Inspection on 10/08/06 for Nightingales Care Home

This inspection was carried out on 10th August 2006.

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

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Nightingales Care Home Islet Road Maidenhead Berks SL6 8LD Lead Inspector Stephen Webb Unannounced Inspection 10th August 2006 10:30 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 DS0000067097.V297893.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. DS0000067097.V297893.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nightingales Care Home Address Islet Road Maidenhead Berks SL6 8LD 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) 01628 621494 Thames Carehome Limited Mrs Richelle Anne Dix Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places DS0000067097.V297893.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection N/A First inspection under new proprietors. Brief Description of the Service: Nightingales is a converted detached house set in attractive grounds, in a quiet residential area close to the river Thames in Maidenhead. The home provides care for residents who require support by reason of old age, and is not registered to admit residents with dementia-related conditions. The home is registered for up to seventeen residents, in eleven single bedrooms and three double bedrooms. Only one of the double rooms is currently shared, with the other two being let as large single rooms. Bedrooms are located on the ground and first floors, with bathrooms and toilets available on each floor and a lift is provided, serving both floors. The home has a single lounge with an attached conservatory. There is a small dining room, which provides space for up to eight residents, while others eat in the lounge or their bedrooms, if they prefer. The home has recently been taken over by new providers, though the manager and staff team have remained consistent through this change. Fees at the time of inspection range from £475-£600 per week for single bedrooms and from £375-£425 for a shared room. Additional charges are made for hairdressing, private chiropody and newspapers. DS0000067097.V297893.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit from 10.30am until 8.30pm on 10th of August 2006. The inspection also included reference to documents completed and supplied by the home, and those examined during the course of the site visit. The report also draws from conversations with service users, relatives, management and staff at the unit, and from eleven returned service user questionnaires, which were completed by residents with the support of the reminiscence worker at the home. The inspector also toured the premises and had lunch with service users. What the service does well: Prospective residents receive appropriate information about the home to enable them to make an informed decision about moving in, and the home undertakes an appropriate assessment to establish whether they are able to meet the needs of the prospective resident. Each resident has a care plan, about which they have been consulted, and these are subject to periodic review. Care plans include a range of risk assessments, and evidence of residents’ choices and preferences. The health needs of residents are managed effectively, and the home enjoys positive relationships with external health professionals. An appropriate medication management system is in place. The privacy and dignity of residents is managed effectively by the staff, on a day-to-day basis. Residents are enabled to make choices in their daily lives and have a say in the colour scheme in the home. The specialist communication needs of one resident are addressed effectively through the use of a communication book, with relevant images which can be referred to when conversing. A range of appropriate activities, events and outings are provided for residents. The home employs a reminiscence therapist for six hours per week, who takes the lead on activities. The spiritual needs of residents are addressed and visitors are encouraged and invited to various events in the home. Residents receive a varied menu and have alternatives provided at meals if they do not like the main item. DS0000067097.V297893.R01.S.doc Version 5.2 Page 6 Most of the residents are aware of the complaints procedure, which is made available to them, and they have other forums and opportunities to raise any concerns they may have. Systems are in place to protect residents from abuse. The home is well maintained, hygienic and homely, and the new providers are undertaking a programme of ongoing improvement. The garden is an asset, and offers areas of natural shade, paved pathways and seating. The home has an established and consistent staff team. Staff receive appropriate induction and have access to an appropriate training regime, some of which is provided in-house. Progress on NVQ is good, and the home has attained the “Investors In People” award. There is an appropriate recruitment system in place. The manager is qualified and experienced to run the home and is an accredited trainer, enabling her to deliver some core training to staff herself. Some elements of the required quality assurance system are in place and in some aspects, the system exceeds minimum requirements. A health and safety audit of the home was undertaken by external consultants. What has improved since the last inspection? What they could do better: Staff will need to be reminded of the importance of following the medication procedure, in terms of maintaining accurate records on Medication Administration Record, (MAR) sheets. The provider should consider re-designating the shared bedrooms as single bedrooms to enable privacy and dignity to be maximised, unless two residents specifically request to share. The dining facilities only provide for eight residents and the provider should consider how the dining provision could be improved to provide sufficient space for all residents to dine together. The issues noted regarding the dining room door must be addressed. The kitchen will need upgrading in due course. DS0000067097.V297893.R01.S.doc Version 5.2 Page 7 The identified omission with regard to a POVA check must be addressed. There is a need for further development of aspects of the quality assurance system in the home. The provider must undertake the required monthly Regulation 26 monitoring visits and must provide a report on the findings at each visit, which is copied to the manager for filing in the unit. The manager must establish the required individual records of accidents to residents within their case files, in addition to the collective record already in place. 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. DS0000067097.V297893.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 DS0000067097.V297893.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their relatives receive appropriate information to assist them in making an informed decision about admission. Service users receive an appropriate assessment prior to admission. The home does not provide a specific intermediate care service. EVIDENCE: The provider is in the process of updating the statement of purpose and service user guide, to reflect the change of registered provider. The home has an appropriately detailed assessment format in place. The admission system begins with obtaining the basic referral details from social worker or prospective resident/relative. The manager first undertakes an initial telephone assessment to judge the likely suitability of the referral. DS0000067097.V297893.R01.S.doc Version 5.2 Page 10 If the referral appears appropriate, the manager usually visits the prospective resident at home or hospital to undertake the detailed assessment. The manager takes into account both the needs of the prospective resident and how well they might integrate into the existing resident group. Admissions are made on the basis of an initial four-week trial period. The size of some of the bedrooms may be a limiting factor in terms of supporting residents with reduced mobility. Nevertheless, the home has a waiting list and the manager is able to make informed choices about admissions without undue pressure to fill beds. Residents and a relative confirmed their involvement and consultation during the assessment process. DS0000067097.V297893.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents care needs are identified within individual care plans, which include appropriate risk assessments. Residents have been consulted on the content of their care plan, which is reviewed regularly. The care plans include evidence of the choices and preferences of residents. The health needs of residents are managed effectively through positive relationships with local health professionals. Specialist external advice is sought when needed, from healthcare services. The home has an appropriate medication management system in place, though staff need to be reminded of the importance of consistently accurate recording on MAR sheets. The privacy and dignity of residents is managed effectively for the most part, though consideration should be given to permanently re-designating at least two of the double bedrooms, as singles. DS0000067097.V297893.R01.S.doc Version 5.2 Page 12 EVIDENCE: Each resident has a care plan within the Standex format, which comprises a comprehensive range of documents on various aspects of care planning and risk assessment, as well as daily notes and records of GP visits. The files examined contained signature sheets completed by the resident confirming their involvement in the preparation of their care plan. The care plans were reported to be written by the care staff, overseen by the deputy. There was evidence of periodic review of the care plans. The care plans also included evidence of records of choices made by residents, records of personal care and of activities. In the case of one resident, the local authority review minutes could not be located, and these should be obtained and filed within the resident’s case record. The medical health needs of residents are addressed via support from the GP and district nurses. The home seeks the support of other external health professionals as required. Pressure relief equipment is sourced from the GP/district nursing service as and when needed. The residents with hearing impairment have hearing aids and see the audiologist periodically. The audiologist did not feel that the current residents would benefit from the installation of an induction loop system, though this should be kept under review. The specialist communication needs of one resident have been addressed by the provision of a “talking book”, with pictures, symbols and letters which the resident can point to, in order to supplement his limited verbal vocabulary. The content of the book was approved, by the speech and language therapist. The resident was able to communicate with the inspector and confirmed that he was happy with the way staff meet his needs. The home manages medication appropriately within a recognised system. Medication records include a photo and medication profile. There is a separate record kept, of all medication received. MAR sheets were completed appropriately apart from a small number of omissions of records of refusals. Staff must be reminded of the importance of accurate medication recording. Observed medication administration practice included discrete observation, ensuring medication was taken by the resident for whom it was prescribed, DS0000067097.V297893.R01.S.doc Version 5.2 Page 13 which is good practice. Encouragement and support were also provided to residents, by the administering staff member. The home has a controlled drugs log, though none were prescribed at the time of this inspection. The home’s medication management system is reviewed four times per year by the pharmacist, who also undertakes an ongoing drug review, as part of this process. Residents’ privacy and dignity was seen to be supported, through staff knocking on bedroom doors, and the provision of personal care behind closed doors. Where a risk assessment indicates they are able, a resident may be helped into the bath, then given the privacy to bathe alone, with staff available outside the door, until they require support to exit the bath. The bedroom that is currently shared is provided with a folding screen to provide a measure of privacy, but this was of the old-fashioned wheeled, hospital type and the manager said there were plans to replace it with a more homely wood and fabric screen. GP and district nurse treatment was also administered in private. Residents confirmed, during the inspection, that their privacy and dignity were addressed effectively. Of the three potential double bedrooms, only one is currently shared, and this was said to be by the choice of at least one of the sharers. Nowadays sharing is only permissible where both parties consent, and in the future, the sharing of bedrooms should only be in such circumstances. Consideration should be given to converting the two smallest double rooms into good-sized singles in the future. DS0000067097.V297893.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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 are provided with a range of optional activities and some outings where able. Photographs are used to remember past events in the home. Visitors are encouraged and made welcome and are also invited to various events throughout the year. Residents’ spiritual needs are met as required. Residents are enabled to make day-to-day choices about their lives and can also have a say in décor and colour schemes. They receive a varied and appropriate menu, and the dining room, though too small to seat all of the residents, is pleasantly decorated. The possibility of extending the dining facilities should be considered. EVIDENCE: The home has a schedule of regular planned activities, though some residents acknowledged they were not always interested in taking part. These include light exercise sessions, quizzes and games, and one-to-one and group conversations. One staff member now undertakes weekly nail-care and DS0000067097.V297893.R01.S.doc Version 5.2 Page 15 pampering sessions, which are provided in addition to her regular care hours. The home has a library of books available to residents. One or two residents confirmed they had been taken out by staff, and others talked fondly of some of the entertainers brought into the home, including Irish dancers and singers. Outings included trips to other residential homes for events, visits to garden centres and cafes and to the nearby riverside. The home has booklets on getting out and about and developing community links, in the activities file. The reminiscence therapist, employed for only six hours per week, keeps records of her input with residents, and notes of individual needs, emotional wellbeing and participation in activities, and has also kept records of pat-a-dog visits, noting the responses of individual residents. Some of the staff also bring in their own dogs for residents to pet. Although she has attended reminiscence training, there was little direct evidence of this skill having been utilised, and perhaps this is an area for possible future development. In the past a qualified aroma-therapist has visited to provide hand and back massage, and the manager plans to reintroduce this. Subject to appropriate risk assessment, this would be a positive development. The home also holds events to which relatives are invited. The most recent was a beach party the weekend before the inspection, which was positively referred to by several residents. Some also recalled a recent in-house “publunch”, held in the garden. A photo-montage had been made of the event and was going to be hung on the wall, together with other similar event reminders. The manager had arranged for the photographs of the beach party to be put onto disc, and showed them to residents on the television as a slide show, which was an effective means to enlarge them for the benefit of residents with impaired sight. Residents said that their visitors were encouraged and made welcome, and several confirmed they received regular visitors. One or two said that their relatives sometimes took them out when they visited. One relative confirmed that they were made to feel welcome by the staff, and said that she was kept informed of any concerns. Several residents have their own telephone in their room, and one was observed using the home’s payphone. Few expressed any particular spiritual needs. A visiting Methodist minister provides an optional monthly church service at the home, and individual communion is arranged when requested. The daughter of one resident takes her out to church services. DS0000067097.V297893.R01.S.doc Version 5.2 Page 16 Residents confirmed that they were able to exercise various choices in day-today life. It was said that the majority of residents tended to retire to their rooms after tea, though not all went to bed straight away. Two residents were said to remain downstairs watching TV till later. This was observed to be the case during the inspection, when two of them were still watching TV in the lounge at 8.30pm when the inspection ended. The manager said that during the upcoming phased redecoration of residents’ bedrooms, residents will be able to choose their colour scheme from a range of options, and that they had already been consulted about the colour of the home’s lounge carpet. This is good practice. Several of the bedrooms contained extensive quantities of residents’ own items, which made them very homely, and residents confirmed that they were encouraged to bring their own things in. As previously noted, residents have choices at mealtimes, and these were observed being offered. Most have breakfast in bed though the option of eating downstairs was available. Verbal feedback about the food and the availability of alternatives, was positive, and was confirmed by the response to the residents’ questionnaire, where all respondents reported either always or usually enjoying the meals. The home has a four-weekly menu cycle which is occasionally updated. The current dining room only has seats for eight residents, with others eating in the lounge on lap tables or in their bedroom. In the future, consideration should be given to extending the dining room facilities to be able to accommodate all of the residents. (Recommendation made under Standard 20, later in report). The existing dining room is satisfactorily decorated and furnished. DS0000067097.V297893.R01.S.doc Version 5.2 Page 17 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The majority of residents are aware of the complaints procedure and know who to speak to if they have any concerns. The also have other forums within which they can raise any issues. Systems are in place to protect residents from abuse. EVIDENCE: The home has an appropriate complaints procedure. The most recent issue raised was in February 2006, and this was appropriately addressed. The complaints procedure is included within the residents’ guide, which is placed in each bedroom. Residents are also consulted via annual residents surveys, and the home has a residents’ forum, which is chaired by one of the residents and meets periodically throughout the year. The manager also talks informally to residents. All of the residents who responded to the inspection questionnaire were aware of who they could speak to if they had a concern, and all bar two of them were clear how to complain. DS0000067097.V297893.R01.S.doc Version 5.2 Page 18 The manager is an accredited POVA trainer and provides in-house training to staff on the protection of vulnerable adults, and receives annual updates to her own training in this area to ensure staff are kept up to date. The home has a policy of not handling residents’ finances at all, preferring to leave this to relatives or advocates, if the resident is unable to manage their own monies. DS0000067097.V297893.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well-maintained and homely and is subject to an ongoing programme of improvement and refurbishment. There is a need to address the issues around the dining-room door, and in the longer term, to consider improvements to the dining facilities and changes to the usage of the existing double bedrooms. The garden is a positive asset to the home. Standards of hygiene were found to be good. EVIDENCE: The home is pleasantly decorated and furnished in a homely style. The photomontages of events in the home will be a positive addition and can be used to remind residents of part events. There is a white-board in the lounge where the menu for the next meal is detailed, as well as a residents’ notice board, which included the minutes of the last residents’ forum meeting. DS0000067097.V297893.R01.S.doc Version 5.2 Page 20 A lift is provided to the first floor. A choice of communal area is available to residents via the lounge and the attached conservatory. Resident’s bedrooms were personalised with plenty of their own personal items, including furniture, pictures and ornaments. Radiators all have covers to protect residents, apart from two in communal areas, which were assessed as low risk, where the fitting of covers would make access more difficult. The current dining facilities are inadequate for the registered numbers, having places for only eight residents, with others eating in the lounge or in their bedrooms. The provider should consider extending the dining facilities as part of any future planned extensions of the home. There was also a problem with the overhead self-closer fitted to the dining room door, which was extremely heavy in operation. The manager stated that several adjustments had been tried without success. This self-closer must be replaced, if it cannot be made to operate without being unduly heavy. A battery-operated restraint had been fitted to this door to hold it open when the dining room was in use, to enable residents to access the room. However, owing to this device not being effective on the flat flooring, a hook-and-eye arrangement had been fitted to override the restraint device. This is not acceptable as it overrides the ability of the restraining device to release the door in the event of the fire alarm sounding. The hook-and-eye must be removed to avoid its use. Proprietary devices are available to enable the device to function on flat floorings. As noted earlier in this report, the home has three designated double bedrooms, though only one was shared at the time of inspection, with the other two being let as single rooms. The provider should consider converting the shared bedrooms to good-sized single rooms in the future, as residents should only share where both have specifically requested to do so. (Recommendation made under Standard 10, earlier in report). The screens provided in the shared bedroom, to improve privacy, are of the old-fashioned hospital style and the manager plans to replace these with a more contemporary design. Eight of the residents have opted to have their own telephone in their bedroom, and the home also provides a payphone. Residents had an input into choosing the colour of the lounge carpet, and are also going to have the opportunity to choose the colour scheme of their bedroom and carpet from a range of options as part of a rolling programme of bedroom refurbishment. This is good practice. DS0000067097.V297893.R01.S.doc Version 5.2 Page 21 The home has a large rear garden, which provides a mixture of lawn areas and paved patio, and there is a paved path round the building, which some residents like to use for regular exercise. The garden is afforded areas of natural shade by surrounding mature trees and a gazebo, and there is a range of suitable seating provided. The current washing machine does not have the necessary sluice cycle, but it was evident from the quotes available, that the manager was planning to replace this with a suitable commercial machine equipped with this facility. The home was found to be clean and hygienic throughout. The latest environmental health inspection report was positive, though the replacement of kitchen cupboard doors was recommended in due course. The kitchen, though adequate, was not equipped to current standards as a commercial kitchen and would benefit from refurbishment in the future. DS0000067097.V297893.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. The needs of residents are met by a settled staff team, who receive an appropriate induction and training. NVQ levels are above the required minimum and the home has attained the Investors In People award. There is an appropriate recruitment system in place though the identified omission must be rectified. EVIDENCE: The home was recently taken over by new providers, though the manager and staff team have remained consistent during the change. This is a stable team and the home uses no agency staff. The home attained the Investors In People award in December 2005. Observations of staff interactions with residents indicated a caring and attentive approach, which was confirmed by most of the feedback from residents and a relative, though two residents felt that a member of staff was not always readily available to meet their needs. Several residents commented that staff were kind and supportive. Staff demonstrated their knowledge of the needs of individual residents, and of the specific communication style of one resident in particular. DS0000067097.V297893.R01.S.doc Version 5.2 Page 23 The usual staffing is three care staff in the mornings until 11.00am, then two for the remainder of the day. At nights there is one staff on waking duty. The manager works office hours during the week, and there is a cook and housekeeper on duty daily. Every Tuesday the reminiscence/activity worker visits from 10.00am to 4:00pm and occasional volunteers also visit. At night staff members take turns on call, (off-site), in the event of any emergency, but have rarely been called upon. The manager feels that the staffing levels meet the current needs of the resident group, though this will need to be kept under review as dependency levels change. Two of the staff had obtained NVQ level 3, seven had level 2, and one is still completing their induction. Six staff will not be undertaking NVQ, but this will be an expectation for all new recruits, once they have completed their induction and foundation training. Examination of a sample of recruitment records indicated that an appropriate system of recruitment checks had been developed including a new interview record, which is good practice. However, in one case the required check-box for the POVA check had not been crossed on the CRB application form, and the POVA check was therefore shown as “none requested” on the CRB. This is not satisfactory, and a new CRB check should be undertaken to include this check. The staff receive an appropriate induction and foundation training, which is recorded and signed off, though the manager is awaiting the new Common Induction Standards, to devise an improved induction record. The staff receive a range of appropriate training, much of which is delivered inhouse, though the manager is exploring external training sources including the local authority. The manager is an accredited trainer for POVA, moving and handling and infection control. First aid and fire safety training are sourced externally from suitably qualified trainers. The home held an evening of achievement to award staff their training and NVQ certificates, to which residents and relatives were invited. The manager maintains individual and collective training records of staff training, which is good practice. The majority of core training was up-to-date for all staff, though a small number are due for updates to first aid training. The manager also takes on social work trainee students on placements and uses them creatively to expand the individual time spent with residents. Skills2-Care have produced individual personal development plans for the staff. All staff had an appraisal in August 2005 and the manager plans to repeat the process this year. DS0000067097.V297893.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 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 well managed, by an experienced and qualified manager. The quality assurance system has some good elements, but requires further development as described, to fully meet the standard. The proprietors must undertake the required monthly monitoring visits and produce reports on each visit, which are copied to the manager. The financial interests of residents are addressed, by the home not having any direct involvement in their finances. The home effectively promotes the health and safety of residents in many areas, though as already noted, there are issues to be addressed regarding the dining room door, and individualised accident records need to be established, in addition to the existing collective record. DS0000067097.V297893.R01.S.doc Version 5.2 Page 25 EVIDENCE: The manager is appropriately experienced and qualified to run the home. She has attained Level 4 NVQ and the Registered Manager’s Award, and has completed the units to become an internal assessor. The manager also has a Leadership Programme certificate and is an accredited trainer for POVA, infection control and moving and handling training, as well as having completed a general train-the–trainer course. She also attends other training from time to time to maintain current knowledge. There are clear lines of accountability, within the staff team in the home. It was commented, however, that the new owners had yet to introduce themselves formally to the staff. The manager undertook a residents’ survey in December 2005 and proposes to undertake another this year. The results were fed back verbally to the residents’ forum, and though a set of graphs of the results were prepared, these were not circulated. In future the report summarising the findings, and any resultant action should be made available to participants and prospective residents/their relatives. The quality assurance process also needs to be broadened out to include specifically targeted questionnaires to relatives and relevant external professionals, in order to obtain a rounded picture of how the service is perceived. The manager had carried out a separate residents’ survey recently, regarding meals and supper provision. There is also a residents’ forum as already noted, which meets periodically. Minutes are posted on the notice board. The manager plans to undertake a further survey of the residents’ views about the recent beach party event and seek possible ideas for future events. The manager also undertook a staff survey in November 2004, and expects staff to complete training feedback forms after undertaking courses. This is good practice. She has also introduced a system of mentoring of the junior staff by the more experienced staff. It was noted however, that the new owners had not been undertaking the required monthly Regulation 26 monitoring visits or producing the resulting reports. These visits must be undertaken and the resulting reports copied to the manager for filing in the home. DS0000067097.V297893.R01.S.doc Version 5.2 Page 26 As noted earlier the manager opts not to have any responsibility for the management of residents’ finances, so there are no records to examine. If items are purchased on behalf of a resident, the receipt is submitted to the relatives or whoever has power of attorney. The health, safety and welfare of residents and staff are maintained by practice in the home for the most part, though the issues identified earlier regarding the dining-room door need to be addressed. A health and safety audit of the home was undertaken by external consultants, in June 2006, which identifies any issues within the home, and a Legionella check was undertaken in 2004, which resulted in some remedial works. Required servicing and certification was sampled and found to be in place, apart from the fire extinguisher service, which was overdue by a month. The manager agreed to pursue this. The home has a written fire risk assessment in place. The manager had the required collective accident records in place as a monitoring tool to identify any indicative patterns, changes in overall dependency levels, or increased risk of falls, and monitors these on a monthly basis, which is good practice. However, there were no individual records of accidents within residents’ case records as required. The manager must establish these records in addition to the existing collective accident record. DS0000067097.V297893.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 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 2 2 X X 2 X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 DS0000067097.V297893.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? N/A 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 2 Standard OP9 OP19 Regulation 13(2) 23(4)(c) Requirement The manager must remind staff of the importance of accurate medication recording. The manager must ensure that the self-closer on the dining room door is suitable to enable residents to access the room, and that the door remains free to close via this device at all times in the event of the fire alarm sounding. The manager must ensure that a full CRB including the POVA check, is undertaken on the identified staff member, and any others where this is absent. The manager/provider must develop the quality assurance system as described. The registered provider must undertake monthly monitoring visits and produce the required reports, which should be copied to the manager, for filing. The manager must establish individual records of accidents to residents within their care files. Timescale for action 13/09/06 13/09/06 3 OP29 19(5)(d) & Schedule 2.7 24 26 13/10/06 4 5 OP33 OP33 13/02/07 13/09/06 6 OP38 17(1)(a) 13/10/06 DS0000067097.V297893.R01.S.doc Version 5.2 Page 29 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 Refer to Standard OP10 OP20 Good Practice Recommendations The provider should consider converting the two smallest double bedrooms into good-sized single bedrooms. The provider should consider increasing the available dining space so that there is sufficient to accommodate all of the residents. DS0000067097.V297893.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 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 DS0000067097.V297893.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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