and guidance would be sought by the end of the day. The home is of an older style and in keeping with its age and layout; there is a continuing programme of repair, maintenance and decoration. The home employs handyman/decorator and a structured plan of work was underway at the time of the inspection. We found areas of the kitchen and laundry to be dirty. The tiled walls behind the washing machines within the laundry area were grimy and dirty. Within the kitchen, the area that stores containers of dried food (flour etc) was not clean. Food containers had loose and spilt food on the covers; the top of cooking oil container had oil mixed with particles of dried food that had come from nearby containers. We saw ants running over and under the containers. The manager and the operations manager confirmed our findings. The AQAA states ‘There is a weekly, fortnightly and periodical schedule for cleaning the home’. There was no evidence of routine cleaning schedules in place for the laundry area or in that particular kitchen area. We raised our concerns with the manager and the operations manager. The operations manager acknowledged the infection control and poor hygiene risk and took immediate action for these areas to be deep cleaned. We saw staff carrying out the cleaning. We acknowledged that immediate action was taken to reduce the risk of infection and raise the level of hygiene standards. The manager must put in place suitable arrangements to ensure that adequate standards of hygiene and cleanliness are maintained in both these areas in future. These findings are referred to again within the ‘management and administration’ section of this report. Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to be cared for by a reliable team of trained and wellrecruited staff. EVIDENCE: A rota was available for inspection. The rota showed us that there is a minimum of six care staff (including a senior carer) on duty during the day and three ‘awake’ care staff (including a senior carer) on duty at night. The home does not have any staff sleeping in facilities. Staff told us that sometimes there are as many as two senior staff on duty for some shifts. The manager confirmed this. Staff spoken with felt that there were enough staff on duty to provide care for the residents. Two members of staff said it was better when there were two senior members of staff on duty and five carers, as it gave them more time to talk to residents. In addition, the home employs domestic and laundry staff, maintenance staff, kitchen assistants, administration staff, a deputy manager and a housekeeper. The home has no staff vacancies and staff confirmed that there is very little turnover. This means that a stable team of staff cares for residents. Residents’ assessed needs had been recorded and staff were able to demonstrate that they had a good understanding of individual resident’s care Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 21 requirements. Staff wore practical clean uniform style dress. Most had name badges on. Staff throughout the day interacted well with us and with residents. In the entrance hall there were photos of all staff working in the home, together with their names. This assisted us in identifying staff and ‘putting faces to names’. If this was of benefit to us, then in our opinion, it must be of benefit to new residents and visitors to the home. Memory House is a large home and this information is of a great help. The manager reported that moral was good and sickness levels low. Staff confirmed that supervision takes place and they attend staff meetings. Records confirmed this. The manager demonstrated that staff training records are kept up to date. Staff confirmed that training opportunities are available for them. One member of staff has just started the NVQ level 3 award, six staff have completed their NVQ level 2 awards and a further seven staff were due to start their NVQ level 2 training the following day. The activities co-ordinator has received training for their particular aspect of work and is booked to receive more. This means that a team of staff who are appropriately trained, care for residents. We looked at the records of three staff that have started work in the home since the last inspection. Files were well indexed and the content was in good order. Induction records were in place. This means that a team of staff who are recruited using appropriate recruitment processes care for residents. Information within the relatives’ surveys indicated that all were satisfied that staff had the right skills and experience to look after their relatives. One survey said ‘staff are very caring and makes sure X is happy and kept occupied’. Another reported ‘we are very impressed with the care given by the staff’. Staff within their surveys confirmed that they feel supported and receive training opportunities. Both reported that they knew what to do if a resident wanted to make a complaint and felt that the home had good communication systems in place. Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a home where the general management is good. EVIDENCE: The manager was registered with us in September 2007. It was evident at this inspection that the management and leadership at this home has improved since the last inspection. For example, residents’ pre-admissions assessments were in place, care plans are kept under review and staff recruitment checks were in place. The manager has the Registered Manager’s Award and is currently undertaking a NVQ level 3 course. Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 23 Safety and maintenance records were sampled and noted to be in good order. The home has a folder of generic safe working and environmental risk assessments. As recorded in the ‘environment’ section of this report, there was no risk assessment in place for the trailing electrical leads in residents’ bedrooms or for the gates across stairwells. Safety and fire evacuation procedural notices were displayed thought the home. The AQAA states that there are ‘regular residents meeting’. The last recorded meeting took place in November 2007. The manager now has a user-friendly comment card for people to complete and provide their views and opinions about the home. We discussed how this should now be given to all residents, staff and stakeholders. The manager reported that the information from these surveys would be used as part of the home’s quality monitoring/quality assurance report. A copy of this should be ready for the next inspection. The operations manager told us that work would now begin on the report. The manager informs us about events we need to know about in the home as appropriate. A representative (operations manager) visits the home monthly. A record of these visits was available. Fire and Rescue Service visited the home in July 2007 and there was a routine Food Hygiene and Food Standards inspection report dated January 2008. The manager told us that there were no outstanding issues. The home looks after resident’s personal monies if requested. There is a computerised system in place identifying resident’s individual transactions. Receipts were available for monies taken from individual accounts and a receipt is issued when money is deposited. The system is explained within the Statement of Purpose and the Service User’s Guide. Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 1 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 2 Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 25 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. 1 Standard OP15 Regulation 16 Timescale for action A suitable recording system must 15/06/08 be in place to demonstrate that residents have been provided with a suitable, wholesome and nutritious diet in an adequate quality. This would enable the wellbeing of residents to be monitored, to provide a record of what food each resident actually ate and in what quantity. The record can be used should there be any concern about this aspect of care. 2 OP26 16 Systems must be in place to 29/04/08 ensure that all areas of the home are kept clean and maintained to an adequate infection and cross contamination control standard. This is with particular reference to the laundry and kitchen areas. Immediate measures were taken by the operations manager to clean both these areas. This is reflected in the timescale of 29/04/08. Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 26 Requirement 3 OP38 13 All areas of risk to residents, staff and visitors to the home must be identified together with the measures in place to minimise accidents. This is to ensure that the environment is safe and people know what risks there are and what they can do to prevent unnecessary accidents. This is with particular reference to gates across staircases and trailing electrical leads within resident’s bedrooms. The operations manager reported that immediate consultation would be taken concerning the gates across staircases because of the significant risk should there be a fire. Further discussion with the manager would take place on the day of inspection to address the trailing leads in bedrooms. This is reflected within the timescale of 29/04/08 29/04/08 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 Memory House Care Centre DS0000015512.V362048.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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