CARE HOMES FOR OLDER PEOPLE
North Corner 1 Prince Edwards Road Lewes East Sussex BN7 1BJ Lead Inspector
Elaine Green Key Unannounced Inspection 7th November 2006 10:00 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 North Corner DS0000055776.V317488.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. North Corner DS0000055776.V317488.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service North Corner Address 1 Prince Edwards Road Lewes East Sussex BN7 1BJ 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) 01273 474642 Mr Schoonraad Mrs Schoonraad Mrs Schoonraad Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places North Corner DS0000055776.V317488.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. That service users are aged sixty five (65) years or over on admission. That the number of service users accommodated must not exceed sixteen (16). 9th November 2005 Date of last inspection Brief Description of the Service: North Corner is a large detached house situated in a quiet residential area of Lewes. It is a short walking distance to the town centre for those capable. There is access to local transport. Rooms are located over two floors. A stair lift is available to assist service users to the first floor. There is a lounge with a piano and T.V and a dining room both on the ground floor. The home is not suitable for wheelchair dependant service users. Service users have access to a lovely garden area, weather permitting. There is adequate street parking available outside the home.. North Corner is registered for 16 service users, of either sex, that are 65 years of age or over. The current proprietors have been have been the owners since 31st October 2003. The current scale of charges is £400 to £450 per week. Fees include all care and accommodation costs, food and drink, heating and lighting, laundry done on the premises, ‘in house’ activities and any other staff services. Fess do not cover the cost of newspapers, dry cleaning, treatments by dentists, doctors or opticians, the purchase of clothing and personal effects, the cost for all of which varies according to the individual. The charges made for the visiting hairdresser is £8.50 and for podiatry is £18 per session. A copy of the last Inspection report can be found I the entrance hall of North Corner and a copy is available upon request. North Corner DS0000055776.V317488.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations 2001 uses the term ‘service users’ to describe those living in care home settings. For the purpose of this report, the people living at North Corner will be referred to as ‘residents’. This was an Unannounced Inspection and there were fifteen residents in residence on the day of the site visit. The Inspection was undertaken over six hours and a number of documents and records were examined; including personnel files, medication charts, residents’ care plans, daily records in relation to the day-to-day running of the home and health and safety records. A tour of the premises was carried out. Three residents, two visitors, three members of staff and the Registered Manager/Provider were spoken with. Prior to the inspection a pre-inspection questionnaire was sent to the home to be completed with information required as part of the inspection process. Unfortunately this was not returned to the Inspector prior to this report being written and so the information it detailed could not be used in this report. A total of 6 comment cards were completed by residents and their relatives and feedback from these will be included in the report. The Registered Manager is also one of the Registered Providers but as she could not be present for the whole of the Inspection the Deputy Manager facilitated the rest of the day. What the service does well:
The home has a satisfactory admission system that ensures prospective residents’ receive the information they require in order for them to make an informed decision about whether or not to reside in the home. This includes having the opportunity to come and look round the home, join existing residents for a meal and having the first months stay on a trial basis. . In relation to the admission process a relative wrote ‘The manager was very helpful, informative and welcoming.’ Another wrote ‘I was able to discuss my mothers’ needs a number of times with both the manager and 2 of the key workers. My mother was also invited to tea prior to her trial period.’ The atmosphere in the home is homely and comfortable. The communication between the staff and residents is friendly and relaxed. The home provides residents with the opportunity to participate in stimulating and appropriate activities. All parts of the home are clean, tidy and well maintained. The garden and grounds are accessible, well maintained and there is seating in the porch, on the lawn and to the side of the building. Residents stated they enjoyed sitting in the garden and grounds and going for short walks in the local community with the staff.
North Corner DS0000055776.V317488.R01.S.doc Version 5.2 Page 6 The home has a core team of staff who have a good understanding of the needs of the people living at the home. Staff were observed to treat residents with care and respect and to offer support in a timely and appropriate manner. Routines are flexible enabling residents to maintain control over their daily lives. Those residents spoken with all remarked on the kindness of staff and the care given. Comments from residents and visitors included: ‘We are very happy with the care my mother receives at North Corner. There are always fresh flowers and the doors and windows are always open. There is a lot of stimulation and they don’t watch television all the time’. ‘The staff at North Corner are kind, patient and welcoming. They are very nice to everyone and treat me with respect.’ ‘My relative was given the opportunity to bring their own furniture but we decided to wait a while for them to settle in first. Our relative was given the chance to stay on a 30 day trial basis, we are all very happy with the home and my relative has decided to reside here permanently.’ ‘All the residents are referred to as Mr or Mrs which I think is respectful.’ ‘The food is always good. It is homemade and the desserts are always delicious.’ ‘My relative has made much improvement since they moved in to North Corner and is very happy here.’ Residents’ care plans contain informative background information in relation to residents’ personal history. This information helps staff get to know residents and helps staff have a real insight into the person they are supporting. The recruitment policies and procedures adopted by the home are safe and largely the required identity and security checks are completed prior to staff being deployed to work in the home. The home continues to work towards achieving the target of 50 of the staff they employ obtaining a National Vocational Qualification (NVQ) in Care at Level 2 or above. Systems for dealing with complaints are satisfactory ensuring that residents and relatives feel their concerns are listened to. There are satisfactory systems in place to ensure residents health, safety and welfare is promoted and protected. Residents are kept informed of the improvements that have been made to the home and of the improvements they plan to make in the future. Regular residents’ meetings are held where residents have the opportunity to air their views. The manager of the home ensures that these views are listened to and that the appropriate corrective action is taken when needed. North Corner DS0000055776.V317488.R01.S.doc Version 5.2 Page 7 The manager/provider of North Corner continues to work towards providing a high standard of care for the residents and to ensure that the home is run in the residents’ best interest. Many improvements have been made over recent years and the manager/provider stated it is the intension of the providers to raise standards wherever possible. What has improved since the last inspection? What they could do better:
Whilst the outcomes for the residents of North Corner are generally good some shortfalls were identified. Improvements in the areas identified would have a positive impact on the lives of the people who reside in the home and further ensure that the health and safety of the people who reside there are protected and promoted. The manager must ensure that all current residents have been given up to date copies of the homes’ Statement of Purpose, Service User Guide and a costed Contract and Statement of Terms and Conditions of Residency. This applies to both self-funding residents and those funded by the Local Authority. All prospective residents must be provided with this information prior to them moving into the home. The manager must ensure that robust risk assessments and care planning systems are implemented and that staff are trained in delivering the specialist care that some residents who are suffering from confusion and or dementia type illnesses need. Care plans are not as detailed as they should be. Not all the risk assessments and associated guidance contained in care plans were signed and dated and there was no evidence to indicate that they had been reviewed on a monthly basis. A record of all accidents and incidents must be kept on residents’ care plans. The Manger must ensure that the homes’ policies and procedures in relation to safe recruitment are followed at all times. Where only one reference has been sought for new employees another appropriate and relevant reference must be sought. North Corner DS0000055776.V317488.R01.S.doc Version 5.2 Page 8 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. North Corner DS0000055776.V317488.R01.S.doc Version 5.2 Page 9 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 North Corner DS0000055776.V317488.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with the relevant information and documentation in order to make and informed decision in respect of whether or not to reside in the home. EVIDENCE: Prospective residents have the opportunity to come and look round the home, meet residents and staff and join them for a meal. One of the relatives comments received stated ‘The manager was very helpful, informative and welcoming.’ Another wrote ‘I was able to discuss my mothers’ needs a number of times with both the manager and 2 of the key workers. My mother was also invited to tea prior to her trial period.’ A visiting relative and resident confirmed that they had been offered the opportunity to come and look round the home prior to making a decision to reside there and that the first 30 days had been on a trial basis. The home ensures that pre admission assessments are completed for all prospective residents prior to them moving into the home. The documentation
North Corner DS0000055776.V317488.R01.S.doc Version 5.2 Page 11 examined in relation to preadmission assessments had not been signed or dated and did not cover all the areas as required so it was not possible to ascertain who had undertaken the assessment, where or when it had taken place. The manager must ensure that the preadmission assessments are robust and are signed and dated by both parties and that they cover all the areas specified in the National Minimum Standards. They must ensure that following the pre admission assessment that they confirm in writing the out come of the assessment and of whether they are able to meet the prospective residents’ assessed needs. The home ensures that all prospective residents are provided with a copy of the service user guide and statement of purpose and that a contract is provided upon admission. However, a change in the Regulations now requires that all prospective residents are provided with copies of the homes’ Statement of Purpose, Service User Guide and a costed Contract and Statement of Terms and Conditions of Residency prior to them moving into the home. This applies to both self-funding residents and those funded by the Local Authority. In addition to this all existing residents must be provided with up to date copies of the same documentation and information. Earlier this year the home admitted a resident suffering from dementia. Initially this was on respite and now they reside here on a permanent basis. North Corner is not registered to accommodate residents suffering from this kind of illness. The relatives of this resident and the staff of the home are confident that the home is able to met this persons’ needs. The manager must demonstrate they can meet this residents needs by ensuring that robust risk assessments and care planning systems are implemented and that staff are trained in delivering the specialist care that this person requires. North Corner DS0000055776.V317488.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Not all aspects of residents’ care needs are specified in their care plans or are regularly reviewed. Residents’ health care needs are met and their privacy and dignity is protected. EVIDENCE: Observation of the care and support given to residents on the day of the site visit and discussions with both Manager of the home and Deputy Manger in relation to the care needs of residents indicates that their needs are met. Feedback from relatives confirms this. One relative wrote: ‘I am amazed at the extra care and thought applied by mothers’ key worker. She is treated as an individual with her special needs considered carefully. The home was keen that my mother was registered with a GP who visits intermittently. Her medication was reviewed soon after she arrived. She is constantly monitored.’ Another wrote ‘Mum is exceptionally well cared for at North Corner. The level of empathy and sensitivity to her needs is consistently very high. When necessary to call a GP this has been done promptly.’ The
North Corner DS0000055776.V317488.R01.S.doc Version 5.2 Page 13 daughter of a resident stated that ‘All the residents are referred to as Mr or Mrs which I think is respectful.’ The Inspector can confirm that all residents and staff are referred to in this way and that staff all have name badges. A resident told the Inspector ‘The staff at North Corner are kind, patient and welcoming. They are very nice to everyone and treat me with respect.’ Three care plans were examined and whilst they did provide some informative background information and included updates re the general well being of residents the care plans are not as detailed as they should be. Not all the risk assessments and associated guidance contained in care plans were signed and dated and there was no evidence to indicate that the guidance and risk assessments had been reviewed on a monthly basis. The manager must ensure that care plans provide the guidance and information needed by staff to ensure that they can support residents in all aspects of their daily lives. They must specify residents’ likes, dislikes and preferences as to how care is provided and all the relevant risk assessments must be completed. Medication administration records were examined and found to be in order. All staff receive training in the administration of medication prior to undertaking this task and this includes having an assessment. The policies and procedures in relation to the administration of medication adopted by the home are safe however shortfalls were identified in respect of the lack of guidance as to when ‘as and when’ or PRN medication can be administered. The manager must ensure that individual specific guidance is written up on the advice of the prescribing GP as to the dosage and frequency of this type of medication. It is important that these guidelines are introduced as the frequency and dose of medication can vary greatly from individual to individual. They should also include timescales for how long this medication can be used before the GP must be contacted. Guidance is also required for when homely remedies and non-prescription drugs such as mild pain killers may be administered. The manager and staff explained that GP’s visit the home and that residents see health care professionals in the privacy of their own rooms. North Corner DS0000055776.V317488.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): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are systems in place for residents to experience a lifestyle that matches their expectations, choice and preferences in respect of both leisure and meals. EVIDENCE: The home provides residents with the opportunity a range of stimulating and appropriate activities to participate in. Amongst the activities provided are the opportunity to attend poetry readings, enjoy the musical entertainer, going on group minibus outings or individual walks in the local neighbourhood etc. The manager of the home explained she feels the acts of engagement and interaction are as important as the participation in the actual activity itself. Of the 6 comment cards returned, 4 stated that the residents ‘always’ enjoyed the activities on offer and 2 that they ‘usually’ did. Comments included ‘There is a very wide variety of social activities provided, poetry readings, outings, musical entertainers and parties of the season. No special day is forgotten such as Remembrance Sunday etc.’ and ‘My mother especially enjoys the musical activities. We are also encouraged to join if we wish.’ ‘We are very happy with the care my mother receives at North Corner. There are always fresh flowers and the doors and windows are always open. There is a lot of stimulation and they don’t watch television all the time’.
North Corner DS0000055776.V317488.R01.S.doc Version 5.2 Page 15 The Inspector joined residents for their midday meal that was hot homemade and well presented. The food was served promptly from a baine Marie and residents who needed assistance were supported appropriately in a timely and dignified manner. The menus were examined and confirmed a wholesome, varied and nutritious menu is provided. One resident said at the midday meal ‘The food is always good. It is homemade and the desserts are always delicious.’ Of the 6 comment cards returned to the Inspector all of them stated that the residents ‘always’ liked the meals at the home. Comments included the following ‘Mum thoroughly enjoys the meals, which are ample, varied and presented well. I am often invited to join her.’ and ‘My mother is eating well and has put weight on. It is nice to see properly laid tables with real napkins.’ Relatives are welcomed in the home and this is confirmed in the comments in the cards returned and the relatives spoken to on the day of the site visit. One relative stated that the ‘Manager is very welcoming.’ another wrote ‘Whenever I ring or visit I am always given time.’ and another ‘I am welcomed at any time.’ Residents are supported to exercise choice over their lives. One resident stated that ‘You have your freedom but also know you have their backing if you need it.’ Residents can get up and go to bed when they choose and have a choice of food to eat at each mealtime. North Corner DS0000055776.V317488.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 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has satisfactory complaints and adult protection procedures. Residents know who to go to to raise concerns. EVIDENCE: Residents and their relatives and friends are confident that their complaints will be listened to. Of the 6 comment cards received 5 stated that they ‘always know how to make a complaint and 1 that they ‘usually’ know. One relative wrote’ I would not hesitate to discuss a complaint if I felt I needed to on my mothers’ behave.’ ‘Mum would be quite quick to choice concerns if she had any. As it is she has nothing but praise for the home and staff.’ The homes’ complaints and adult protection policies and procedures are safe. There have been no adult protection issues in the home since the last Inspection but staff stated that they were aware of the procedures that they must follow if they suspected an incident of abuse had occurred. Staff receive the relevant training in relation to recognising abuse. North Corner DS0000055776.V317488.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): 19,20,24 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of décor is good, providing residents with a safe, clean, homely, hygienic and attractive place in which to live. EVIDENCE: On the day of the site visit the Inspector had a tour of the home and found it to be clean, tidy and hygienic. The hallway into the home is spacious and provides seating. There is a cold water dispenser and information relating to the home including the daily menu which is also displayed here. Off the hallway there is a lounge area that is pleasantly decorated and homely in character. There is a piano, a television and a range of seating suitable for the needs of the residents. The dining room is also off the hallway and it too is homely in character and provides dining and seating enough for all residents to eat at the same time. Off the dining room is a tea and coffee making area and this is accessible to relatives should they wish to prepare themselves or their relatives a hot drink. Further down the corridor are bedrooms and a bathroom.
North Corner DS0000055776.V317488.R01.S.doc Version 5.2 Page 18 More bedrooms and the office are located on the ground floor whilst the kitchen and food storage areas are located in the basement to which residents access is restricted. Further bedrooms and bathrooms are located on the 1st and 2nd floors and access to the first floor is via a flight of stairs or chair lift. The home has an enclosed garden that provides a range of seating and residents stated that they enjoy sitting in the garden and porch area especially in the warmer months. All 6 comments cards returned from residents and relatives stated that the home is ‘always’ fresh and clean. One relative wrote ‘Great attention to detail is evident. There are almost always fresh flowers around and the whole home is clean and welcoming.’ and another wrote ‘It is pleasant place to sit and relax in and there is no ‘care home smell’. All our friends and relations have made the same comment.’ The Inspector had the opportunity to view some of the residents’ own rooms. Whilst these rooms were personalised some of the furniture provided by the home in one of the rooms particularly appeared old and somewhat ‘tatty’. Improvements are required in some other areas of the home with particular reference to the communal bathrooms where amongst other things a bath panel is broken and it is in need of redecoration and updating. The Deputy Manager explained that the Manager/Provider had already identified that this work was needed so no requirements will be made within this report. However should this work remain outstanding at the next Inspection requirements will be made. Residents are given the opportunity to bring their own furniture when they move in to the home and this was confirmed at the site visit by a resident and their visiting relative who stated that ‘My relative was given the opportunity to bring their own furniture but we decided to wait a while for them to settle in first. Our relative was given the chance to stay on a 30 day trial basis, we are all very happy with the home and my has decided to reside here permanently.’ North Corner DS0000055776.V317488.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): 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 number of staff and the skill mix ensures residents’ needs are met and consistent care is provided. The recruitment practices adopted by the home are, on the whole safe. EVIDENCE: The homes’ recruitment policies, procedures and practices are on the whole safe. All the required checks are undertaken by the home in relation to security and identity prior to new staff being deployed to work in the home apart form on two of the three recruitment files examined only one relevant and appropriate reference had been obtained. The manager must take steps to ensure that a further reference is obtained for both of these employees. The home is in the process of introducing a new induction package that will cover all the core induction standards that are required to be completed by staff working in the care industry. Alongside this the home has its’ own induction pack that new staff must complete when they start working at North Corner which covers such things as meeting the residents, reading the homes’ policies and procedures, health and safety, fire safety etc. Unfortunately there was no evidence to support the fact that any of the new members of staff had completed either of these inductions. However the Manager did state that all staff including staff that had been employed by the home for some time were going to complete the new inductions over the coming weeks. This is intended to raise awareness of modern practices in care and ensure consistency across
North Corner DS0000055776.V317488.R01.S.doc Version 5.2 Page 20 the staff team. The Manager must ensure that the relevant inductions are completed within the required timescales and that records are kept to provide evidence of this. The target for 50 of the staff employed by the home to hold a National Vocational Qualification (NVQ) 2 in Care at Level 2 or above has not been met. However the home continues to work hard towards achieving this. The Mandatory training that all care staff must have is generally provided to all staff within the required timescales and the staff spoken to and observed on the day of the site visit demonstrated a good understanding of the needs of the residents in their care. The staff rota was examined and sufficient staff are on duty at all times. Of the 6 comment cards received 5 stated that staff are ‘always’ available when they need them and one stated that they ‘usually’ are. North Corner DS0000055776.V317488.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): 31,33,34,35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff and residents benefit from clear leadership and direction and all aspects of residents’ health, safety and welfare are protected and promoted. EVIDENCE: The Manager has the required qualifications in care and management and has owned and managed the home for the past 3 years. The other Registered Provider also has relevant qualifications in Care. They are both qualified to provide guidance and support to staff and have worked in the care industry for many years. The providers live on the premises and so are always on call should they be needed in the night in case of emergency. A range of records relating to the health and safety of residents were examined including accident and incident forms, fire evacuation procedures, risk assessments etc. the management of the home had recently had a
North Corner DS0000055776.V317488.R01.S.doc Version 5.2 Page 22 meeting in relation to Health and Safety Law and changes that may affect the home. The home has recently replaced the fire alarm panel on the advice of a fire safety expert. Information examined confirmed that safety checks are carried out on all electrical and gas systems and appliances and that they are serviced annually. In addition documents relating to safe working practices and Health and Safety are available and regularly reviewed. It is recommended that when a resident is involved in a fall, incident or other accident all the actions taken must be recorded on the accident form including whether or not a risk assessment and care plan has been reviewed and or updated. A record of all accidents and incidents should be kept on residents’ care plans. The Inspector was informed that work has started in relation to gathering documentation, including residents’ surveys to inform the quality monitoring process and reviewing the quality assurance systems to enable management to objectively evaluate the service and ensure it is run in residents’ best interests. Although the process is not yet complete the Manager understands this is an on-going process. Residents’ meetings are held on a regular basis and information is passed on to residents and relatives in relation to all aspects of the running of the home in the form of newsletters. The most recent newsletter was examined and contained information relating to health and safety issues, staff that had been recently employed to work in the home, notification of the fact that a new member of staff will be starting in the near future, entertainment, activities organised and information relating to the key worker system in operation in the home. Minutes from staff and residents meetings were viewed and it was evident that both groups are given the opportunity to influence how the home is run. Residents are responsible for their own finances if appropriate; relatives and solicitors support others. North Corner DS0000055776.V317488.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 2 2 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 X X x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 3 3 X X 3 North Corner DS0000055776.V317488.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. 1. Standard OP2 Regulation 5(1b) Requirement Timescale for action 14/01/07 2. OP3 14(1abcd, 2ab) 3. OP4 12(1ab) 18(1a) 4. OP9 13(2,4abc ) That all service users current and prospective, are provided with up to date copies of the Service Users Guide, Statement of Purpose and a costed terms and conditions of residency. That the preadmission 30/12/06 assessment is robust and includes all areas specified in the NMS and that following a preadmission assessment that prospective service users are informed in writing of whether or not the home can meet their assessed needs. That the home demonstrates 30/01/07 through the assessment and care planning processes that they are able to meet the assessed needs of all the service users resident in the home including those who have specific care needs e.g. dementia. Staff must be appropriately trained in delivering this specialist care. That residents prescribing GP’s 30/01/07 are contacted in relation to the guidance for when PRN medication can be administered
DS0000055776.V317488.R01.S.doc Version 5.2 North Corner Page 25 5. OP29 19(5) Schedule 2 6. OP30 18(1ac(i)( ii) 1291ab) as detailed in the report. Recruitment Policies and 30/12/06 procedures must be followed at all times. The home must obtain 2 relevant and appropriate references prior to staff being deployed to work in the home. Records in relation to the 30/03/07 inductions completed by all staff must be kept in the home. All staff must complete the relevant induction training within the required timescales. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP38 Good Practice Recommendations Accidents and incident forms should record all action taken including the reviewing of relevant risk assessments and care plans. A record must be kept on the care plan. North Corner DS0000055776.V317488.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 North Corner DS0000055776.V317488.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
